Intro
00:00
Welcome to Cancer Care Connections. On this week’s episode, Cheryl spoke with Dr. Graham Watson, oncologist and hematologist for Virginia Oncology Associates. Dr. Watson navigates the complexities of two cutting-edge therapies in cancer treatment, immunotherapy and targeted therapy. And discusses how they differ from the more well-known cancer treatment, chemotherapy.
Cheryl
00:34
Dr Graham Watson is a medical oncology specialist who began with Virginia Oncology Associates in 2017. He considers himself an advisor and educator for his patients, with the goal of helping them make the best treatment decisions for their individual situation. Dr Watson treats patients with all types of cancers and blood disorders, and his clinical interests include lung cancer, lymphoma, melanoma, and cancers of the head and neck. Outside of medicine, dr Watson enjoys fishing, playing the guitar, and spending time with his wife, who is a pediatric oncologist at CHKD, and his children. Dr Watson, thanks so much for joining us today.
Dr. Watson
01:02
Thank you for having me.
Cheryl
01:03
I know that communication is so important to you, and your practice philosophy is to focus on excellent communication with patients and their families. What have you noticed over the years has been so impactful when you're clear and communicate effectively with the patients that you work with?
Dr. Watson
01:34
Yeah, it's a good question. I really think that, as medical oncologists, really what we do and what we specialize in is communication. We don't cut with scalpels or administer radiation. We communicate and help patients to understand their disease and the treatments. And I think that you can really tell when a patient gets it and understand some of the concepts of what's going on.
Cheryl
01:55
I think that it helps them to follow along with their treatment and, ultimately, to be more engaged. And that's really what you're looking for. It can be a scary situation, and to have somebody give you potentially disturbing news, to have that conversation and better communication makes everything a lot better.
Dr. Watson
02:13
Yeah, I think that communication in the medical oncology setting or inside an exam room with a patient who has cancer is a little different than what you're used to doing at a party with friends. I mean, I heard the term once that I've never forgotten, called 'fear muffs'; which is when you're afraid, we tend to put on these ear muffs that sort of muffle the messages are being given to us. And so, as a cancer provider, you have to understand that you need to be patient. Sometimes, even though you're using normal terminology, a patient may have a little more difficult time understanding or need to have things spoken in different ways because of the idea that when you're hearing difficult news, sometimes our brain starts to race and it's harder to listen and comprehend.
Cheryl
02:59
We want to talk today about novel cancer treatments, immunotherapy, and targeted therapy. Let's talk about the definition first, of what a novel cancer treatment is. People might be like, oh you know, it's just cancer treatments, but this is something that maybe they just haven't heard put together.
Dr. Watson
03:15
Yeah, yeah. I think a lot of times when you're an oncologist or an oncology nurse, you use these terms every day, and so they just get thrown around. But if you're entering the world of oncology with a new diagnosis, this is all new to you. And so I think the term that everyone anchors on and is familiar with is chemotherapy. And we think that chemotherapy has been around for decades. Everyone probably has a picture in their mind of what it is going to be like to go through chemotherapy. We think of someone who may have lost their hair. We might think of someone who's having nausea or throwing up as a result of their treatment, and chemotherapy is still around. It still can be very effective in treating cancer. But when we talk about novel cancer therapies, really what we're referring to are cancer treatments that are different from chemotherapy. Think about things like immunotherapy and targeted therapy, but the way that they work and the side effects and other implications are quite different, and that's worth explaining to the patient.
Cheryl
04:16
And what that can mean, as I'm hearing you, is that for a cancer patient, it's not one size fits all. And what they're thinking may be one size fits all, but it's really not.
Dr. Watson
04:27
Correct, correct. We talk about the term personalized medicine. And you know, I think that's a nice thing to say. Certainly, as we develop more research into cancer and understand the differences between different, not only different types of cancer but even within one type of cancer, there are different flavors of that cancer and they need to be treated a little bit differently. So it truly is personalized, and the way that you might sequence the therapies and obviously which ones you choose, are going to depend a lot on each individual situation.
Cheryl
04:57
I know, as people do their homework, they're googling, they're asking people, and one of the things I know they're probably searching to get more information on is immunotherapy. It's like that buzzword, isn't it? So what is it, how does it work, and what should people take away from that?
