Information Session: Managing Blood Cancer or a Bone Marrow Transplant

Corporate Speakers

• Sergio Giralt; Memorial Sloan Kettering Cancer Center; Deputy Division Head, Hematologic Malignancies
• Mini Kamboj; Memorial Sloan Kettering Cancer Center; Chief Medical Epidemiologist
• Anita Kumar; Memorial Sloan Kettering Cancer Center; Lymphoma Specialist and Medical Oncologist
• Martin Tallman; Memorial Sloan Kettering Cancer Center; Hematologic Oncologist, Chief of Leukemia Service
• Nicole LeStrange; Memorial Sloan Kettering Cancer Center; Nurse Practitioner

Presentation

Operator: Good afternoon and welcome to the Memorial Sloan Kettering Information Session, Managing Blood Cancer or a Bone Marrow Transplant.  Our host and moderator for today's call is Dr. Sergio Giralt, Deputy Division Head, Division of Hematologic Malignancies at Memorial Sloan Kettering Cancer Center. 

I will now turn the call over to Dr. Giralt, please go ahead.

Sergio Giralt:  Thank you very much.  And welcome all to this information center session where we will be covering the managing of blood – management of blood cancer and bone marrow transplant and cellular therapies in this COVID time.

I'm Sergio Giralt, the Deputy Division Head of Hematologic Malignancies here at Memorial Sloan Kettering, and I specialize in bone marrow transplant and cellular therapies.

Thank you to the hundreds of you who have already joined the call today.  I want you to know that MSK is working hard to keep you and your loved one safe when you come for an appointment or treatment at any of our locations.

We understand that you may be feeling particularly vulnerable during this time, with all the different things that are happening and what we're hearing both on TV and other social media.  Together with our panel of experts we'll discuss the many common concerns people wrote to share with us.  We will try to get to as many of the questions you sent during the time that we have.

I want to remind you that your MSK doctors and care teams are ready and willing to talk to you directly about your concerns.  I encourage you to reach out to them to discuss the next steps in your care and to ask them any questions that do not get answered here today.

Let's begin and I would like to begin with Dr. Mini Kamboj, who's our Chief Medical Epidemiologist and Infection Control and has actually been doing, you know, leading us and giving us all the guidance of how we should deal with COVID-19 to keep our self safe, our patients safe and their caregivers safe.

Mini, could you give us a brief overview of where we are now in the research, treatment and testing for COVID-19?

Mini Kamboj:  Yes, of course.  Thank you very much, Sergio, and good afternoon, everyone.  My name is Mini Kamboj, I'm an infectious disease physician and I oversee the Infection Control Program here at MSK.

Members of our group, they work with colleagues all across MSK, whether it's clinic space or our hospital across all settings to ensure that our patients and our staff stay safe from all infectious threats, including COVID-19.

I want to begin by briefly talking about the impact of COVID-19 at MSK.  COVID-19 began to spread widely in the tri-state area around late February.  We diagnosed our first case at MSK on March 10.  And so it's steady rise in cases at the hospitals, very much parallel to what was going on in the community at large in New York City.

We witnessed the peak in cases around mid April, but a steady decline since then.  In recent weeks, things are looking much better.  Our case numbers have been the lowest they have ever been since the epidemic affected the region.

In the last two weeks, we have done well over 3600 tests in our patients, and admitted on the three patients with newly diagnosed COVID-19 infection.

The percentage of positive test, a marker of monitoring infection remains well below 1 percent for several weeks at this time.  We are testing extensively as you can see from our testing numbers and not finding much in terms of new cases.  We absolutely plan to sustain this level of testing in coming months. 

And finally, we currently have 11 COVID positive patients in the hospital, compared to over 100 patients at the peak of the epidemic.

Next, I want to take a minute to briefly talk about all the safeguards that have been put into place.  Starting with our clinic spaces, all our patients are being screened for symptoms prior to the visit at MSK.  And again, at the time they arrive.  Everyone has to mask at the entrances and remain masked throughout our facility, unless instructed by their providers.

A visitor's policies remain restricted and stringent at this time, again, to keep our patients safe.  And these are being implemented as per the guidance from state public health officials. 

