The James Cancer-Free World Podcast

Two James physicians are part of an international clinical trial that utilizes an artificial intelligence (AI) algorithm to better determine the risk factor of a patient’s colon cancer and whether or not chemotherapy is necessary after surgery. “The algorithm determines if a patient is high, medium or low risk category,” said Eric Miller, MD. Miller is a radiation oncologist who specializes in treating patients with gastro-intestinal cancers such as colon cancer. He has teamed with Vidya Arole, MD, MBBS, an assistant professor in the Department of pathology and an expert in the pathology of colon cancer. The clinical trial began after Arole met a team in Norway. “They had a tool, an algorithm, for stage 2 and 3 colon cancer patients and we decided to collaborate,” she explained. “They basically trained their algorithm from thousands of patients in Europe already treated for colon cancer to predict the outcomes,” Miller added. “The next step, here at Ohio State, was to use the algorithm on patients we had already treated, in which we knew the outcomes, and to see if the algorithm could accurately predict the outcomes … and it did a pretty good job.” Understanding and predicting the severity of a patient’s colon cancer and whether or not chemotherapy is needed after surgery has traditionally been the role of pathologists, in consultation with a patient’s oncologist. “We are the doctors who give a diagnosis by looking at the cells under a microscope traditionally [and now with digitized pathology],” Arole said. The James is a world leader in adopting and utilizing digital pathology. AI is the next step forward. “It’s like having a second set of eyes,” Arole said. The work is in the clinical trails stage and has great potential. “The first goal was to validate the findings from Norway here in the United States,” Miller said. “The next goal is to increase the patient numbers and make sure the results still stand.” Miller is optimistic the AI algorithm will continue to “learn” and help him and his James colleagues better understand which patients need the additional chemotherapy and which ones don’t.

The mission of Chyke Doubeni, MD, MPH, is clear. “I believe everyone deserves the right and opportunity to get the best care possible and I believe people who have socioeconomic and other barriers need not be prevented from getting that care,” said the Wexner Medical Center’s Chief Health Equity Officer and the OSUCCC- James Associate Director for Diversity, Equity and Inclusion. “All of us at the Wexner and James are very motivated by our mission to insure that everyone in Ohio has the best healthcare possible.” Dr. Doubeni is a family doctor and his research focuses on the effectiveness of screenings, such as colonoscopies, lung cancer and breast cancer screenings and recognizing and overcoming the social determinants of health. “These social factors are major contributors to poor health outcomes for underserved communities and understanding and addressing these barriers is crucial and my role is to create the processes to allow us to do this with better fidelity,” he said. His goal for the James is to provide better educational, screening, testing and treatment options to underserved populations in Columbus and in rural areas of Ohio, such as Appalachia. One of the ways to do this, Doubeni explained, “is to go to people where they are … with our mobile lung cancer van, our mobile breast cancer van and a free colonoscopy program run by the staff of the Wexner and James who volunteer their time.” Colon cancer screenings are another important area. The James is in the midst of what Dr. Doubeni called a pilot program in which people are given a fecal immunochemical test (FIT) that that is not invasive and that they can take at home to detect this all-too common type of cancer. “Our hope is to reach even more people who wouldn’t otherwise be screened,” he said. The James is also leading the way in using circulating tumor DNA to detect cancer in its early stages. “We have found ways to use a liquid biopsy, a blood sample, to detect cancer in the blood,” Dr. Doubeni said. This type of screening is still in the early stages, shows great promise and could be effective in reaching underserved populations.

The OSUCCC-James has one of the largest and most comprehensive blood and bone marrow transplant (BMT) and cellular therapy programs in the country, led by Marco de Lima, MD. “You want to cure everyone, period and we work toward that,” de Lima said, as he explained what drives him to find better treatment options for patients. “That’s the motivation and the only currency that matters, and that’s helping people.” Dr. de Lima described three new programs designed to help patients in Ohio and beyond: providing bone and blood marrow transplants (BMTs) and chimeric antigen receptor (CAR) T-cell therapy on an outpatient basis; engineering the genetic modifications of the cells used in CAR T-cell therapy inhouse; and a partnership to expand cellular therapy programs in Brazil. In the CAR T-cell process, T cells (the cells that fight cancer) are removed from a patient and reengineered in a lab to make them more efficient in recognizing and killing cancer cells. They are then put back into the patient to do their job. In the past, patients were admitted to the James during BMT and CAR T-cell treatments “and their stay was three to five weeks, in relative isolation,” de Lima explained, adding that “our ability to prevent infections, safer chemotherapies have set the stage where we don’t have to admit some patients … We will continue to offer inpatient options but will expand the option of coming here daily instead of being admitted to the hospital.” About 20 patients have undergone CAR T-cell treatment on an outpatient basis already. “Of these, 40 percent never needed admission to the hospital and the other 60 percent had their admission times dramatically reduced,” de Lima said. “We want to increase the percentage who will never see the inside of a hospital.” In the past, it took up to two months to send and receive back a patient’s re-engineered T cells from labs located throughout the country. “That’s too long,” de Lima said and then explained that the OSUCCC – James can now re-engineer the T cells inhouse. “We’ve currently treated 14 patients in a clinical trial and it’s taken us seven days from collecting the cells to giving them back to the patient,” he said. Dr. de Lima also described a partnership with Caring Cross (an organization devoted to providing medical services to underserved populations around the world) and Brazilian health officials. Members of de Lima’s team at the James will provide the technical expertise and training to create mobile clean rooms in Brazil that will re-engineer cells for CAR T-cell treatment. “This is a very ambitious program to provide CAR T-cell for free within the Brazilian healthcare system,” de Lima said.

