The Role of Surgical Oncology in Treating Metastatic Cancers

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care
00:14 --> 00:15by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation about
00:21 --> 00:23advances in the treatment of metastatic
00:23 --> 00:25cancers with Doctor Kiran Turaga.
00:25 --> 00:27Dr Turaga is chief of surgical
00:27 --> 00:29Oncology and assistant medical
00:29 --> 00:31director of the Clinical Trials Office
00:31 --> 00:33at the Yale School of Medicine,
00:33 --> 00:35where Doctor Chagpar is a
00:35 --> 00:36professor of surgical oncology.
00:37 --> 00:39Kiran, maybe we can start off by
00:39 --> 00:42you telling us a little bit more
00:42 --> 00:43about yourself and what you do.
00:44 --> 00:46I'm a surgical oncologist,
00:46 --> 00:50which means I'm a cancer doctor first
00:50 --> 00:52and I'm also a surgeon.
00:52 --> 00:53And I grew up in India,
00:53 --> 00:55which is where I did my medical training.
00:55 --> 00:58I spent now half of my life in the
00:58 --> 01:01United States and half my life in India.
01:01 --> 01:04My journey in cancer surgery
01:04 --> 01:08started when I met patients during my
01:08 --> 01:10training and surgery who had immense
01:10 --> 01:13suffering and the suffering was
01:13 --> 01:15much more than I had ever wanted
01:15 --> 01:18to see any human being go through.
01:18 --> 01:22And I resolved then that I would dedicate
01:22 --> 01:24myself to to working on cancer care and
01:24 --> 01:26and that's where my journey has taken me.
01:26 --> 01:28It's also very personal to me.
01:28 --> 01:31My grandfather died of cancer and my father
01:31 --> 01:32recently expired also of cancer.
01:33 --> 01:36So I think it is something that is very
01:36 --> 01:39personal and motivates me every day.
01:42 --> 01:45Kiran, when we talk about cancer and on
01:45 --> 01:49this show we talk a lot about cancer,
01:49 --> 01:52oftentimes we
01:52 --> 01:55have kind of these two buckets, right.
01:55 --> 01:58We have the buckets of early stage
01:58 --> 02:02cancers that oftentimes we talk about.
02:02 --> 02:05The fact that these can be cured
02:05 --> 02:07essentially many early stage cancers
02:07 --> 02:11when picked up really early like early
02:11 --> 02:14stage breast cancers can be cured.
02:14 --> 02:16And then we talk about the later
02:16 --> 02:19stage cancers and it sounds to me
02:19 --> 02:21when you were talking about your
02:21 --> 02:23story that many of these patients
02:23 --> 02:25who are suffering with cancer
02:25 --> 02:28often have metastatic cancer,
02:28 --> 02:30cancer that has spread,
02:30 --> 02:33but that's not often the kind that
02:33 --> 02:36we think about in terms of surgery.
02:36 --> 02:38So can you tell us the role that
02:39 --> 02:41surgery plays in in metastatic cancers?
02:43 --> 02:46And I think you
02:46 --> 02:48framed this question very well.
02:48 --> 02:51I think both importantly and carefully,
02:51 --> 02:54which is number one, that there is a
02:54 --> 02:56common misconception that surgery may
02:56 --> 02:58not have a role in stage 4 cancers.
02:58 --> 03:01And so if you think about the history of how
03:01 --> 03:05cancer therapeutics have evolved in the past,
03:05 --> 03:07we had no modality for treating
03:07 --> 03:08cancer other than surgery.
03:08 --> 03:12So in the early 1900s, all the way
03:12 --> 03:16up to the discovery of chemotherapy,
03:16 --> 03:17surgery was the mainstay of
03:17 --> 03:19treating cancers and it was used
03:19 --> 03:21for treating cancers which were
03:21 --> 03:22both localized,
03:22 --> 03:26which meant they were early stage and late stage.
03:26 --> 03:28And then once chemotherapy came about
03:28 --> 03:31and we understood that cancer is a
03:31 --> 03:33disease that spreads throughout the
03:33 --> 03:35body and you need treatments
03:35 --> 03:38that are effective with cancers that
03:38 --> 03:39are spreading through the body,
03:39 --> 03:42there was a paradigm shift where
03:42 --> 03:44more treatments went towards using
03:44 --> 03:47what we call cytotoxic chemotherapy
03:47 --> 03:49or chemotherapy that kills
03:49 --> 03:52cells which are dividing.