A lot of work has gone into making sure that physical distancing, which is key to preventing the spread of COVID is always maintained in our clinical spaces whether it is the waiting area, or the chemo suite.  There have been (design) reconfigurations and creative ways of staggering appointments so as to avoid crowding in the clinic spaces.

In our hospitals, we are testing all patients at admission in every three days, regardless of whether they have symptoms.  If there is a problem, we want to know about it early and control it.  We are simultaneously also testing our employees who are working in inpatient and procedural areas every two weeks, even if they have no symptoms.  At this time, we are finding very low rate of positive tests in our staff, similar to our patients, well below 1 percent.

These numbers provide reassurance that the risk of contracting COVID from someone who has yet without symptoms or not feeling ill is extremely low at this time at MSK.  This is again something we will continue to watch closely over coming weeks and months.

Additionally, all our employees are being screened for symptoms of COVID before they come to work.  And if they do report anything that suspicious for COVID, they're instructed to stay at home, get medical care from the local provider, and declared back to work only when fully recovered, and it is safe for them to be around others.

In terms of research, there are two main things that I would like to share.  The first is what we have learned from our own experience.  We have found that overall cancer treatments especially chemotherapy, does not adversely impact risk of getting severely ill from COVID.  And I'm sure my colleagues will also share their experiences, not only at MSK, other centers in the U.S., Canada and Europe have reported a very similar experience.  While there are several aspects of COVID-19, on the impact in patients with blood cancer that remain unknown, these early reports provide added reassurance as decisions about treatment are being made.

Second, what I want to talk about in terms of research are the treatment approaches, and how those are being evaluated at MSK.  Several different avenues of treatment are being explored.  And I will briefly mention just a few. 

You may have heard of a drug called Remdesivir, the first and only drug currently authorized to treat COVID-19.  The drug is available at MSK.  And it's also being studied in the clinical trial context to understand the benefits for cancer patients infected with COVID-19.

Hydroxychloroquine, which is a drug that has been in the news for different reasons, has not proven to be effective for prevention.  Offer treatment and studies that have been conducted thus far, but continues to be evaluated in others.  At this time, they are not offering hydroxychloroquine routinely to our patients outside of a clinical trial.

Finally, a form of therapy called monoclonal antibodies, which is a synthetic antibody that has the ability to neutralize the virus but to directly attach and neutralize the virus.  This form of therapy we think would be particularly beneficial for our patients if proven to be effective.  This remain in early phase clinical trials is not available for broader use, but something that we are closely following.

Sergio, I think I will stop here and I want to thank everyone for dialing in.

Questions and Answers

Sergio Giralt: Mini, thank you very much for that very comprehensive review.  A lot of our patients have asked a question, particularly our transplant patients, you know, if I'm seven years out, am I still considered immune compromised?  Should I still continue to practice social distancing?  And I think that question also applies to all our blood cancer patients.

So, you know, should they ever consider that their immune system returns to normal and should social distancing be a form of universal precaution for them and for how long

Mini Kamboj: So great question, Sergio.  I think at this time, social distancing is the norm.  And I think all of us have to be vigilant and absolutely practice it.

In terms of the duration of immunosuppression, I think most cancer treatments weaken the immune system to some degree.  The extent of this and how soon you will recover really depends on the type of the treatment.  And what I will say is that patients receiving active chemotherapy that's expected to suppress their white cell counts for an extended period of time which is generally considered to be one week should be especially careful because these are the cells that really help fight infections whether it's, you know, a viral infection, bacterial or fungal infection.

In regards to your question about transplant, I think, again, this is a very general rule.  But the duration of immunosuppression for someone who has undergone an auto transplant is somebody around six months to a year for an allotransplant a year to two years, but it really depends, you know, if they developed any complications, or remain on immunosuppression, but those are generally the broad guidelines that we use.

Sergio Giralt: Thank you so much.  So Dr. Anita Kumar is one of our lymphoma specialists and she practices out in our regional sites.  So Anita, two questions for you that are coming out from our readers.  One is, is the situation in the regional sites different from the main campus?  And are the precautions being taken in the regional sites similar?

