Integrating Rheumatology Into Cancer Immunotherapy Care

Alexa Simon Meara, MD, an associate professor in the Division of Oncology at The Ohio State University Wexner Medical Center James Cancer Center, discusses the importance of including a rheumatology approach to immunotherapy treatment for cancer.

Transcription:

0:10 | Immunotherapy has changed the landscape to make cancer more [of a] chronic disease, which is great, right? It disrupts the immune system in specific targeted checkpoints to upregulate the immune system to allow T cells to attack the cancer. But when you dysregulate the immune system, you open the door to autoimmune disease.

0:42 | I am going to pause for one second because I think this is an important point of what we do not understand about autoimmune diseases in general. In lupus, rheumatoid arthritis, we do not know what causes those diseases to begin with. What we tell people is it is the right genetic host with the right environmental stimulus. That is why we ask about family histories and different things. But not everyone in the same family will have the same autoimmune disease.

1:19 | So now that a patient has cancer, they already have an up and up immune system, because there is a foreign body they are trying to attack. Now we are trying to heighten that immune system to attack the cancer by turning off certain regulatory checkpoints, getting the immune system to rise. Therefore, you now have an open door to an unregulated immune system. So, what is that second hit? What is that environmental stimulus? We have no idea. But then that opens the door to a wide variety of autoimmune diseases that can happen in any organ at any time.

1:53 | I think this idea that somehow, we can predict [autoimmune diseases], we have not been able to do that in rheumatology ever, and we have a whole specialty related to that. Oncologists are so good at trying to be predictive, and it is interesting to take a black-and-white world, and we are marrying it with a very gray world. It is like the yin and the yang of it; it is still figuring itself out in that kind of sense. It is like we are still trying to feel each other out the beginning of the marriage; we are trying to figure out how to load a dishwasher without fighting.

2:38 | I think even immune-related adverse effects or the toxicity of immunotherapy is a wrong name. We have already had them for 15 years, and we have had all this research with this, so I do not want to change the name, but it is not an event. It is actually a new disease, a new sequela. Some are one and done. Some are one and done over a year. Some happen a year to 2 years after [the patient has] already had the drug. Some may be chronic, and we are with the patient for the rest of their life. Because we do not quite understand how to predict them, we are not quite there on diagnosis because it is a brand-new disease. We do not quite understand pathophysiology.

3:21 | We do not have a lot of clinical trials, and medicine already is so siloed in the sense of who should be taking care of these patients. I would argue, and I know my bias group as a rheumatologist, that oncologists are good at treating cancer. There is a reason why there is a subspecialist in treating autoimmune disease. This is not a turf war. This is an opportunity to take care of [patients with] cancer and a new thinking about survivorship.