03:52 --> 03:54The understanding that this is not
03:54 --> 03:57always the case for metastatic or
03:57 --> 03:59stage four cancer was a concept
03:59 --> 04:01that was pioneered actually at the
04:01 --> 04:04University of Chicago in the late 1990s,
04:04 --> 04:08where a term called oligometastasis
04:08 --> 04:11was defined, and what this meant was
04:11 --> 04:13if cancer was truly spreading
04:13 --> 04:14through the entire body,
04:15 --> 04:17why isn't every organ and every part
04:17 --> 04:19of every organ affected by the cancer?
04:19 --> 04:21Why is it that it selectively goes
04:21 --> 04:23to some organs and only in some
04:23 --> 04:25locations in some organs like the
04:25 --> 04:28liver or the lungs or the lining of
04:28 --> 04:29the abdomen called the peritoneum?
04:29 --> 04:32And this brought about this whole
04:32 --> 04:34concept of where when patients
04:34 --> 04:36have stage four cancer,
04:36 --> 04:38there is still the body's immune
04:38 --> 04:40system that is controlling these
04:40 --> 04:41sort of metastases or
04:41 --> 04:44stage 4 spreads in different parts of the body.
04:44 --> 04:47And in conjunction with other
04:47 --> 04:50treatments like chemotherapy or
04:50 --> 04:52immunotherapy or endocrine therapy,
04:52 --> 04:55you could actually combine it with
04:55 --> 04:57surgical or ablative treatments like
04:57 --> 04:59radiation or burning it with a needle
04:59 --> 05:03to enhance the survival of patients.
05:03 --> 05:05And so in the early 2000s when
05:05 --> 05:07people started doing this more
05:07 --> 05:10predominantly for colorectal cancers,
05:10 --> 05:11which had spread
05:11 --> 05:13we found that patients were actually
05:13 --> 05:15cured with surgery alone and in
05:15 --> 05:17fact the survival of these patients
05:17 --> 05:20which was much lower when
05:20 --> 05:22they just got chemotherapy alone
05:22 --> 05:24had significantly increased once we
05:24 --> 05:27were able to fold in treatments like
05:27 --> 05:30surgery in the treatment of these cancers.
05:30 --> 05:32And so over the last couple of decades,
05:32 --> 05:35our understanding of these tumors
05:35 --> 05:37have evolved significantly where we
05:37 --> 05:39believe that surgery plays a mainstay
05:39 --> 05:43role in the treatment of metastatic cancers.
05:43 --> 05:45And as treatments are evolving even further,
05:45 --> 05:48like immunotherapy or newer treatments,
05:48 --> 05:51there is an increased understanding
05:51 --> 05:52of where surgical therapeutics
05:52 --> 05:55are important in facilitating some
05:55 --> 05:57of these immunotherapies as well.
05:58 --> 06:02So that sounds really hopeful
06:02 --> 06:05that even in patients who have
06:05 --> 06:08had cancers that have spread,
06:08 --> 06:12the combination of using chemotherapy
06:12 --> 06:16or systemic therapies more broadly and
06:16 --> 06:19surgery may actually improve survival.
06:19 --> 06:22But is that only the case in certain cancers?
06:22 --> 06:25You mentioned that this was
06:25 --> 06:27pioneered with colorectal cancer.
06:27 --> 06:29Can this be used for all cancers
06:29 --> 06:32or is it still limited just to a few?
06:33 --> 06:36Yeah, I think that's a very
06:36 --> 06:38good question and the answer lies
06:38 --> 06:40in understanding the type of cancer.
06:40 --> 06:43So in the past we would only understand
06:43 --> 06:45cancers as the site of origin,
06:45 --> 06:48which means where they started from.
06:48 --> 06:49So we would think of cancers
06:49 --> 06:50only as breast cancer,
06:50 --> 06:52lung cancer, colon cancer,
06:52 --> 06:53prostate cancer.
06:53 --> 06:54In the last few years,
06:54 --> 06:56we've certainly evolved in our
06:56 --> 06:58understanding of how we think
06:58 --> 07:00of cancers and we bucket them
07:00 --> 07:01maybe slightly differently based
07:01 --> 07:03on their molecular profiles.
07:03 --> 07:05And so combining the information of
07:05 --> 07:08what we call the site of disease with
07:08 --> 07:10the molecular profiles give us this
07:10 --> 07:14group of cancers that are amenable
07:14 --> 07:17to treatments with surgical therapeutics.
07:17 --> 07:19And predominantly right now,
07:19 --> 07:22most of these applications in the
07:22 --> 07:24treatment and cure of stage four cancer
07:24 --> 07:27is limited to colorectal cancers,
07:27 --> 07:28ovarian cancers,
07:28 --> 07:32other cancers like appendix cancers,
07:32 --> 07:33mesotheliomas,
07:33 --> 07:36some stomach cancers like gastric cancers.