And two, particularly in patients with lymphoma who we know also may affect blood vessels.  And there is a lot talking about whether COVID-19 may be also affect the endothelial cells or the blood vessels.  Are there any particular manifestations of COVID-19 and lymphoma patients that, you know, they should be aware of?  And again, address the issue about, you know, what are we doing in our regional sites to keep our patients or staff in their caregiver sick?

Anita Kumar: Thank you very much, Dr. Giralt, and good afternoon to everybody.  My name is Anita Kumar, and I'm a lymphoma specialist and medical oncologist here at Memorial Sloan Kettering.  And during the COVID pandemic, I've been practicing at one of our regional care network sites in New Jersey and Basking Ridge, as well as in Manhattan.

So, to address the second question about the involvement of coronavirus and the blood vessels and how that may impact patients with lymphoma.  What I will say is that there does seem to be quite a lot of research which demonstrates that coronavirus has a major impact on blood vessels in the lung and throughout the body.

The virus is associated with causing damage to the cells that line the blood vessels, the so called endothelial cells.  And when these cells are damaged, it causes a series of different effects.  One is that fluid begins to leak out of blood vessels, trigger blood clotting, and there's activation of number of immune cells and other proteins which causes widespread inflammation within the body.

Patients with COVID-19 have an increased risk for blood clots to form in the veins and arteries and this can lead to the development of deep vein thrombosis or clots within the veins of legs, thighs or pelvis, or what's called pulmonary embolism where clots lodged in the blood vessels in the lung, or even strokes.

Inflammation and clotting within the small blood vessels can cause organs to dysfunction during a severe COVID-19 illness, and this can impact the lungs, the heart, the kidneys, in patients with severe COVID-19 illness.

However, the impact of the virus on the blood vessels is likely not what drives why patients with lymphoma or patients with blood cancers may be at increased risk for COVID-19.  While there is still ongoing research to try to understand why patients with blood cancers are at increased risk, we believe that lymphoma patients probably have increased risk for severe COVID-19 for several reasons. 

One is that lymphoma is a disease that's associated with the development of malignant or dysfunctional white blood cells called lymphocytes.  These lymphocytes called B or T cells play a very important role in the body's immune system and help to fight off viruses, like the coronavirus.

These cells in lymphoma patients are often impaired or don't work as well, making patients more at risk for developing infections in general and specifically COVID-19.

In addition, many treatments for lymphoma are associated with further immune suppression, such as antibodies that target malignant or normal immune cells, high dose chemotherapy and bone marrow transplantation.

But not all patients with lymphoma are at equal risk.  And many do not have a significantly increased risk for severe COVID-19.  For example, lymphoma patients who are young and otherwise healthy and who have been in remission for many years that have normal blood counts, they are certainly at lower risk.

In contrast, patients with impaired immune systems due to active disease or those with weakened immune function related to therapy are potentially at the highest risk.

To answer your other question about the regional care network, it has been a great asset that at MSK during the COVID pandemic, we have been able to reach our patients across a wider geography.  And we have six regional care network locations, two in Long Island, one in Westchester, and three in New Jersey.

The infection control precautions that have been taken throughout MSK in Manhattan and the Regional Care Network have been implemented to keep patients safe no matter where they access their care.  This includes universal masking, screening of patients and proper protective equipment when treating COVID positive, patience and isolation of these patients and a number of other precautions have been implemented to ensure the utmost safety of our patients and staff.

It has been an asset to have the regional care network sites open and available for our patients who lives outside of Manhattan so that they can receive their chemotherapy or immunotherapy infusions, laboratory testing or radiology at our regional care network sites, which have been open throughout the COVID-19 pandemic and have been serving many of our cancer patients.

So we do believe that with our one MSK approach, we have been able to maintain the safety for those cancer patients who needed to continue their treatments, even throughout the height of the pandemic and in the future, across all of our sites, including the network.  Thanks.

Sergio Giralt: Anita, that that is so great.  And I can tell you from the standpoint of my patients and I'll ask Marty and Nicole and Alex to also comment, the ability to now get some of the treatment that they use to get a main campus in the regionals has been so positively received from our patients, particularly because of the concern of coming into New York City.  And really, the fact that they have now be able to stay on therapy without with minimal interruptions is really something that they really appreciate.