Dr. Watson
05:17
Immunotherapy is out there in the lay press, even in the advertisements. It always blows my mind when I'm watching a television show and a commercial for Keytruda comes on, because it's not something you just go down to the local Walgreens and pick up. But I think it's actually not a bad thing that it's being advertised. It's good when a patient is familiar. I always encourage my patients if they'd like to Google something, to go ahead and do that, because at least it starts their educational process. And even if there are things that need to be corrected, that's what we're here for. But I don't think that it's ever the right thing to tell someone to not read or not look up, especially if it helps some of their anxiety that they're having about their disease.
Immunotherapy has really revolutionized the treatment of cancer. It's been under development for many years. I would say that it came into being as far as into the mainstream, probably in the early 2000s. So it's been around for 20 years in the post-clinical trial setting where we're actually using it in lots of patients. And as more clinical research is done, it's used in almost every type of cancer.
The way that it works...and this is so cool. I love talking about it because I think it's such a neat thing in the way that it works when you compare it to chemotherapy, which is essentially poison that you put in someone's body and it poisons the cancer, which is good, but it poisons other cells in the body and that's what causes the chemotherapy side effects.
But immunotherapy is very different. The way that it works is it tries to get your body's immune system, your own innate immune system, to recognize the cancer cells in your body as being evil and to kill them. One of the tricks that cancer plays on your body is it has a way of telling your immune system that it is a normal cell, and so the immune cell will bump up against the cancer cell. Any first-year pathology resident could look at that cell and tell you it's a cancer cell, but the cancer cell can turn off the immune cell so that it floats right on past and doesn't bother it in any way. The way that immunotherapy works is it blocks that communication and now the immune system can see the cancer cell for what it is and it can kill it, rid it from the body, and also recruit other immune cells to that area where the tumor is located and start a real battle against that cancer tumor in the person's body.
Cheryl
07:44
Well, I can definitely see why people are like I want some of that.
Dr. Watson
07:47
Right right.
Cheryl
07:49
It's not for everybody, though, is it?
Dr. Watson
07:50
Correct, correct. It works better in certain types of cancer, and there are tests that we can run as physicians to figure out which tumors might respond a higher percentage of the time or have a better response. And so you might find that your doctors might sometimes use immunotherapy along with chemotherapy, but other situations might call for using immunotherapy as the only treatment for a patient who comes in.
Cheryl
08:15
I think people have an understanding when they're thinking about chemotherapy, of the side effects. How about with immunotherapy? What are some things that patients should also be made aware of? It sounds wonderful, but it's still therapy.
Dr. Watson
08:30
Absolutely, and there's no drug in the world that has zero side effects. Right, if a doctor tells you the drug has no side effects, you should leave the office and never come back. So of course there are risks. The immunotherapy risks mostly have to do with, again, the immune system. If the immune system becomes active against the cancer, that's what we want. But if that activity and increased activity of the immune system affects or attacks one of the normal parts of your body, that's where you can potentially experience side effects.
You can really go down the list of organ systems in your body and it's possible that you could experience a side effect in multiple different areas. For example, immunotherapy could affect the skin and cause rash or itching. It could affect the lungs and it can cause some inflammation which can feel like shortness of breath. It could affect, for example, the colon and if that happens you can get some diarrhea with it. But the really good news about immunotherapy is that very often, if the patient does experience a side effect, it can be fairly mild and the percentage of patients that experience a serious side effect is much lower than with chemotherapy. I quote patients around a 10 to 12% risk of a serious side effect, with serious meaning we have to stop the drug and give them some of the agents to reverse the side effect. But if you compare the risk of serious side effects from immunotherapy to something like chemotherapy, immunotherapy is far better.
Cheryl
10:02
So if someone were to have a choice, if their body allows it, if what the diagnosis they have makes it possible, they would maybe choose that.
