Episode 1: Introduction to Blood Cancer with Dr. Jared Kobulnicky
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Welcome to Cancer Care Connections. On this week’s episode, Cheryl Tan spoke with Dr. Jared Kobulnicky, hematologist oncologist for Virginia Oncology Associates. Cheryl and Dr. Kobulnicky dove into what blood cancer is and the latest developments in treatment for patients with a blood cancer disorder.
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Cheryl Tan:
Our guest today is Dr. Jared Kobulnicky. He has been providing cancer care for Virginia Oncology Associates since 2019. He earned his medical degree from the Medical College of Virginia. Dr. Kobulnicky, also known as Dr. K, has been voted a Coastal Virginia magazine top doc by his peers in both 2021 and 2022. He's a strong proponent of cancer research as well as patient-centered care.
He is a hematologist oncologist who takes care of patients with a variety of cancers to include blood cancers such as myeloma, lymphoma, and leukemia. In his free time, he enjoys spending time with his family, cycling, and gardening. Dr. K, it's so good to talk with you today.
Dr. K:
Cheryl, Thank you for having me on. I'm really excited to be talking with you guys today about blood cancer.
It's something that I really enjoy talking about and also educating my patients on. It's something that a lot of patients and family members don't know a whole lot about. It's kind of ethereal. May not be something they have a whole lot of personal experience about. So I think that you know, talking with patients has a big role to play in blood cancer.
Cheryl:
I think patients want to understand and the families of patients as well. I want to go back, though, and hear more about how you got this passion for treating blood cancers and helping patients in general. How did you get your start in medicine? Why why did you decide to do that?
Dr. K:
Well, I think, you know, as everyone's going through their medical training, they're trying on different hats, so to speak.
One of the things that I always liked about hematology, and this is also something that I think that has allowed our field to advance quickly, is the fact that you can look at blood under the microscope, you can study blood easily. And so one of the primary jobs of a hematologist is to analyze the blood of the patient they're seeing.
And we call that a peripheral smear. And, you know, many other doctors do not have that privilege or that ability to study the problem in the way that a hematologist does. And I think that's why we've been so successful at advancing new treatments and at something that I enjoy because it is a physical test that accompanies the relationship of an oncologist.
One of the things that, you know, drives a lot of people into cancer care is the fact that you get to have continuing ongoing relationships with people. You're not, you know, fixing a problem and moving on. You're building kind of lifelong relationships with people. And that's something that I think, you know, also drives people into oncology. So, really a mixture of I enjoyed the science, I enjoyed the art and practice of hematology, and I also liked having those relationships with people.
Cheryl
I love that. And so I can imagine you as a maybe as a young boy interested in the science and maybe getting scrapes and bruises and thinking about the blood and the cleanup that as a result.
Dr. K:
That might be a little bit too far of a story. I think it probably is something that happened later in life. But, you know, I think, you know, when I was a kid, I wanted to play football and, you know, and do those kinds of things. And so why I would like to say that, you know, from age five, I knew I wanted to be a hematologist, I just don't think that would be an honest story to tell you, Cheryl.
Cheryl:
What brought you to Virginia Oncology Associates?
Dr. K:
Well, a couple of things. You know, some of these things are just practical things in life. I have family here. You know, both my father and my in-laws are retired military and they live here in the area. And it was important for me, for my kids to, you know, be close to their grandparents. I wanted that experience for them.
The other thing is that I thought this was a great practice. We're doing a lot of dynamic things here. You know, we're a major provider of cancer care here in Hampton Roads. I think the largest provider of cancer care here in Hampton Roads. And I think we're doing a great job. One of the things that we're really excelling in is our research platform in that we have a number of clinical trials to offer patients throughout a variety of cancers, not only lymphoma and myeloma and certain leukemias but also other cancers that patients may be more familiar with, such as breast and colon and prostate cancer.
And so I thought that this was a dynamic place here where I could have a great career. And, and that's proving to be true.
Cheryl
That's wonderful. And congratulations on the Top Doc award that you received. It's wonderful, so short after you arrived here to be recognized by your peers.