So I would like to bring in Dr. Martin Tallman, our chief of our leukemia service and also our – the president-elect of our professional society, American Society of Hematology.

Marty, many people had to delay or alter their treatment plans because of COVID-19.  Many of our listeners wanted to know if these delays could put them at a risk for recurrence.  And could you talk about how, you know, the leukemia service handled their patients with leukemia during the COVID-19 epidemic?  And at the end also talk about, what the American Society of hematology is doing for the patients with blood cancer during this time?

Martin Tallman: Well, thank you very much Sergio.  I am Martin Tallman, Chief of the Leukemia Service and appreciate the opportunity to participate today.

It's an important question about delays in therapy because it was, to a certain extent, an inevitable delay when we had to reduce our ability to see patients, our ability to see patients in person and our ability to carry out some of our normal routine therapies.

There were some delays during the height of the pandemic in our institution that may have had the potential to increase the risk of relapse.  But we've tried very hard during the pandemic, tried our best not to induce and contribute to the delay for patients who are at very high risk of recurrence.

We've actually become much better at identifying the risk of recurrence of the patient.  If a patient – at the time of a patient presentation to medical care with a malignant disease such as leukemia, we now have the ability to look inside the leukemia cell and determined by the genetic makeup of the cell, for example, molecular genetics, chromosome analysis, and other techniques to identify and categorize patients as to the risk of recurrence.

And patients who we've identified at high risk we have made some modifications again during the height of the pandemic.  For example, we've perhaps given additional cycles of consolidation chemotherapy.  Sometimes we've given maintenance chemotherapy for perhaps longer than we might have otherwise to maintain a remission.

We've worked very closely with our colleagues in the transplant service to identify those patients at very high risk and those who are lesser or minimal risk to try to accommodate to the timing ability to carry out a transplant.

Sometimes we've actually modified our chemotherapy regimens and given reduced doses of chemotherapy, for example, during the height of the pandemic, to try to contribute to less prolonged cytopenias, less prolonged low blood counts as Dr. Kamboj mentioned, or sometimes we've actually changed from intensive chemotherapy.

Once the patients in remission, as their consolidation, chemotherapy to much milder chemotherapy, but still an effective regimen.  So again, during the height of the pandemic, we made a number of modifications to adjust to the risk, to the identified risk of a given patient.  But now we think we're fairly back on track.  And we don't – we really don't think we've contributed to the pandemic, contributed to much delay.

Sergio Giralt: That's excellent, Marty.  And the American Society of Hematology has a website for the public and patients with blood cancer.  Would you like to talk a little bit about that resource for patients?

Martin Tallman: Yes, the American Society of Hematology is of course participated very vigorously and trying to contribute to education and serving our, not only the public, but our members, the members of our society.

There is a website that actually it's phenomenal how quickly the website went up in a matter of days, members of the American Society of Hematology worked very hard to write and curate and edit the website, which contains lots of information, not only for, for patients, for caregivers and clinicians. 

We've also initiated a major endeavor of a registry, the COVID-19 registry where we're collecting data from patients with the disease, a huge database will be – is underway, and we hope to contribute a lot of knowledge to the disease and its treatment to this registry.

Sergio Giralt: That's great to hear and actually echoing what you said, a lot of our right of our patients and – patients and people who are currently on this information session, have been asking, you know, have bone marrow transplant procedures been delayed?  When will they be restarted?  What new protocols are planned for keeping BMT patients safe during the procedure and post transplant process?

I think actually, this is an excellent question when COVID-19 pandemic started as Dr. Tallman alluded to.  We in the transplant program actually, you know, we reduced all our activities to only the essential activities needed.  We would only transplant patients who were very high risk for relapse, or who were at very low risk of developing COVID-19 complications, even in the websites of both the American Society of Hematology and the American Society of Transplant and Cellular Therapy, ASTCT, many of us had said that we were delaying stem cell collections and patients undergoing, autologous transplant.

Over the last two months, that has been the case.  We now have reopened and we have reopened completely, as the new cases have gone down significantly, and as we've learned to manage COVID-19 much better and the ability of having protective personal equipment has actually increased.

