Transcription:

Scott Webb: Welcome to Aspirus Health Talk. I'm your host, Scott Webb. And there've been many advancements in the diagnosis and treatment of cancer in the past few years including CAR T-cell therapy immunotherapy. And joining me today to discuss the advancements and the importance of accuracy in cancer and staging diagnosis is Dr. Divis Khaira. She's a hematologist-oncologist in the Aspirus Health System.

So doctor, thanks so much for your time today, we're talking about cancer and cancer diagnosis and why it's so important that cancer and staging be diagnosed accurately. So let's start here, why is it so important that cancers are diagnosed accurately?

Dr. Divis Khaira: It's important to diagnose cancer accurately, because you have to design the treatment for that particular kind of cancer. These days, the cancers are going into more personalized treatment, especially with what we call molecular targets. It's very important to get the right diagnosis upfront so you can give the right treatment.

Scott Webb: Yeah, I think you're so right. And it does seem like, you know, in the past that it was a sort of a one-size-fits-all for this cancer or that cancer. But as you say, things have changed and for the better both probably for doctors and for patients. Let's go through and talk about stages and staging. What are cancer stages and why is staging so important in determining the best treatment for patients?

Dr. Divis Khaira: Staging is important because it tells us how much or what kind of treatment. Especially in the earlier stage, we often want to do surgery for some of the cancers, or we can just get away with radiation. And in the latest stages, we often have to give chemotherapy. So stage 0 indicates that the cancer hasn't spread. It's kind of where it started. Stage I is when the cancer is small and hasn't spread anywhere else. Stage II, mainly the cancer has grown, but still hasn't spread. So you're looking at maybe a pea size versus something that's now the size of an orange or almond. Stage III, it's larger and it may have gone to the surrounding tissues and the lymph nodes. And stage IV, which is what nobody wants to hear is when it's gone to other areas in the body, away from the primary cancer.

Different cancers have different treatments. For example, in a stage 0 or I or II in a lung, you can do surgery. But in stage III, you may want to give some chemotherapy, shrink it down, and then do surgery. And stage IV, generally, it means surgery is not an option.

Accuracy is important. We usually depend on multiple team members to help us come to the conclusion as to whether it's an early stage or a stage IV. For example, you could get a PET scan and it could look like it's a stage IV because it's picking up in several areas. But then once you sort it out, it may end up being a lower stage than originally thought of. To get the right treatment then is very important.

Scott Webb: Yeah, it definitely is. And it's good to know that you and your team there at Aspirus, you work together, you know, to reach a consensus, to make sure that the staging is correct. Because as you're saying, it's so critical to the treatment and the treatment plans to make sure that the staging is right. And when we come back now to diagnosis of cancers, you as an oncologist and hematologist, I know this is a fairly broad question, but how is cancer diagnosed?

Dr. Divis Khaira: Well, I think for the most part, the cancer is usually diagnosed by the primary care physician who has worked up certain abnormal things that are seen. For example, lab tests may indicate something abnormal in the blood like liver function tests that are high and then a follow-up scan might then indicate a cancer in the liver. And if it's in the liver, is it a primary liver cancer or has it come from somewhere else?

The next step after the history, which maybe somebody might come with bloating or weight loss or vomiting or nausea, blood in the stool, the next step is to do these lab tests and get a series of imaging studies with their CAT scans or MRI. And then if you find something, the next step would be to get a biopsy. The biopsy is often with a needle. It may be that you might need to have some surgery to get the biopsy. But usually if it's in a place where it's not dangerously close during an artery or other vital organ like the heart, usually it can just be biopsied with a radiological procedure.

And then the next team members, the pathologist who then looks at it under the microscope and tries to make a determination as to what kind of cancer it is. And sometimes people don't understand that you can have a lung cancer that's gone to the liver, but it's still a lung cancer in the liver. And I tell patients it's like an immigrant, you may come from a different country and go and live in LA, but your original ethnicity is still there, because people get confused. If it's in the bone, they think it's bone cancer; if it's liver, they think it's liver cancer, but it may just have traveled from elsewhere.

And then, you know, there's always the screening tests. Women getting mammograms. Forty-five to fifty-four, they get mammograms every year. Fifty-five and older, you know, every two years. And so you can pick up an early cancer. Same for colon cancer screening, usually start at age 45. And same with PSA and same with cervical cancer.

These days, we're finding cancer earlier and earlier because we're looking for them. And people get surprised and often they get angry, because they say, "I don't feel anything. I don't feel any pain. Why do you say I have cancer? I couldn't have it."