Dr. K
I appreciate that. I mean, truthfully. Most of that's not me. Most that's just the position my practice put me in, to be successful. And I appreciate them for that.
Cheryl
Well, let's dive into some of the research that you're talking about, some of the research you yourself have done, and the focus, of course, being on blood cancers. So can you can you just really simply explain what that is?
Dr. K
Well, I think the easiest place to start is talking about like what is blood cancer? And that's a really kind of ethereal and confusing thing for a lot of patients because they you know, they know what the lung is and they know what their, you know, colon and their breast are because, you know, they can see those and imagine them. But blood is less tangible in your blood system's made up of your lymph nodes, the red blood that you know everyone's familiar that courses throughout your body, your bone marrow, where the blood is produced, which is inside the bones, as well as your spleen, which filters their blood. And so blood cancers are cancers that originate from the bone marrow, the lymph nodes, the regular blood in the spleen.
And we kind of fit them into different categories that help us understand things. These categories aren't perfect, but they help us organize the field and describe things so we can treat similar patients similarly. And, you know, in general, we call cancers that originate in the blood leukemia and cancers that originate within the lymph node portion of the blood system lymphoma.
There's some other disorders out there as well, you know, called Milo dysplasia and Milo proliferative problems that also have to do with origination in the blood, but don't neatly fit within either of those two categories of leukemia and lymphoma.
Cheryl:
Yeah.
Dr. K:
And so, you know, one of the first things that I do with the patient is just kind of make sure they really understand that it's a blood cancer and how does it fit in relation to other things they may have heard because it's easy to get confused.
Cheryl:
Yeah, no, I want to hear all about that. So how common are these blood cancers versus the other types of cancers that you see patients in at Virginia Oncology Associates?
Dr. K:
So blood cancers are moderately common. It is something that a hematologist oncologist will see with some regularity, but they are not as common as breast cancer, prostate cancer, lung cancer, colon cancer, and skin cancer.
They are not as common. And so a lot of patients just have never met anybody that has blood cancer. But I guarantee you, when you walk in around the grocery store, you know, or at church or wherever, you kind of hang out, that there are people around you that have these problems and you just may not know about it because they're not as common, but they're also not rare. And so neither as common nor as rare as you might think.
Sorry Cheryl, that last line is a bit of a mouthful there, but...
Cheryl:
No. Well, no, I mean, it actually makes quite a bit of sense. Right. It's one of those things that even though you might not have a close friend or friends who have had to deal with this, it's something that is maybe in your church group or relatives or friends of relatives. And it's certainly people, you know, maybe second or third.
Dr. K:
Absolutely. And most of our patients are, they themselves or have family members diagnosed with a blood cancer, sometimes they're kind of caught off guard because they just never heard about it, thought about it, and it kind of catches them by surprise in a way that another cancer that's more common might not have.
Cheryl:
So when you think about cancers, I think people like to think about treatment. And I know that research is really something that you focus on in your practice. But what are some of the major types of treatment for leukemia and lymphoma, for these types of cancers?
Dr. K:
So medical treatment is the mainstay of all blood cancer treatment. And one of the first things I focus on explaining to a patient is your blood is everywhere. And so you can't cut your blood out and you can't use x-ray treatments called radiation because blood is everywhere. Right? And then I think most patients, you know, have kind of an aha moment that, yeah, now you need to use some type of treatment that goes everywhere that the blood is. And that's a medicine. Right. Because medicines, you know, come into your body and of course throughout your body.
And so medicines are the mainstay of treatment for all blood cancers. Now that's a really vague term. What do I mean by medicines? That can take the form of chemotherapy, which has been, you know, used ever since, you know, World War Two, basically for the treatment of blood cancer, Immunotherapy, which is designed to use the immune system to control cancer, and there's a lot of different subtypes there. And we should delve into that a little bit because I think there are some interesting things our patients want to hear about that.
Cheryl:
Yeah.
Dr. K:
Targeted therapy, which involves medicines that are very specifically engineered for the problem and avoid some of the general problems that chemotherapy therapy can have. And so those are the three main categories.