We currently have protocols in place to be able to collect patients for stem cells, both patients and donors, which are extremely effective in preventing patients from either infecting or getting infected with COVID-19.

We've actually had to delay about 70 patients for transplant.  These patients are now being readmitted.  And as Dr. Tallman alluded to, we hope and expect that the pandemic is not necessarily affected anybody in a negative way.

Now, having said that, I'd like to – I would like to ask Nicole LeStrange, our nurse practitioner Adult BMT Service, to talk about how we are currently doing outpatient transplants and that we are – continue to do outpatient transplants, and how, from the nursing perspective and the provider perspective, how important telemedicine has been, and doing these virtual visits have been to be able to continue to deliver care to our transplant patients.  And this actually is probably the same for all our blood cancer patients.  Nicole, please.

Nicole LeStrange: Thank you, Dr. Giralt.

There are many safeguards in place to allow for all of our clinical teams to safely provide care in the outpatient setting.  Dr. Kamboj briefly touched on some of those including screening the patient prior to their visit.  They're usually called the day prior to their visit and they're also screened upon arrival to MSK site both patients and clinical staff are wearing masks at all time.  Social distancing and limiting visitors are also in place which was discussed.

As Dr. Giralt mentioned, we have incorporated telemedicine throughout all of the Outpatient Human Services.  And in the transplant service, it depends on what's going on with the patient, clinically and if they're feeling well, the primary team will typically decide at a given visit if the next visit could be done virtually or if they have to come in person.  And we work with the patient and their family if they're, you know, traveling or even if they're staying local.  And as Dr. Giralt said, it has really enhanced the patient experience and has made everyone feel a little bit more comfortable in this error of that pandemic.

Sergio Giralt: Nicole, needless to say telemedicine was not the way we used to conduct business before the pandemic and actually a lot of regulations had to be lifted so that we could do this.  Do you feel that this, you know, lifting these regulations really facilitated the use of telemedicine?

Nicole LeStrange: I think so.  I think telemedicine was done briefly on some of our services.  But I think this kind of pushed us to do it that much more.  And as you mentioned, it kind of lifted some of the restrictions with having licensure in certain states and, you know, not being able to call patients if they were somewhere else.  So, given that leeway that we have now has really allowed us to enhance that model, which, again, patients have really appreciated.

Sergio Giralt: Marty, do you think the American Society of Hematology and other professional society should weigh in that we continue to, you know, facilitate the use of telemedicine across state lines, because our patients particularly come from all over the place?

Martin Tallman: Yes, I think so.  I think that the American Society of Hematology recognizes the importance, certainly during the pandemic and we're in the so called peri-pandemic period.  And I think that the American Society of Hematology is supportive of continuing telemedicine.  I think telemedicine is here to stay.  I think it will certainly facilitate visits from patients.  But also, it may play an important – an increasingly important role and accrual of patients to important clinical trials across state lines, so yes.

Sergio Giralt: Talking about clinical trials and clinical research, I'd like to ask Dr. Alexander Lesokhin, one of our faculty members from the Multiple Myeloma Service at Memorial Sloan Kettering to talk a little bit about how research into blood cancer has been affected during this time.  And have we, you know, how we've been able to continue to do research in these diseases?  And also a little bit of, you know, following up of what Dr. Tallman said, how telemedicine and virtual, you know, visits can help us to continue to expand access to research trials.  Alex, please.

Alexander Lesokhin: Thanks so much, Dr. Giralt.  My name is Alex Lesokhin.  I'm a hematologist, ecologist here at Memorial Sloan Kettering specializing in multiple myeloma.  I would say that research in these diseases during the COVID era has not stopped.  However, there have been some very important modifications that have taken place, especially during the peak times that really tried to balance the need for access to highly novel and therapies that have a high likelihood of benefit for our patients.  And to balance that with the potential immune effects and management of possible side effects of these treatments, particularly given the increased patient load related to COVID-19, especially in the critically ill individual, meaning the (ICT) level patients.