07:36 --> 07:40But we just started a clinical trial
07:40 --> 07:42which is challenging the paradigm of
07:42 --> 07:44how do we treat metastatic cancers
07:44 --> 07:47from some very rapidly aggressive
07:47 --> 07:50lethal cancers like pancreas cancer,
07:50 --> 07:52esophagus cancer,
07:52 --> 07:56bile duct cancer using this biological
07:56 --> 07:58information that
07:58 --> 07:59these tumors have.
07:59 --> 08:01Understanding that there's always
08:01 --> 08:03a group of patients that are
08:03 --> 08:06different than all the conventional
08:06 --> 08:07stage four cancer patients.
08:07 --> 08:10And so I think you know there will be
08:10 --> 08:13a widely applicable role of surgical
08:13 --> 08:16therapeutics in many oligometastatic
08:16 --> 08:19cancers including lung cancers and
08:19 --> 08:22melanomas and other types of cancers.
08:22 --> 08:24It's just that we are in the process
08:24 --> 08:26of trying to define who these
08:26 --> 08:27patients are that would benefit
08:27 --> 08:29the most from surgical therapeutics.
08:29 --> 08:32And I think you bring up a good
08:32 --> 08:34point in terms of clinical trials.
08:34 --> 08:36I mean when you talked
08:36 --> 08:38about this paradigm shift,
08:38 --> 08:42the 1st shift from essentially cancers
08:42 --> 08:44being treated surgically to then
08:44 --> 08:47the evolution of systemic therapy to
08:47 --> 08:50now adding in surgery to the mix,
08:50 --> 08:53it seems like at each junction
08:53 --> 08:56when we move the needle forward,
08:56 --> 08:59it's always on the basis of science.
08:59 --> 09:03And on the basis of clinical trials,
09:03 --> 09:07so can you talk a little bit about
09:07 --> 09:09the importance of patients
09:09 --> 09:11participating in these clinical
09:11 --> 09:14trials and perhaps some of the
09:14 --> 09:16apprehension that patients face and
09:16 --> 09:18and how you address it with them.
09:19 --> 09:21Yeah, I think
09:21 --> 09:23it's a very important question
09:23 --> 09:26and I think having gone
09:26 --> 09:29through cancer in our own family and
09:29 --> 09:31having seen it from the other side,
09:31 --> 09:34there is no question it is
09:34 --> 09:37very daunting to think about adopting a
09:37 --> 09:40treatment that seems at least
09:40 --> 09:44in sort of the common understanding
09:44 --> 09:48is being experimental and many times I
09:48 --> 09:51think there is this misunderstanding that
09:51 --> 09:52just because it's experimental,
09:52 --> 09:54that we're being treated
09:54 --> 09:56as Guinea pigs or this is not the
09:56 --> 09:58right way of thinking about things.
09:58 --> 10:00But what I will tell you,
10:00 --> 10:02and I'll tell you a small anecdote and
10:02 --> 10:04then maybe speak a little bit more
10:04 --> 10:06specifically about clinical trials,
10:06 --> 10:08but when I was a trainee,
10:08 --> 10:11when I was working as a surgical resident,
10:11 --> 10:13I took care of this young woman who had
10:13 --> 10:17a young daughter who had metastatic Melanoma.
10:17 --> 10:20And we did numerous
10:20 --> 10:21disfiguring surgeries,
10:21 --> 10:23we gave her chemotherapy,
10:23 --> 10:25and I took care of her for a couple
10:25 --> 10:28of years when I was in training and
10:28 --> 10:30she passed away right under my care.
10:30 --> 10:33It was a very sad moment for
10:33 --> 10:35all of us to see this young life
10:35 --> 10:39lost. And in 2016,
10:39 --> 10:41I met almost an identical woman
10:41 --> 10:44who also had a young child who was
10:44 --> 10:46also diagnosed at the same time,
10:46 --> 10:49who had participated in the first
10:49 --> 10:51immunotherapy trial and was alive.
10:51 --> 10:53Had presented to all of us doctors
10:53 --> 10:56at that meeting about how well she
10:56 --> 10:58had overcome her cancer, and had
11:00 --> 11:02essentially come to the other side
11:02 --> 11:05of this and and it's just a very stark
11:05 --> 11:07comparison of where sometimes our
11:07 --> 11:09conventional treatments or treatments that
11:09 --> 11:13we think work don't work as well.
11:13 --> 11:16And so I think clinical trials should be
11:16 --> 11:19thought of more as an opportunity for hope.
11:19 --> 11:24They are not always
11:24 --> 11:26the most appropriate for patients.
11:26 --> 11:28And so it is very important that you
11:28 --> 11:30speak with your treating team to make sure
11:30 --> 11:33that you're getting the right treatment.