And so one of the jobs your doctor has to figure out is where is the state of science and practice in medicine in relationship to your diagnosis and what affords you the best ability for success, as well as the minimum amount of side effects. And that's a highly personalized conversation. You know, one of the things I tell patients is that there are three things that you want to know when you have cancer.
Once you know these three things, making decisions and coming up with a plan is easy. You want to know the diagnosis, you want to know the extent of the problem, doctors call that stage, and you want to know what's going on with the patient; who they are, what kind of medical problems they have, what's important to them, what do they think about these treatments.
And once you and your doctor get to know those three things, making decisions on what to do is easy.
Cheryl:
That's so clear. I mean, that was really, really good to help put into perspective when someone is to get a diagnosis like this, it feels and I can only imagine what it feels like, it feels like an end. But here you have a plan, a diagnosis, figure out the extent of the problem, and figure out what's going on with the patient. It's a very clear way to kind of take a look at what you do with that information. So I want to focus, as you had mentioned, on these two types of treatment, the immunotherapy and the targeted therapy, because those are two topics that I know get a lot of... I know you get a lot of questions about it. So let's...
Dr. K:
Absolutely.
Cheryl:
Yeah, let's start with immunotherapy and kind of the latest with that and what people should take away from that.
Dr. K:
In the last five years, there's been an enormous revolution in cancer care. And it's really only just beginning because we want to get the immune system involved in controlling cancer and we've had much more success with this strategy than we have with chemotherapy. And there's a lot of different ways that we're doing this. Some are infusional treatments that help unmask the cancer. Cancer makes chemicals that help hide itself from the immune system. That's a very descriptive definition. You know, the science is always more complicated, but that's, I think, helps people understand that, you know, cancer finds ways to hide itself, you know, from the immune system.
The other thing we're doing is we're coming up with medications that can connect the immune system to the cancer.
And we call that BITE therapy. And it stands for Bispecific T-cell Engagers and this helps connect the immune system directly. You know, prior treatments helped unmask the immune system or help bring attention to the cancer. But these newer treatments, called BITE therapies, are directly connecting the immune system. And some of my partners in Norfolk have been involved in establishing our program here and enrolling patients in clinical trials.
And that really benefits everybody in Hampton Roads, You know, to have this kind of level of expertise. Right now, it's kind of a niche thing, you know, for, you know, patients with, you know, advanced cancers or unfortunately their cancers come back. But I think it's going to be a big thing in a couple of years.
And the last thing is we're coming up with ways to utilize the immune system and create blood cells that can attack the cancer directly. We call that CAR-T. That's more technically complicated because you're actually working with human blood cells to engineer them to attack the cancer. But for patients that need it, it can work really well and they can be put into remission or potentially cured. It's a big deal, you know, for patients. I think probably the most widespread use now are medications that help, help the immune system identify the cancer, because that's for technical reasons, the easiest thing, you know, for patients to receive. And you're seeing commercials for a lot of these brands out there right now, you know, that are being advertised for different cancers. You know, pembrolizumab, obdivo. I don't know why they advertise directly, you know, to patients because nobody wants to need these medications, but it's just the nature of the moment, so to speak.
But in blood cancer specifically, you know, our two most common blood cancers are chronic lymphocytic leukemia and multiple myeloma. And in multiple myeloma we've been using forms of immunotherapy for a very long time that help, you know, called rituximab and obinutuzumab, and that really help the immune system target specific abnormalities that are on the leukemia cell. Those have been used for a long time, but they're only getting better.
In myeloma, you know, a very commonly used medication right now is something called daratumumab. And that now is generally used as one of the first treatments for nearly all patients with multiple myeloma at the time of diagnosis. And that's a new thing in the last couple of years that really has improved the outcomes for patients with myeloma, which is exciting.
Cheryl:
As you're talking, it really does sound exciting. And how maybe in years and years past, people with a diagnosis of a certain type of disease like myeloma or leukemia would have only one path of treatment. But now it has more of an opportunity for you to say, you person A, you person B, have different ways to get better.