Dr. Watson
10:12
Yeah, I would say that often, if there are two options, then you might choose immunotherapy. And I think, also importantly, some of our patients come to us and they might have a more advanced age or they might have other medical problems that would make it dangerous to give them chemotherapy. Whereas you can give immunotherapy to folks who have other serious medical problems. You can give it to folks of very advanced age. In fact, I've given immunotherapy to a 100-year-old. This individual had melanoma and we were able to shrink the tumor on his arm. Prior to coming to see me, the only treatment option he had was to amputate his arm and he was treated for about a year and a half. He ended up passing away at age 101 because of other causes, but the melanoma actually shrunk significantly. He experienced very little to no side effects and I was very happy that we were able to give him that extension of time so that he could live out his natural life expectancy without having to deal with the melanoma.
Cheryl
11:15
With that issue...Thank you for sharing that. As we're talking about immunotherapy and you mentioned a little earlier that sometimes chemotherapy works in conjunction with immunotherapy. When does that work together better? When is that a situation that might happen?
Dr. Watson
11:32
Yeah, so there's a test that we can run on a patient's biopsy, and if the expression of a certain marker on the cell is very low, our confidence that the immunotherapy will work if used by itself is less, and so in that situation, we might use chemotherapy along with immunotherapy to boost our chances that the tumor will shrink and that the response will be good. Even in patients where the marker is a lower percentage, those patients can sometimes still respond well to immunotherapy, but that's when you might use it in combination with something else.
Cheryl
12:08
Again, as we mentioned, it's very individualized and you can kind of pull a lot of the tools out of the toolbox to help make somebody well.
Dr. Watson
12:17
Absolutely, and that's why there's a real art to doing oncology. A lot of people think of your physician as a scientist, and generally, that's what our backgrounds are. But when you do clinical oncology you realize that you have to be able to understand the data that's been studied and what we've learned. But also to apply that to an individual takes understanding the individual's values, what their tolerance for side effects might be, how well can they take care of themselves, and what type of support system do they have. These are all the nuances of choosing the correct treatment for an individual patient, and so that's what your doctors are experts in at Virginia Oncology Associates.
Cheryl
12:57
For sure. Let's switch gears a little bit and talk about the genetics of cancer and how this relates to another type of treatment that I've heard about called targeted therapy.
Dr. Watson
13:08
Yeah, that's another really exciting novel treatment for cancer and targeted therapy has to do with the DNA of the tumor itself. This is a really important thing to explain. People think about genetics as what you inherit from your parents and you pass down to your children. And it can actually be quite distressing if a doctor comes in and they're talking about the genetics and the DNA of their tumor, because now you're worried that you might have given your lung cancer to your daughter or your son. And actually what we're talking about a lot of times has to do with the DNA of the cancer cell itself, and so that DNA change or that DNA problem is only present in the cancer cell. It's not part of the rest of your body and so for that reason, it's not something that you pass along to other family members. I think that one of the most interesting things about cancer, and one of the reasons that I chose to become an oncologist, is that cancer is really a disease of the genes.
People sometimes ask me, "what exactly is cancer?" We understand that it's a tumor on the CAT scan or something that makes me feel sick, but what exactly is it? And basically the difference between a normal cell and a cancer cell is that there's been a change in the DNA. In some cases, it's multiple DNA mutations, that's the word for a change in the DNA, multiple mutations that have led to the cell becoming cancerous. In some cases, it's a single mutation, and if it's a single mutation, we call that a driver mutation and that's where targeted therapy comes in. If we can identify a single-driver mutation that is propelling the cancer cell along, it's causing it to grow, it's causing it to spread, and make a person sick. We have many options of treatments that are specifically targeted. You hear that word targeted, targeted to that DNA mutation. So that's where one of the common misnomers comes in. If I come in the office blabbing about targeted therapy, I think a lot of patients' minds start thinking about a laser beam pointing towards the cancer, the target, right? But targeted therapy actually means you're targeting the DNA mutation that has been identified, and so your doctor may recommend sending off a test to try to identify a DNA mutation. Unfortunately, not all cancers have a DNA mutation that can be targeted, but for the ones that do, it opens up this type of treatment called targeted therapy that you can use.
Cheryl
15:48
I'm so glad you made that distinction, because that's exactly what I would have thought. If we're talking about targeted therapy, it's kind of like a bull's eye, but you're looking at it actually from the symptom or the beginning part of it.