11:33 --> 11:35But I do think it's very important
11:35 --> 11:37to keep an open mind to participate
11:37 --> 11:39in these studies because as everyone
11:39 --> 11:41knows we haven't figured out all
11:41 --> 11:43the answers to cancer.
11:43 --> 11:44We need to cure cancer.
11:44 --> 11:46It's not enough to tell a 30
11:47 --> 11:49year old or a 40 year old that you're
11:49 --> 11:50going to live five years or 10 years.
11:50 --> 11:53We have to tell patients
11:53 --> 11:54that we're going to cure this.
11:55 --> 11:57And the only way we're going to do
11:57 --> 11:58it is by advancing our science,
11:58 --> 12:01being bold and trying new treatments.
12:01 --> 12:03Cancer patients are remarkably courageous.
12:04 --> 12:06They're willing to go through
12:06 --> 12:08lots of treatments and they're willing
12:08 --> 12:10to put their bodies through lots of
12:10 --> 12:13suffering and pain if done in the right way.
12:13 --> 12:16And I think clinical trials are also
12:16 --> 12:17protections for patients to make
12:17 --> 12:20sure that these are being done in
12:20 --> 12:21scientifically rigorous and appropriate
12:21 --> 12:24ways that match the courage that they show.
12:25 --> 12:27Yeah. And I think the other point
12:27 --> 12:30that you bring up is that clinical
12:30 --> 12:32trials are not always the last resort.
12:32 --> 12:35Many patients sometimes think that
12:35 --> 12:38they can only participate in the
12:38 --> 12:41clinical trial if all else is lost.
12:41 --> 12:44But the point that I hear you making,
12:44 --> 12:46is that you know for
12:46 --> 12:48many patients clinical trials
12:48 --> 12:51actually offer the opportunity to
12:51 --> 12:53get tomorrow's therapies today,
12:53 --> 12:54the therapies
12:54 --> 12:57that we think are going to revolutionize
12:57 --> 13:00care that are going to advance the science.
13:00 --> 13:02Those are the things that we need
13:02 --> 13:04to test in clinical trials.
13:04 --> 13:06And so sometimes patients can get
13:06 --> 13:09that early on without it being
13:09 --> 13:11quote you know the last resort,
13:11 --> 13:12is that right?
13:12 --> 13:13Completely agree.
13:13 --> 13:15I think that's a very
13:15 --> 13:17important concept and I would just
13:17 --> 13:19highlight again the two very,
13:19 --> 13:20very important points you made which
13:20 --> 13:23is number one, it doesn't and should
13:23 --> 13:25not actually be the last resort.
13:25 --> 13:27It's important to consider it even
13:27 --> 13:30early on and #2 that it does allow
13:30 --> 13:33in a very safe and controlled
13:33 --> 13:35way for patients to have access
13:35 --> 13:37to therapies in the future.
13:37 --> 13:39I would say both fantastic points.
13:39 --> 13:41Well we are going to take
13:41 --> 13:43a very short break for a medical
13:43 --> 13:45minute and when we come back,
13:45 --> 13:48we'll learn more about surgical oncology
13:48 --> 13:50and its role in metastatic cancer
13:50 --> 13:52with my guest Doctor Kiran Turaga.
13:53 --> 13:55Funding for Yale Cancer Answers is
13:55 --> 13:57provided by Smilow Cancer Hospital,
13:57 --> 13:59where their survivorship clinic
13:59 --> 14:01is available to educate survivors
14:01 --> 14:02on the prevention, detection,
14:02 --> 14:04and treatment of complications
14:04 --> 14:06resulting from cancer treatment.
14:06 --> 14:10Smilowcancerhospital.org.
14:10 --> 14:12The American Cancer Society
14:12 --> 14:15estimates that nearly 150,000 people
14:15 --> 14:17in the US will be diagnosed with
14:17 --> 14:19colorectal cancer this year alone.
14:19 --> 14:21When detected early,
14:21 --> 14:22colorectal cancer is easily
14:22 --> 14:24treated and highly curable,
14:24 --> 14:26and men and women over the age of 45
14:26 --> 14:28should have regular colonoscopies
14:28 --> 14:30to screen for the disease.
14:30 --> 14:31Patients with colorectal cancer
14:31 --> 14:34have more hope than ever before,
14:34 --> 14:36thanks to increased access to advanced
14:36 --> 14:38therapies and specialized care.
14:38 --> 14:40Clinical trials are currently underway.
14:40 --> 14:42Federally designated comprehensive
14:42 --> 14:45cancer centers such as Yale Cancer
14:45 --> 14:47Center and at Smilow Cancer Hospital
14:47 --> 14:49to test innovative new treatments.