So, as an example, cellular therapies, particularly with CAR T-cell therapies, really, were a space where one would expect a significant amount of benefit, however, the infusion of cells is preceded by immunosuppressive chemotherapy.  And there are also possible side effects such as CRS or cytokine release syndrome that would require a higher level of care and, of course, the potential especially during the peak time of COVID-19 in the hospital of exposure to infection.  So all of these things led us to significantly curtail the utilization of CAR T-cell therapy, and in fact, around the country sponsors – or companies that sponsor these trials, actually hope that some of these trials because of the similar concern.

However, other therapies, I would say that this did not stop us from considering these treatments on a case by case basis and particularly high risk individuals.  And we also did not, and have not limited these therapies among individuals who have already had products made available.  Other therapies were also pursued, particularly ones available, sort of like a pharmacy.  And they're of course, again, the likelihood of particularly benefit of a therapy and the individual patients situation were very much to take into account.

The one other aspect to this that was very important is that our laboratories, that research laboratory because of the need for social distancing also paused which limited one of the other aspects of research endeavors, which is the collection of samples from our patients from which additional (inaudible) information about various therapies that we are investigating.

So, this also limited some of the implementation or research activities.  I think now as we are in the peri-COVID peak or coming down on the other side of that all of these activities are resuming, again, focusing in on therapies with the highest likelihood of benefit as the first sort of prioritization of clinical studies.

In terms of individuals that already were on trials, all of these individuals continue to receive their treatment and here the telemedicine component was incredibly helpful.  In many cases, we have been able to supplement or and even maybe replace in-person visits with visits via telemedicine and painting the necessary laboratory evaluation to assess safety and efficacy remotely where patient – in laboratories in the patient's home towns or alternatively at our regional sites.

Sergio Giralt: Thank you, Alex.  Mini, we have many of our writers are also writing, you know, now that the states across the country are beginning to open in various phases.  Is social distancing the only way to protect themselves?  Are there other ways and particularly the favorites are, should they be taking herbs or medical supplements to enhance immunity?  What can you tell us about that?

Mini Kamboj: Great question, Sergio.  If there's a herb out there, I'd like to learn more about it.  Yes, so it's a, of course, social distancing has really been shown to be the most effective step.  And I think they'll need to continue to exercise that until we have an effective vaccine, which is looking promising, but it seems like we will have to go through fall and this coming fall and winter with the current tools that we have, which is mostly around social distancing.

But to answer your question, yes, there are other things that can – that one should practice as well.  Frequent time bushing, of course, minimizing exposure to contacts and avoiding large crowds, for safe distancing six feet, you know, I get I get asked a lot what is safe distancing?  Six feet is what's really scientifically been shown to greatly reduce your chance of catching infection.

Of course, use a mask when you go outside that protects others, that protects you.  Keep up-to-date with your medical appointments.  If you don't feel well, take your temperature regularly.  And something that I mentioned earlier, find out from your doctor when your white blood cell counts are likely to be the lowest or you might be in the most vulnerable stage after treatment, and just exercise extra caution during that time, especially, you know, being around others.

Finally, staying up-to-date with the CDC guidance is a good idea because it's such a fluid situation.  There are new guidelines and recommendations coming every day and we try to keep our patient informed.  But look up here, local Department of Health and CDC guidelines as often as you can, and encourage your caregivers to also follow these precautions.

Sergio Giralt: Nicole, a lot of our patients and other people who are on the webinar have asked the question, you know, sometimes they are not – their jabber doesn't work or their phone connection doesn't work, you know, what can we tell these people that, you know, if we can't make the connection, we – how are we making sure that we connect with them?  And what are we doing to make it easier to do telemedicine from their standpoint?

Nicole LeStrange: So we do have a support administrative staff that focuses on enhancing the patient experience when it comes to telemedicine.  And they are reaching out to the patients prior to their visit to make sure they have, you know, the appropriate app downloaded and if not can help them troubleshoot. 

If all out fails with that technology on the smartphone, we can use – just do a regular phone visit, minus the video.  So we have done that in certain situations where the patient side in terms of the application isn't functioning properly.  So we do have a support system in place to, you know, make it as easy as possible for patients.