Dr. Watson
16:01
Yeah, absolutely. You're thinking about that terminology, targeted therapy, meaning that we're targeting this single DNA mutation that we can target, and then if you can stop that mutation from causing problems, that really stops the cancer in its tracks. You can look at a CAT scan and see that the tumor stops growing, you can see that new areas in the person's body do not crop up and then often you can actually see that the tumor will shrink. And all that time a patient might start to gain weight back and feel better, and ultimately that's our goal is to help patients improve from their cancer.
Cheryl
16:39
You mentioned earlier that sometimes people say to you oh, this has happened to me, this cancer has happened to me and I'm worried that this DNA mutation is something that I'm passing on to my children. But I do know..I've heard that there are some things that are hereditary, that are genetic. Can you talk a little bit about that difference from what you mentioned earlier? And what we've maybe heard out there.
Dr. Watson
17:05
Sure, no, it's a really great question because it's an important distinction and it's often very confusing. But there absolutely is a role for testing things that can be inherited. Some of the most common examples would be BRCA mutations, or you might have heard the term "brah-kuh" for BRCA mutations. Those are mutations that can be inherited through your family and that might cause risks for things like breast cancer or ovarian cancer and some others. And so there often is a role for genetic testing, that is inherited genetic testing. We offer that at VOA through our genetic counselors, and the genetic counselors can explain what the implications might be for family members and whether they should be tested in the right situation.
But with targeted therapy, where we're testing the DNA of the actual cancer cell, that's a different thing. We don't pass that down and that's what we use to actually prescribe treatments. So the targeted therapies that we are talking about have to do with the cancer DNA. The inherited mutations we're talking about are present in all the cells in your body and you got them from either mom or dad and then you will have a chance of passing them down to your children. And so you need to be informed about that. You need to understand the timing of when people should be tested, at what age, and then, of course, what you can do to detect cancers early or prevent a person from developing cancer in that situation.
Cheryl
18:37
You talked earlier about treatment, how can a doctor use a DNA mutation you find to help with treatment?
Dr. Watson
18:43
Yeah, that's a great question, and so we talked earlier about immunotherapy, and immunotherapy is given intravenously. So, much like chemotherapy, you come to the office, you sit in the infusion room chair and you get an IV put in your arm or medicine given through your port, and that medicine is given IV. Targeted therapies are almost always given in pill form, so you actually take them at home. Of course, we treat them with care, and so you get education about exactly how to take them. We look at all of your other medications to make sure there are no interactions between the new pill you'll be taking with your, let's say, your blood pressure medication. But in general, you can continue all of your regular medications and still take your targeted therapy. But targeted therapy is a pill that you take and it goes into your bloodstream by being absorbed through your stomach and your intestines, like a lot of oral medications. And it can go and find the cancer cells. Inside the cancer cells, these DNA mutations which have caused the cell from performing its normal functions to become cancerous, where it's rapidly dividing and causing these tumors and often secreting chemicals in your body that take away your appetite and make you very tired.
This is what cancer can do to really bring a person down. These molecules that get into your bloodstream through the pill you've taken will block that type of cell division and chemicals being put out in your body and will stop the cancer from growing. And again, it's a really beautiful thing when you see someone who's got cancer that on the scans is enlarging. You identify this DNA mutation, you give the patient the correct, targeted therapy and you can see that the tumors melt away. And all the while the patient might report, "Yeah, my appetite is back, I'm feeling better and really doing better."
Cheryl
20:35
I Love hearing that. I really do. I have to ask, though, side effects? There are side effects I imagine?
Dr. Watson
20:43
Absolutely, and unfortunately, there are. I do think that I often will caution patients when I'm talking to them I'll say," Isn't this good news?, you get to take a pill at home instead of having to come and be in the office for multiple hours getting an infusion?" But don't mistake that there still can be significant side effects. Again, when you make a distinction between chemotherapy with hair loss and nausea and some of the things, lowering of blood counts that chemotherapy can do, I do think that the side effects from targeted therapy are often different. For example, we don't typically see hair loss with targeted therapy.