14:49 --> 14:51For colorectal cancer tumors
14:51 --> 14:53gene analysis has helped improve
14:53 --> 14:56management of colorectal cancer by
14:56 --> 14:58identifying the patients most likely
14:58 --> 15:00to benefit from chemotherapy and
15:00 --> 15:03newer targeted agents resulting in
15:03 --> 15:05more patient specific treatment.
15:05 --> 15:07More information is available
15:07 --> 15:08at yalecancercenter.org.
15:08 --> 15:10You're listening to Connecticut public radio.
15:11 --> 15:13Welcome back to Yale Cancer Answers.
15:13 --> 15:15This is doctor Anees Chagpar
15:15 --> 15:17and I'm joined tonight by my guest,
15:17 --> 15:18Doctor Kiran Turaga.
15:18 --> 15:21We're discussing the role of surgical
15:21 --> 15:23oncology in treating metastatic cancers.
15:23 --> 15:26And Kiran, before the break,
15:26 --> 15:30we were talking about the fact that
15:30 --> 15:32heretofore many people thought
15:32 --> 15:33that metastatic cancer was
15:33 --> 15:35a devastating diagnosis,
15:35 --> 15:38that this was not something
15:38 --> 15:41where surgery had a role.
15:41 --> 15:43It certainly was not
15:43 --> 15:46curable and sometimes patients even
15:46 --> 15:49believed that this was not treatable,
15:49 --> 15:54but we're really changing that paradigm.
15:54 --> 15:56Just a couple of questions.
15:56 --> 16:00You had mentioned that you have some
16:00 --> 16:03ongoing clinical trials looking at the
16:03 --> 16:06role of surgery in metastatic cancer.
16:06 --> 16:09And really expanding the indications.
16:09 --> 16:12So whereas this was originally something
16:12 --> 16:15that had been pioneered in colorectal cancer,
16:15 --> 16:18it's now being looked at in
16:18 --> 16:19more aggressive cancers.
16:19 --> 16:21One question that perhaps comes to mind
16:21 --> 16:24for some of our audience members might be,
16:24 --> 16:26does it matter where the metastasis
16:26 --> 16:29is or how many metastases there are,
16:29 --> 16:32does it make a difference if this is
16:32 --> 16:34just a couple of liver metastases
16:34 --> 16:36versus if this is widespread?
16:41 --> 16:44Yeah, I think, I think that's a good
16:44 --> 16:46question and very important to
16:46 --> 16:49clarify the we don't fully understand
16:49 --> 16:54the concept of what is oligometastasis,
16:54 --> 16:57which means what are the cancers that can
16:57 --> 16:59be treated by surgical therapeutics or
16:59 --> 17:02local treatments like radiation or ablation.
17:02 --> 17:05So until we have very good understanding
17:05 --> 17:08of that the concept of oligo,
17:08 --> 17:10oligo means few, is limited to patients
17:10 --> 17:13who have metastases in just a few
17:13 --> 17:16locations which could be like the liver,
17:16 --> 17:17the lining of the abdomen called
17:17 --> 17:19the peritoneum, the lungs,
17:19 --> 17:22occasionally the lymph nodes and rarely
17:22 --> 17:25the brain or the the spine or the bone.
17:25 --> 17:27I think when patients have widely
17:27 --> 17:29disseminated disease which means that
17:29 --> 17:30there is a large burden of cancer
17:30 --> 17:32and it spread widely to different
17:32 --> 17:33parts of the body,
17:33 --> 17:35those are much harder to treat
17:36 --> 17:37with surgical therapeutics.
17:37 --> 17:39And those patients are probably
17:39 --> 17:41most often better served with
17:41 --> 17:43either systemic chemotherapy,
17:43 --> 17:45novel therapies such as
17:45 --> 17:46those in clinical trials.
17:47 --> 17:50Which kind of brings me to my next question.
17:50 --> 17:53So we know that one of the things that
17:53 --> 17:56really revolutionized cancer care
17:56 --> 17:59was early detection, finding cancers
17:59 --> 18:02at their earliest possible stage.
18:02 --> 18:04So if it makes a difference
18:04 --> 18:06in the metastatic setting,
18:06 --> 18:08the volume of disease, are there ways
18:08 --> 18:11for us to detect that early too?
18:11 --> 18:15I mean, have we made any inroads into
18:15 --> 18:18finding distant metastatic disease?
18:18 --> 18:21Earlier, when it's perhaps more in that
18:21 --> 18:24oligo bucket than the widely disseminated
18:24 --> 18:26bucket where it's more treatable?
18:27 --> 18:30I think this is a very,
18:30 --> 18:33very exciting field for science and
18:33 --> 18:35I think a very important field for
18:35 --> 18:38patients to understand and certainly
18:38 --> 18:40ask their healthcare teams about.