Sergio Giralt: And I think that's important that we are making sure that we stay in connection, and then we continue to follow your care.  So, I mean, let's get beyond COVID-19.  I think, you know, we've all you know, this has all affected our lives, but we're really here to continue to deliver the best cancer care and to, you know, improve the, you know, everybody's cancer journey and to, you know, take care of patients and their needs and the care and the needs of their caregiver.

So, Marty, can you talk a bit of what's new in the horizon for you?  What's exciting you in the area of leukemia?  What do you think is going to make the biggest difference?

Martin Tallman: I think you actually made a very good introductory point.  And that is that despite the difficulties with COVID-19, we’re all trying to cope the best we can.  There's actually never been a more exciting time to be in the field of I think hematologic malignancies.  There's been an absolute explosion of new drugs and new treatment strategies.

For example, take acute myeloid leukemia.  The date – the initial treatment for acute myeloid leukemia was described in 1973.  And until 2017, 44 years later, we had no new drugs, approved, no sustained approvals of new drugs in 44 years.  And then beginning in 2017, in the course of about 24 months, we had eight new drugs approved by the U.S. FDA for AML.  There have also been new agents approved in ALL, acute lymphoblastic leukemia, chronic lymphocytic leukemia, chronic myeloid leukemia in the last few years. 

I think the new is being one fitting one of three major categories.  The first are small molecule inhibitors.  These are small molecules interfere with the machinery of the leukemia cell and inhibit the growth of the leukemia cell.  They often inhibit specific abnormal genes.  They're called again small molecule inhibitors.

The second of the three major categories of what's new in the horizon are antibodies.  These are targeted or directed against a specific marker on the surface of a specific cell.  And sometimes these antibodies are actually linked or connected to a very potent toxin so that the antibody brings the potent toxin with it, targets the cell, gets inside the cell, the antibody releases and drifts away, leaving the potent toxin in the cell to kill the cell.

So the second of the new agent – of the new strategies, what's new in the horizon, I think are antibodies.  The first was small molecule inhibitors, the secondary antibodies and antibodies connected or linked to potent toxins. 

And the third I think are what we call cellular therapies.  We've mentioned briefly this afternoon.  CAR T-cell therapies, for example, are the example of cellular therapies, which is proving more and more important strategy for patients with hematologic malignancies.

Sergio Giralt: Thank you very much, Marty.  Anita, what's exciting you and how is the field of lymphoma going to change dramatically over the next five years?

Anita Kumar: So, you know, I really share Dr. Tallman's excitement and optimism, you know, it's been really tremendous within, you know, my career to see such a tremendous development of so many new therapies that are really meaningfully changing outcomes for patients with lymphoma.

And there are, you know, many common themes between leukemia and lymphoma in terms of the treatments and the advances.  One of the things that have been really exciting is to have a better or deeper understanding of the biology or the unique features of different types of lymphoma.  There are over 100 different subtypes of Hodgkin and non-Hodgkin lymphoma.  And increasingly, we have a better understanding of the lymphoma cell at the level of the DNA or the genetic programming that drives the cell and how it behaves.

Fundamentally, cancer cells grow and divide in an unchecked manner.  And we have, in recent years gained insights into how changes at the level of the DNA or genes, which are called mutations can learn, can lead to, you know, really turning on different pathways in the cell that drives the growth of these cancer cells.

And what's been really exciting, as Dr. Tallman mentioned is the development of biologically targeted therapies, which can target these abnormal genes or mutations or key pathways within the cancer cell and lead to cancer cell death and really, you know, effective control of lymphomas over the course of time.

And many of these treatments are actually oral therapies, meaning they can be taken as a pill, you know, every day or twice a day by patients.  And, you know, excitingly, they are oftentimes less toxic than many of the standard chemo therapies that we used in the past, which means that patients can live fuller lives and have a better quality of life and not have to deal with as many of the side effects and toxicities that were associated with chemotherapy and high dose therapies in the past.

In terms of other exciting areas of research in lymphoma, I think broadly speaking immunotherapy has really led to dramatic improvement in outcomes for patients with lymphoma and patients with cancer in general.