Dr. K:
Absolutely. So one of our goals alongside all these advances is...our idea is not that everyone gets the same treatment. Our idea is that you know, patients should have personalized treatment, personalized to who the patient is in terms of their age and medical problems, but also personalized to the type of cancer. Because even though, you know, two patients may both have leukemia or myeloma, lymphoma, they may have different forms or different subtypes. And we want to be able to kind of personalize that so that patients can have the best outcome, right? You know, gone are the days in which everybody is kind of given the same exact treatment, kind of no matter what.
Cheryl:
You were talking about, the immunotherapy treatments, and then the targeted therapy treatments are separate. They are a different type of treatment. Am I right about that?
Dr. K:
Absolutely. Targeted therapies are generally pills that patients take by mouth and they work a little bit differently. They have less to do with the immune system and more to do with interfering with the way that the cancer cell works. So cancer cells, and this is true, basically all cancers have a unique way of running their machine, so to speak, a unique metabolism. And, you know, research that's been done by lab scientists, mainly at the universities, has allowed us to exploit this knowledge to develop medications that can interfere with how those, you know, cancer machines work and also allow those medications to be more or less delivered more to the cancer cells than to the rest of the body. And that allows patients to have one more, effective treatment, but two also, you know, potentially fewer side effects. That doesn't mean that there are not any side effects, because there are, but have fewer side effects. And so the idea of chemotherapy was mainly to be injurious to, you know, cancer. But the idea behind targeted therapy is to take a more selective approach. And that's being, you know, widely used across many blood cancers in chronic lymphocytic leukemia, which is, you know, one of the two most common forms of blood cancer, you know, targeted therapy in the form of what we call BTK inhibitors are now the standard treatment for patients. And even if that doesn't work, you know, another targeted therapy called venetoclax, is the commonly used treatment.
And so those targeted therapy, as well as immunotherapy, are now the predominant treatment for patients with chronic lymphocytic leukemia, [stuttering] excuse me. And they are working their way into treatment of common forms of lymphoma as well as acute leukemia and myeloma itself, too.
Cheryl:
What is the message to patients or patients, families who may be listening to this, as they're hearing about all of these advances and the individualistic plans of treatment for patients? What is the message for them as they're hearing this and thinking, "Oh, my goodness, there's so much." Then, and then you're maybe thinking there is so much. And it may be a different message for both. But what is your message for them?
Dr. K:
Well, I think they got to talk with their doctors. Right? There's so much information out on the Internet.
It's very easy to get confused as to what's true for me, what's true for somebody else. And so I encourage people to talk with their doctors. But also ask their doctors for more information about them. One of the things that I do for patient education is that you know, once we've made a diagnosis, I provide them education material through the Leukemia Lymphoma Society, which has booklets that they've written for patients that talk with them about diagnosis, treatment, staging, research, causes.
And these are usually, you know, 40 to 60-page booklets that really help patients dive into information that's relevant to them and helps them have better conversations with their doctors about what the right treatment for them would be. And so that's what I'd tell them to do talk with their doctors and ask for high-quality information so that they can be more educated and better participants as patients.
Cheryl:
I know that Virginia Oncology Associates is involved in a lot of research. What does VOA do right now in research for blood cancer?
Dr. K:
Well, we have several clinical trials opened. We've got, I think at least, you know, 40 or 50, you know, trials open for patients across all cancer types. But we do have clinical trials open now for patients with chronic myeloid leukemia, chronic lymphocytic leukemia, myeloma, as well as diffuse large B-cell lymphoma.
The thing about clinical trials is that they are designed for a very specific situation and patient. So you have to, you know [stuttering], some patients are interested in research, but we have to make sure that they are candidates for the clinical trial. You know, for example, one may be that you have to have diffuse large B-cell lymphoma, and this is your first time that you've had it, it's not a recurrence. And you have to not have any excluding health problems. And so one of the jobs of the research doctor is to make sure that the patient is a candidate, you know, for the trial, because as we're studying new medications, we want there to be a fair assessment as to whether the new treatment is better than the old treatment.