18:40 --> 18:42As I'd said before,
18:42 --> 18:44metastatic cancers by definition
18:44 --> 18:46have the ability to spread.
18:47 --> 18:49And in the past, we would only know of
18:49 --> 18:52metastatic cancers once we found cancer
18:52 --> 18:54spots either during surgery or when we
18:54 --> 18:57got a CT scan or some form of imaging,
18:57 --> 18:59and that's when we would know
18:59 --> 19:01that the cancer has spread.
19:01 --> 19:04The latest advances have been in trying
19:04 --> 19:07to detect either cancer cells in the
19:07 --> 19:10blood or even fragments of their DNA
19:10 --> 19:12and now even further modifications
19:12 --> 19:15of their DNA in the blood to see
19:15 --> 19:17if we can identify cancers early.
19:17 --> 19:20And this has been a remarkable
19:20 --> 19:21finding because for instance,
19:21 --> 19:24when we think that a cancer has not spread,
19:24 --> 19:27but we find a lot of DNA in the blood
19:27 --> 19:29and it doesn't go away after surgery,
19:29 --> 19:30we know that
19:30 --> 19:32these patients will have their
19:32 --> 19:33cancers come back quickly.
19:33 --> 19:35We also know that many times when
19:35 --> 19:37cancers are not visible on scans,
19:37 --> 19:40you can actually pick up these cancers with
19:40 --> 19:43the DNA that's floating around in the blood.
19:43 --> 19:46The other very interesting thing that
19:46 --> 19:48we're also finding is that these DNA
19:48 --> 19:51technologies are able to detect what
19:51 --> 19:53we call mutations in these cancers.
19:53 --> 19:56And so it's not a perfect analogy,
19:56 --> 19:58but if you think about, say,
19:58 --> 20:00an infection and you're
20:00 --> 20:01treated with an antibiotic,
20:01 --> 20:03there's two possible outcomes.
20:03 --> 20:04One, the infection gets better and
20:04 --> 20:06it goes away and it's gone for good.
20:06 --> 20:09Or the bacteria develops
20:09 --> 20:11resistance and it starts mutating,
20:11 --> 20:13so it actually develops
20:13 --> 20:14resistance to the antibiotics.
20:14 --> 20:15In cancer,
20:15 --> 20:17what ends up happening quite often is
20:17 --> 20:19when we're treating these cancers with
20:19 --> 20:21chemotherapies or some form of treatment,
20:21 --> 20:23the cancer appears to shrink
20:23 --> 20:24or appears to get better.
20:24 --> 20:26But then after you stop the
20:26 --> 20:28chemotherapy or take a little break,
20:28 --> 20:30the cancer tends to come back or recur.
20:30 --> 20:32What these technologies are helping
20:32 --> 20:34us do is actually find out the
20:34 --> 20:36clones of these cancer cells that
20:36 --> 20:38are changing and also allowing
20:38 --> 20:40physicians to start thinking about
20:40 --> 20:42how can we be much more personalized,
20:42 --> 20:44how can we be much more
20:44 --> 20:45directed towards the cancer.
20:45 --> 20:48So that we're treating it before it
20:48 --> 20:50develops resistance to our chemotherapy.
20:50 --> 20:51So it's a very,
20:51 --> 20:52very exciting field.
20:52 --> 20:53There's numerous different technologies
20:53 --> 20:56that are involved and we're utilizing
20:56 --> 20:58some of these technologies to
20:58 --> 21:00actually make decisions for patients
21:00 --> 21:02that undergo cancer surgery,
21:02 --> 21:04especially for oligometastatic disease.
21:05 --> 21:08So a few questions on that one is
21:08 --> 21:10it certainly does sound really exciting
21:10 --> 21:14and many patients may be wondering
21:14 --> 21:17is this something that is widespread.
21:17 --> 21:20So, first and foremost this
21:20 --> 21:21is incredible technology,
21:21 --> 21:23but the basis of this technology
21:23 --> 21:25which occurred with lots of scientific
21:25 --> 21:27revolutions that happened in the
21:27 --> 21:30early 2000s and lots of patients who
21:30 --> 21:32participated on trials has allowed
21:32 --> 21:34this to become quite widespread.
21:34 --> 21:35So in fact
21:35 --> 21:37these are technologies through
21:37 --> 21:39companies where patients can get
21:39 --> 21:41these labs drawn at their own homes.
21:41 --> 21:42They don't even have to come to
21:42 --> 21:43a large academic Medical Center.
21:43 --> 21:46And these DNA technologies
21:46 --> 21:49can be used to identify the DNA in
21:49 --> 21:51in patients in every cancer that's
21:51 --> 21:54being tested in clinical trials.