Lot of things go into a diagnosis and we're getting better and better at diagnosing cancer and maybe even treating it. And I think in about five years, they're working on doing blood tests to screen for a bunch of different cancers. So that's coming down the pike, but not there as yet. The Cleveland Clinic has had a prototype and detection was about 60% in about 12 cancer types, but it's not ready for prime time as yet.

Scott Webb: And doctor, as we think about cancer treatment in the future. It almost seems in a way that some treatments are already here, that the future is now. It's upon us already. And one that I'm wondering if you could speak about is CAR T-cell immunotherapy, which sounds like science fiction to me, but I'm wondering if you can explain what that is to listeners.

Dr. Divis Khaira: Yes, I actually did a lot of work in CAR T-cell. And that's coming of age and it's the type of immunotherapy called adoptive cell therapy and they extract the T-cells and hype them up to becoming a type of heat-seeking missile. And those cells produce chemicals that kill cancer. See, what happens is when you have a cancer cell, it's like those Harry Potter wizards, it puts a cloak around itself, so the cancer treatments may not be able to see those things in the body. But the CAR T-cell and some of the newer treatments go and uncover the cloak, so then the treatment can go in and target the invader and kill them.

And that's what's so interesting about treatment now. It's mostly like Star Wars. And CAR T treatment is very good for certain kinds of cancer. It's used in multiple myeloma. It's also used in non-Hodgkin's lymphoma and childhood acute leukemia, lymphoblastic leukemia. It's associated with a lot of side effects to begin with, something called cytokine release, where your body goes through this process, where there's a big fight in there, you get fever, you get heart rate that's increased, you can get neurological problems. And on top of that, it was taking a little while to get those CAR Ts manufactured. But the drug companies have streamlined that. And I think they are going to be able to give it in the clinics down the line, not this year, maybe not next year, but we're kind of at the crossroads where it will become more mainstream treatment outpatient, which is what's important. Right now, it's inpatient treatment at some of the big centers. They don't do it at all in the hospitals. I think the main thing about the CAR T cells also is neurological problems, but they're working to get that fixed. So down the line, I think it will be a very good treatment that's available for more people.

Scott Webb: Yeah, I think you're right. And from a patient's perspective, you know, as they prepare for different tests or procedures, especially after they've been diagnosed, what would your recommendations be?

Dr. Divis Khaira: I think that this is all evolving so fast and we'll get recommendations for one thing. And then, two months later, it's changed or the FDA is fast-tracking a lot of things. And, for example, recently I had a situation where FDA fast-tracked a treatment in April and then retracted it in July and then agreed to the treatment, you know, with some of the chemotherapy in August. And that can leave patients upset and confused.

Having said that, there's a lot of good stuff. I think this is the fastest and the most that we've seen things come down the pike in years and years of cancer care. Just a lot out there. It's kind of like a blizzard, but things will settle down and we'll get more information at times goes down. But I think one of the things for patients to understand is the recommendations change so fast. And so there's always something around the corner.

Scott Webb: Yeah. There definitely is. And it's got to be difficult. And, you know, doctors, nurses, patients. Doctor, as we wrap up, and this has been really educational today. As we wrap up, what would be your takeaways when it comes to cancer diagnosis, cancer treatment, and where the patients kind of fit into all of this?

Dr. Divis Khaira: I think that the treatments are moving very rapidly. We're going into a new era of immunotherapy for a lot of treatments. There's a lot of data being collected. There's going to be a lot of changes. I think also for patients when they're being diagnosed right now, some of the studies for the molecular targets take two to three weeks, so be patient. Patients get upset and stressed out because they're not treated immediately. But sometimes waiting to see if you have a target that can be treated specifically with a drug is very important for long-term and longevity. It's not like the old days that you got a diagnosis and you wanted to be treated in three, four days. These days, some of those tests and studies take longer, but there's something for everybody coming up the pike.

Scott Webb: Yeah, it sounds that way. And I really appreciate your time today. You have a great way with analogies. We dropped in Star Wars and Harry Potter. And a really educational podcast and I'm sure that listeners would agree. So doctor, thanks so much for your time today and you stay well.

Dr. Divis Khaira: Thank you for having me.

Scott Webb: And thank you for listening to Aspirus Health Talk. For more information, visit aspirus.org. And please remember to subscribe, rate and review this podcast and all the other Aspirus podcasts. For more health tips and updates, follow us on your social channels. I'm Scott Webb. Stay well.