However, a lot of the side effects are related to your gastrointestinal tract, potentially causing low levels of nausea. Sometimes just a lack of appetite can be part of the side effects. Even things like diarrhea. So there definitely can be side effects. They obviously vary depending on the drug. Some of the medications are better tolerated than others, but I do warn patients that just because it's a pill you take at home doesn't mean it's as easy as taking Tylenol. It probably will have some degree of side effect. The good news is that if you are experiencing severe side effects at the normal dosage, often the doctor can reduce the dose or change the schedule and try to find a way that you can tolerate the medicine and it also can do well to fight the cancer.
Cheryl
21:33
Thank you so much for this explanation of these novel treatments. I want to ask you, how do you see the future of cancer treatment developing when it comes to the role of chemotherapy, immunotherapy, and targeted therapy?
Dr. Watson
22:06
Yeah, you know, I would love there to become a day, maybe during my career, over the next 25, 30 years, where we stop giving chemotherapy. I don't know if that will happen. I don't think it's going to happen anytime very soon, but we do think about chemotherapy as a little bit more of a crude instrument. It's just more of a tool that we use to go out and it's not as focused and specific to the cancer and the way the cancer is developing. I think that immunotherapy will be here to stay. I think that we'll continue to develop more targeted therapies as we learn more about the human genome and DNA that makes up who we are as human beings. And there's definitely even more novel treatments coming down the pike. We talk about things like CAR T cells; CAR T therapy. We have a wonderful doctor that we've recruited here, named Gary Simmons, who's really building our CAR T program at VOA.
So you know our focus is always that patients who live in Hampton Roads can receive cutting-edge care right here in Hampton Roads.
We don't want patients to feel like they have to travel to other places to get the best care, and so we've taken a lot of steps to look into the future, to specialize so that our doctors are on the cutting edge of the newest treatments. And I think the future is definitely very exciting for patients with cancer. We always wish that we could move things along faster, and so I think that any excitement that you have with a new treatment has to be tempered with the fact that, for most cancer patients who walk in the door, they're going to need to be treated with the medications that we have now, and so we want to continue to make strides. But certainly, we appreciate when patients are willing to participate in clinical trials, because that's exactly how we learn new information and make these gains. And we have a very robust clinical trial portfolio here at VOA, so we certainly appreciate the partnership that we have with our local community so we can help add to the research base as we move forward.
Cheryl
24:25
We also had the opportunity to speak with Dr. Simmons, so definitely look in your podcast app for that episode. It was a great one and we appreciate your time, your expertise, and the care that you are taking with your patients and with us to share these treatments with us and what it means for the future. Any last words you'd like to say for someone who's listening, it could be a patient, it could be someone close to that patient who is just looking for any shred of hope.
Dr. Watson
24:55
Yeah, no, I think that you know the things I would tell folks...as far as specifically learning about these therapies and just on the idea of helping to communicate with your physician and understand what's going on, number one, it's always really great to have a second or even a third set of ears. We can all look back during the COVID era when we had to limit the amount of family members or support people coming into the office. But that's lightning now. And I would say, if you have someone that's going through cancer in your life, offering to come to their doctor's visit with them, bring a notepad and take some notes while you're listening in. Because it's often hard to recall everything that was said. And just remember that just because you don't understand something the first time through doesn't mean that you're not smart. These are very difficult concepts. Even as physicians, we have to learn what are the best ways to effectively communicate some of these things to folks.
So ask questions. It's always good to ask questions and you know, if I take my car to the mechanic, I promise you I ask a lot of questions and I don't usually understand their answers right away. And so you shouldn't feel intimidated when you talk to your doctor or your provider team about asking questions so that you understand. Remember, there's lots of good data that shows that if you can understand your cancer better, you can be engaged in your treatment, and you know what to look out for, you'll actually have better survival and do better. Because Patients who can really be involved with their care tend to have better outcomes. So it's worth making the effort to really communicate well with your physician and your treatment team and always ask good questions.
Cheryl
26:35
Dr Watson, thank you so much.
Dr. Watson
26:38
It's been a pleasure.
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26:42
That’s all for this episode of Cancer Care Connections. Stay tuned for our next episode where Cheryl will sit down with Kara DeMott, Urgent Care Physician Assistant and APP Supervisor for Virginia Oncology Associates. Kara will discuss cancer symptom management. She will provide you with tips on how to treat symptoms at home and advise when it’s important to see your oncology care team.
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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.