21:54 --> 21:57So far most of the studies are positive,
21:57 --> 21:59which means they're informing doctors
21:59 --> 22:02and patients about their cancer
22:02 --> 22:04and cancer characteristics that are
22:04 --> 22:06actually helping make very good decisions.
22:06 --> 22:07So for instance,
22:07 --> 22:09a lot of patients who have treatable
22:09 --> 22:10colon cancer have their cancers
22:10 --> 22:12removed and then they're given a
22:12 --> 22:14standard prescription of chemotherapy,
22:14 --> 22:15which they can get from many months
22:15 --> 22:17and it can cause debilitating
22:17 --> 22:18symptoms and side effects.
22:18 --> 22:20And now using CT DNA,
22:20 --> 22:22you can actually define the patient
22:22 --> 22:24population for who longer courses
22:24 --> 22:26of chemotherapy is important and
22:26 --> 22:28those that can actually do OK
22:28 --> 22:30with shorter chemotherapy,
22:30 --> 22:31so they can get back to their lives
22:31 --> 22:33better and live a longer life.
22:33 --> 22:35So I would say it's a remarkable technology.
22:35 --> 22:37It has slowly become a little bit more
22:37 --> 22:38mainstream,
22:38 --> 22:42but it isn't completely supported by what
22:42 --> 22:44we call level one evidence in all cancers.
22:44 --> 22:46So it's not something that
22:46 --> 22:48is well supported yet.
22:48 --> 22:50I suspect it will be with regards to
22:50 --> 22:52insurance coverage for this right now.
22:52 --> 22:53Fortunately,
22:53 --> 22:55because these are newer technologies
22:55 --> 22:59and there is a lot of interest and
22:59 --> 23:01investment in these technologies,
23:01 --> 23:05many times these technologies are either
23:05 --> 23:08covered by the insurance company
23:08 --> 23:09or they're covered by the company
23:09 --> 23:11that actually runs the test.
23:11 --> 23:14So far the patient portion of
23:14 --> 23:17the expenditure has been minimal.
23:17 --> 23:20However, just like everything else,
23:20 --> 23:22things are expensive and we just
23:22 --> 23:24have to be careful and good stewards
23:24 --> 23:26of the resources that we have.
23:26 --> 23:28The other question that comes to mind
23:28 --> 23:31is you think about the role of CT DNA
23:31 --> 23:33is whether it has a role in screening.
23:33 --> 23:36I mean when you talk about
23:36 --> 23:38CT DNA being able to detect
23:38 --> 23:41cancers before they become evident on
23:41 --> 23:44imaging in the metastatic setting
23:44 --> 23:46one may imagine that this may play
23:46 --> 23:49a role in screening populations
23:49 --> 23:52instead of imaging.
23:52 --> 23:56Do you see that as a potential
23:56 --> 23:59application of CT DNA or is that
23:59 --> 24:02a little bit too far fetched?
24:02 --> 24:05You know, growing up I watched
24:05 --> 24:07Star Trek and it's always
24:07 --> 24:09remarkable when you have a device
24:09 --> 24:12and you can run it over a patient's
24:12 --> 24:14body and you can find all their diseases
24:14 --> 24:16and illnesses and potentially treat it.
24:16 --> 24:18It's always very appealing to think
24:18 --> 24:20of this concept of what we call
24:20 --> 24:22non invasive or minimally invasive
24:22 --> 24:23ways of identifying cancers.
24:23 --> 24:26And you're spot on in saying that the
24:26 --> 24:28the true potential of these treatments
24:28 --> 24:31of these technologies would
24:31 --> 24:34be for us to identify cancers at
24:34 --> 24:36very early stage or even identify
24:36 --> 24:38what we call precancerous lesions,
24:38 --> 24:40so before they become cancerous.
24:40 --> 24:42And identify it in the blood.
24:42 --> 24:45So there's several technologies that are
24:45 --> 24:48being evaluated in this setting and one
24:48 --> 24:50of these technologies actually uses stool.
24:50 --> 24:52So you test this stool to see if
24:52 --> 24:54there's cancer in the colon and
24:54 --> 24:56that's one way of looking at it.
24:56 --> 24:58We have worked with the chemist at
24:58 --> 25:00the University of Chicago and we
25:00 --> 25:02have a test where we can kind of
25:02 --> 25:04look at patients and look at their
25:04 --> 25:08blood and find polyps in the colon,
25:08 --> 25:10but they're not 100% sensitive.
25:11 --> 25:13And so from a population standpoint,
25:13 --> 25:16they're not ready for prime time
25:16 --> 25:18yet because they're expensive and
25:18 --> 25:21they're big tests and they still
25:21 --> 25:23don't give you the results and the
25:23 --> 25:25safety that you want when you have
25:25 --> 25:27these sort of liquid biopsy tests.
