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Episode #8 - Immunotherapy 103

Steve:

Hello everyone. And welcome back to Episode 8 of our Medical Minute podcast series. We're coming to you once again from our new office space in beautiful downtown Norwood, where we're still under renovation. We don't have our Christmas tree up yet, but as you can see, that's okay, because Jill's dressed like a Christmas tree today and she's got me dressed up like a Scotch tape logo. So anyway, we're going to go back to where we left off on immunotherapy last week. We, unfortunately, had to kind of close out before we could really differentiate the different types of therapy. So, today we'll talk about immune modulators, immune checkpoint inhibitors, and cell therapy. So, why don't we start off with immune modulators and immune checkpoint inhibitors?


Jill:

We touched on last week, the checkpoint inhibitors and because of drugs like Yervoy and Opdivo and Keytruda, some of the others like Tecentriq and Bavencio and Libtayo, people are hearing more and more about this because they're seeing the advertisements come across their computer screens and their TV screens. But what people don't realize is that immunotherapy is not a new term or a new treatment option in cancer treatment.


Steve:

Okay.


Jill:

So, you had mentioned immune modulators, which are drugs that have been around for a very long time, and medications like Interferon and Interleukin, which essentially stimulate the immune system. So, a good way to paint a picture, if you imagine a fire that you throw gasoline on and you get that burst, that is what these types of drugs do to the immune system, versus the checkpoint inhibitors, which are kind of all the new rage that everybody is talking about. These drugs actually have recently just been approved. The first checkpoint inhibitor was approved back in 2011 and these drugs essentially are taking the brakes off the immune system. So, as we're talking today, all of the treatment options that we're talking about, they all work with the immune system, they just work it a little bit different.


Steve:

Okay. So in this context, the word modulator is that meaning that it's modifying the action or modifying something that the immune system's doing?


Jill:

So, yes. So, these drugs either stimulate or they suppress the effects of the immune system.


Steve:

Okay. Interesting. Okay. So, let's talk about... And you'll remember last week where I kind of got cell therapies confused with what you just talked about. So let's talk about cell therapies now.


Jill:

Okay. So, cell therapies are where we are taking our own immune cells and we're boosting them in numbers. And so most of the time it's the T-cell that's being used with these therapies and they are being taken and then boosted into large quantities, usually in a lab. And so, what I want you to think about is if you've ever seen the movie, The Santa Claus 3-


Steve:

Oh boy, here we go.


Jill:

So, in The Santa Claus 3, the bad Santa, he actually takes the nutcrackers and he puts them through a machine and it essentially cranks out a bunch of those nutcrackers and he uses those as his army. So, what cell therapy is doing is it's taking your T-cells and you're making large quantities of them and giving them back to the person to fight their cancer.


Steve:

Okay. It's probably going to shock you, but I have not seen Santa Claus 3, or 2, or 1, and a whole lot of other Christmas movies that my wife has seen. So, probably a huge surprise. So, before you completely hijack Christmas to use them as analogies for cancer, why don't you take us through a little bit about... You've talked to me about this before, and so has Dr. Leming. TIL therapy and CAR T-cell therapy.


Jill:

Okay. So, TIL therapy is... What TIL stands for is T- infiltrating lymphocyte. And to kind of break it down as basic as I possibly can, what happens is when a person has a cancerous tumor, they remove that cancerous tumor and inside the tumor, they extract the T-cells that have already gotten in and started attacking the cancer.


Steve:

Okay.


Jill:

So essentially, those T-cells are already programmed to do what they need to do. And so they remove those, and then they start to replicate them in mass quantities inside a lab. And then it's actually pretty crazy and almost uneventful. When they give them back, it drips in just almost similar to a blood transfusion. It drips in through the tubing, and the patient just sits there and receives it.


Jill:

And then with CAR T-cell therapy, this is a little bit different because the doctors add a special receptor to the surface of the T-cell, and it essentially turns your T-cell into these super cancer-fighting machines. So, it's kind of like equipping your T-cell with a high-powered assault rifle. And so currently, CAR T is actually FDA approved. It's FDA approved for ALL, which is an acute or a rapid form of leukemia. And then also some of the non-Hodgkin's lymphomas. So, both of these cell therapies, different from some of the others that we've already talked about, these have to be given in the hospital setting just because of some of the side effects and toxicities that can occur.


Steve:

Okay. Well, and I think we all heard examples of where that can go a little bit bad, but when it goes well, I mean, it can be curative. I mean, it can be pretty powerful therapy, right?


Jill:

Absolutely. So with TIL cell therapy, patients will have a response rate. So they'll see a shrinkage in their cancer of 50% or greater.


Steve:

Wow.


Jill:

And when you look at long, durable remissions, it's greater than 20%.


Steve:

Wow. Okay.


Jill:

And then when you're looking at CAR T therapy, those patients, you're looking at 30 to 40% of patients have a long-lasting remission.


Steve:

Okay. So, one more thing to talk about, and I'm kind of aware of vaccines being used because Provenge is used in the prostate cancer setting.


Jill:

Correct.


Steve:

So, I know about that one and I knew there were a couple more. I've never heard talk until we started talking about virus being used, or... Can you explain how that works?


Jill:

Yeah. So what they're doing is they're manufacturing and altering these viruses essentially to infect and kill the cancer. One of the oncolytic viruses that is actually currently FDA approved is called T-VEC or Imlygic, and it's used in the metastatic melanoma setting. The cool thing about this treatment is that it's actually injected directly into the tumor. So, because of that, patients have to have... you to be able to palpate lumps or bumps of the cancer to be able to inject into this. And then in regards to the cancer vaccine, you had talked about Provenge, that is one that's used to treat prostate cancer. T-VEC actually also falls into the vaccine category. And then one of our older vaccines that's been used for quite some time is BCG, which is used in early stages of bladder cancer.


Steve:

Okay. Okay. Well, I think we'll go ahead and start to wrap up for today. We'll come back to immunotherapy at some point because it's just too important not to. And I think maybe when we do, I say that maybe what we do is we talk about the... Take Provenge as an example, the extreme cost of that-


Jill:

Yes.


Steve:

... and kind of compare that to the extension of life and quality of life, thing like that. But I think that's a topic for another day. So, we will be back next week. I don't know what we're going to be talking about yet. If we don't have time to throw something together, Jill can always read to us The Night Before Christmas or some silliness like that. But either way, we'll have a topic and we'll look forward seeing you here next Wednesday at noon. Take care, everybody.


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