There are a number of different kinds of immunotherapies like Dr. Tallman discussed, targeted antibodies, also category of drugs called checkpoint inhibitors, and CAR T-cell therapy.  And, you know, for example, the checkpoint inhibitors which work by releasing a natural break on a patient's immune system so that immune cells called T-cells can recognize and attack cancer cells have really revolutionized the care of patients, for example, with classical Hodgkin lymphoma that didn't respond well to chemotherapy or bone marrow transplantation.  And the same is true with CAR T-cell therapy, which has really dramatically improved outcomes for patients with aggressive B cell non-Hodgkin lymphoma.

Sergio Giralt: Thank you very much, Anita.  I am sorry, because I think we're starting to run out of time and I wanted to give Alex a chance to also talk about what's happening in myeloma and obviously, I need to talk about transplant.

Alexander Lesokhin: Thanks very much for the opportunity.  I echo all of the enthusiasm from both the Dr. Tallman and Dr. Kumar.  You know, in myeloma, there's also been a tremendous amount of development of both new drugs focused on, mainly on monoclonal antibodies and the utilization of monoclonal antibody technologies. 

I think daratumumab has been sort of the – one of the transformational agents approved in recent years.  And current research endeavors really focus in on how to best use this drug in the frontline setting.  And so one of the more exciting things that's coming out of this is development of an antibody plus sort of more traditional myeloma drug triplet combination, so basically, antibody plus triplets or quadruplets combination that really is quite tolerable and has really good first line efficacy.

To add to that, our ability to both to measure efficacy in a more deep sense sort of minimal the concept of measuring minimal residual disease as an outcome measure is really something that's emerging that will help us guide our treatment strategies to help identify patients at risk for early disease recurrence.

And things that are currently being evaluated in the more advanced disease settings, and which will hopefully soon move earlier into the therapeutic realm of myeloma are similar to what Dr. Kumar and Tallman have already talked about things like CAR T-cells antibodies with toxins attached as well as engineered antibodies that bind to myeloma cells and also bring in other immune cells these class of drugs called Bi-specific engagers, or BiTE drugs that can bring in T-cells that are already in the patient to the side of the myeloma and activate them at that site and offer a therapeutic that's kind of off the shelf ready.  That provides a strong immune effect.

And these kinds of targeted agents can be targeted against multiple targets it seems.  There is one target that is highest on the list here for evaluation, DCMA is its name.  But there are other targets that are also not far behind and in development and also look very, very promising.  So all of these things, I think, offer a lot of excitement, for continued benefit for an improvement in both quality and longevity for our patients.

Sergio Giralt: And we're very excited in the transplant arena that we can use and, you know, incorporate many of these new strategies into our transplant platforms to be able to give patients the longest life with the best quality of life.  We're also working hard and trying to make the transplant journey a lot easier.

You've already heard from Nicole of how we do outpatient transplants, we're trying to minimize the time of patients need to visit the hospital. We have a huge research agenda and try to reduce all transplant related toxicities.  We're going from what we call, you know, push the drugs, pour the cells and pray that it all works out to what we call the new triple p transplant, we call it personalized, precise and predictable.

So really a lot is happening in the field of blood cancers.  We're hoping to give patients longer life, better quality of life and reduce the burden of treatment.

I want to thank everyone who submitted questions and thanks to all of you who made the time to join this call.  We hope you find it informative and helpful.  I want to thank my colleagues who join this call, Dr. Lesokhin, Dr. Kumar, Dr. Tallman, and Nicole LeStrange.  I want to thank our friends from communications who made this call possible.

We plan to host more calls like this in the future.  We look forward to speaking with you again.  A replay of this call will be available soon on our website, which I urge you to visit often for the latest updates at MSKCC.org.

We are dedicated to moving your cancer care forward and want to encourage you again to be in touch with your MSK doctors and care teams.

Please be safe and take care of yourselves and your loved ones.  And I want to also thank Dr. Mini Kamboj for her excellent presentation of where we stand with COVID today and for her leadership during this COVID-19 pandemic and she has kept us safe and kept us sane.  Thank you all once again and enjoy the rest of your afternoon.

Operator: This concludes today's call.  Thank you for joining this Information Session for Patients and Caregivers.  Have a great afternoon.