25:27 --> 25:29But I wouldn't be surprised
25:29 --> 25:31if in five or ten years,
25:31 --> 25:33just like when you go to your
25:33 --> 25:35doctor and check your cholesterol
25:35 --> 25:37levels or or other health tests,
25:37 --> 25:39you could get a liquid biopsy
25:39 --> 25:40test that would
25:41 --> 25:43either predict cancer risk or would
25:43 --> 25:45predict precancerous lesions and
25:45 --> 25:48then of course if there is cancer,
25:48 --> 25:49detect cancer as well.
25:49 --> 25:50So I suspect it will come
25:50 --> 25:52in the next 5 to 10 years,
25:52 --> 25:53but it's not prime time yet.
25:55 --> 25:57Do you think that there's
25:57 --> 26:00a role in terms of CT DNA for
26:00 --> 26:02identifying the site of the cancer?
26:02 --> 26:05So is it that the CT DNA simply says
26:05 --> 26:08there is cancer or risk of cancer
26:08 --> 26:11somewhere in which case without really
26:11 --> 26:13knowing much more about the cancer
26:13 --> 26:16might only lead to patient anxiety?
26:16 --> 26:19Or do you think that we would be
26:19 --> 26:21able to be more specific so that
26:21 --> 26:24you know we would have targetable
26:24 --> 26:27mutations that we could treat
26:27 --> 26:30and know the site of origin
26:30 --> 26:33so that we could develop imaging
26:33 --> 26:35modalities that could pinpoint where
26:35 --> 26:38exactly that malignancy is before
26:38 --> 26:40it becomes widely disseminated?
26:41 --> 26:43Other fantastic question and I think
26:43 --> 26:45just for for the sake of the listeners,
26:45 --> 26:48I just wanted to make make sure that I
26:48 --> 26:51elaborate on one point which is that,
26:51 --> 26:52first and foremost,
26:52 --> 26:54all of us have some amount of DNA
26:54 --> 26:56that's floating around in our blood
26:56 --> 26:58and that's from cells dividing,
26:58 --> 26:59cells breaking down.
26:59 --> 27:02And so there's always DNA that's
27:02 --> 27:03floating around in our blood.
27:03 --> 27:06That DNA is called cell free DNA,
27:06 --> 27:09which means it's DNA that's outside of cells,
27:09 --> 27:10it's from dead cells and it's
27:10 --> 27:11just kind of
27:11 --> 27:13in in the bloodstream that doesn't
27:13 --> 27:15necessarily mean it's cancerous DNA,
27:15 --> 27:18but it means that there is DNA.
27:19 --> 27:21There is another concept course circulating
27:21 --> 27:23tumor DNA which we call CT DNA,
27:23 --> 27:25which is where you clearly have a
27:25 --> 27:27cancer and it's the cancer that's
27:27 --> 27:29producing this sort of DNA that's kind
27:29 --> 27:31of floating around in the blood that
27:31 --> 27:33you then identify and call it that.
27:33 --> 27:35So you know in the question of where
27:35 --> 27:37sometimes when you have these cancers
27:37 --> 27:39which we call unknown primary,
27:39 --> 27:41which means you don't really know
27:41 --> 27:43where the cancer is or you don't know
27:43 --> 27:44where the site of the location is,
27:44 --> 27:45CT DNA,
27:45 --> 27:47which is the circulating free DNA,
27:47 --> 27:50can actually identify those cancers.
27:50 --> 27:53And in fact there's a lot of interest
27:53 --> 27:55right now in using what we call
27:55 --> 27:57epigenetic changes as well as tumor
27:57 --> 28:00mutations to identify the site of disease.
28:00 --> 28:03And clearly I know of at least three
28:03 --> 28:05technologies that are very close to
28:05 --> 28:08either getting FDA approval or in the
28:08 --> 28:10process of for use in cancers of unknown origin.
28:11 --> 28:14So I think it's a very exciting
28:14 --> 28:15space.
28:15 --> 28:15Again,
28:15 --> 28:18I would say right now it it can be
28:18 --> 28:21used by doctors such as oncologists
28:21 --> 28:24in sort of very clearly prescribed
28:24 --> 28:25settings to identify these,
28:25 --> 28:28but I would say not quite ready
28:28 --> 28:29for prime time widespread.
28:30 --> 28:32Doctor Kiran Turaga is chief of
28:32 --> 28:34surgical oncology and assistant medical
28:34 --> 28:36director of the Clinical Trials Office
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

The Role of Surgical Oncology in Treating Metastatic Cancers with guest Dr. Kiran Turaga December 11, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095