The other thing, you know, that, you know, I think patients should know is that we don't do, you know, sugar pill trials or placebo trials. Most trials these days, compare the old standard to something new or additional. And because a lot of patients are worried that if they, you know, think about research or go on a clinical trial, that they may not get treatment or they may get, you know, a placebo treatment. And that's really not what's done anymore. The big barriers that we have to enrollment in research are one, trying to help patients, you know, overcome fears that they have about research. Some of those fears are legitimate. And some of those fears, I think, can be, you know, through a good conversation, eliminated. And so your doctor should be looking for opportunities for you to participate in research. It doesn't mean that you need to participate, doesn't mean that you have to take that option. And you should feel comfortable to tell your doctor, "No", that's not something that you'd want to do. But we all benefit from research because that's what creates the better treatments of tomorrow.
Cheryl:
It helps give answers to you as a medical care provider and helps not only that patient but the other ones who are dealing with the same thing.
Dr. K:
Absolutely. Without research, we'd still be doing the same things we did 50 years ago.
Cheryl:
I mean, think about all the things that we've talked about just in the last 10-15 minutes about the advances in medical care for blood cancer. It's incredible.
Dr. K:
It's been a big time. And one of the things that, you know, caught Medicare and government insurance companies by surprise is how advances in cancer care are now, you know, the single most costly sector of medicine, but also the single fastest changing sector of medicine.
I don't think there's any other field right now that's changing, improving, evolving as fast as we are.
Cheryl:
Well, thank you for your work and your dedication, and your passion. It is so clear how passionate you are about research and providing the best plan individually for a patient. Patient A, patient B are totally two different people, and finding the right plan for each one is work in and of itself. So I can see the passion there.
Dr. K:
I appreciate your comments.
Cheryl:
Yeah. So where can people go for more information about the clinical trials, about some of the things that you've talked about regarding immunotherapy and targeted therapy, and just the work that Virginia Oncology Associates does?
Dr. K:
Well, one of the places that I would direct you is our Web site (VirginaCancer.com).
As you know, we have several podcasts now available for patients to listen to on different topics that are meant for patients. You know, these aren't, you know, complicated doctor-to-doctor conversations that are above the patient's head, but these are articles and podcasts that are, you know, produced by Physicians for Patients to help them learn more and get more engaged in their disease and their treatment.
I mean, the second thing is cancer.gov. This is the National Institutes of Health patient cancer portal. They have a lot of information there and you could look up by disease and get generic but reasonable information on diagnosis and treatment. It's actually a good way to check your doctor because you can look up and see, you know, I have this type of cancer and these are standard things that are being done. It's a good way to kind of see if what you're being told is something that other patients are being told. And so I commonly recommend cancer.gov as an external website that I think is really valuable.
There are other websites out there too. You just have to be a little bit careful on the Internet because not everyone is equally qualified to provide you with good advice on the Internet, you know?
Cheryl:
Right, Absolutely. And you know, what you were saying is so smart, is that there's so much information out there and you do go to certain medical professionals for guidance and support. But then if there are other organizations like the cancer.gov website you mentioned, there's a way to kind of balance it a little bit. Fact check, if you will, to make sure that the path that you're on and the path that you've agreed on with your medical care provider is the one that makes the most sense.
Dr. K:
As a third site, I think that the Leukemia Lymphoma Society is also a great place for patient information.
Cheryl:
Okay, wonderful. Any last words for our patients and partners who are listening today?
Dr. K:
Well, I think I should say, you know, thank you to our patients. You know, they, their what it's about, you know, helping them, supporting them and in trying to get them better is really all it's about. Also want to say thank you to our staff for making that happen. You know, it's more than just your physicians. Cancer care is nurses, administrators, secretaries, you know, medical assistants that check-in, pharmacists. It's a complex process of providing cancer care. And it's not just one person. So it really takes a team and we have it here.
Cheryl:
It's definitely a team effort and we thank you and your team for your passion and your support.
Dr. K:
Thank you, Cheryl.
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That’s all for this week’s episode of Cancer Care Connections. Stay tuned for our next episode where Cheryl will be talking with Dr. Kruger and Dawn Quinn about palliative care and how it relates to your cancer journey.
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Virginia Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information visit us at virginiacancer.com or find us on Facebook or Instagram at Virgina Oncology Associates.
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