The James has one of the largest head and neck cancer departments in the country, featuring experts in robotic and reconstructive surgery, proton radiation, chemotherapy and immunotherapy treatments, as well as cutting-edge clinical trials. “The key is you need a huge support network [of nurses, therapists and other specialists] to get patients through surgery, radiation, chemotherapy and immunotherapy … we have a team of more than 200,” said Matthew Old, MD, director of the James Department of Otolaryngology – Head and Neck Surgery. Any cancer above the clavicle, except for brain tumors, are head and neck cancers. The number of head and neck cancer cases is on the rise, Old said, adding the reason is the prevalence of the human papillomavirus in adults. “We’ll see an increased rate for the next 10 to 15 years because the HPV vaccine wasn’t available a few decades ago … HPV is the cause of about half the head and neck cancers we see.” James surgeons perform about 350 transplants a year for their head and neck cancer patients. “We are all cross trained in reconstructive surgery,” Old said. “We can take tissue and bone from a patient’s body and use it to reconstruct their tongue, mouth, jaw, any type of defect.” Old said that between 50 and 60 head and neck cancer patients receive radiation therapy daily at the James. The James is one of the few cancer hospitals offering proton radiation and it’s “more precise and we think it minimizes the long-term consequences to the patient,” Old said. There are about 20 head and neck cancer clinical trials at the James. In one trial initiated by James physicians and scientists, patients receive immunotherapy before surgery. “This is done to prime the immune system to recognize the cancer cells as foreign,” Old said. “Then after surgery, the patient receives a year of immunotherapy.” In another clinical trial, James doctors utilize circulating tumor DNA to determine the effectiveness of treatment for their patients. “We can watch their response to treatment and tailor the treatment accordingly,” Old said.

Breast screenings saves lives, and the James Cancer Hospital’s Stefanie Spielman Comprehensive Breast Center is a world leader in providing screenings, such as mammograms. “I really care about each and every patient and I want to make sure every woman has access to good health care and knows that we’re here to help then through this,” said Amy Kerger, DO, a diagnostic radiologist and mammogram expert. In this episode, Kerger explains the history of breast screening, which dates back more than 100 years and began with X-rays. Low-dose radiation mammogram machines were introduced in the 1960s “and the United States started screenings programs in the 1990s when the (Food and Drug Administration) enacted standards,” Kerger said. Every woman should begin getting yearly mammograms at the age of 40, and those considered high risk, due to family history and other factors, should start at an earlier age in consultation with their doctors. “There are still 20 to 30 percent of women who don’t come for yearly screenings,” Kerger said. “If you wait until it’s palpable or other symptoms, the treatments are harder and it’s harder to save that woman’s life.” The Spielman offers breast screenings in several locations throughout central Ohio. All James mammograms are done with the latest 3D technology, which is known as breast tomosynthesis. “Ultrasound is often used for women with dense breast tissue,” Kerger explained. “Women with dense breast tissue have a small, increased risk of breast cancer and it’s easier to see through the dense tissue with ultrasound.” Overall, 8 percent of women will get breast cancer during their lives, Kerger said. Spielman experts discuss family history and several other factors, such as having a child at a later age or getting periods at a younger age, and determine each patient’s risk of breast cancer. Those who score a 20-percent risk are considered high risk and are referred to the Spielman’s High-Risk Breast Cancer Program. “At the Spielman we are all specialists in breast cancer,” Kerger says. “I only read breast imaging. Our surgeons and radiologists only specialize in breast cancer. I feel that we know what patients are going through and we’re there to help you get through that.

The James provides a comprehensive survivorship program for patients and their families. “People are living longer with cancer and how do we make sure they have the best quality of life during their treatment and the years beyond,” said Denise Schimming, APRN-CNP, a certified nurse practitioner and survivorship specialist. Schimming and Julie DeBord, MSW, LISW-S, manager of JamesCare for Life, discussed the history, growth, the numerous and growing number of programs they offer and how they connect with patients and their families. “JamesCare for Life has been around for more than 20 years,” DeBord said. “We started with 10 programs and now we average more than 30 programs a month and we’re continually looking at how can we meet the needs of our cancer patients and their families.” Some of the many programs JamesCare for Life offers include music and art therapy, nutrition classes and healthy cooking demonstrations, physical therapy, individual and group sessions from mental-health professionals, and presentations by James experts on a wide range of cancer-related topics, such as lymphedema. JamesCare for Life also provides equine therapy for families and the Garden of Hope is a large farm that provides patients and caregivers the opportunity to harvest and take home a wide variety of vegetables and herbs. “Cancer can be isolating and scary and we have educational classes to help with coping during times of uncertainty to manage stress, mindfulness programs for stress reduction and support groups and one-on-one care support,” DeBord said. Schimming and her team connect with patients while they undergo treatment, while DeBord and her JamesCare for Life team offer free programs for patients and their caregivers after treatment. Schimming and DeBord work together to meet the needs of patients and create new programs. An example is the recent addition of two certified child-life specialists. “We heard from patients that they didn’t know how to tell their children and their grandchildren about their cancer,” Schimming said. “We hired two certified child-life specialists, one for inpatients and one for outpatients. They’re experts in helping families cope with medical illness and we created a special playroom [in the James] for these interventions.”

The James Cancer and Aging Resiliency (CARE) clinic is a leader in treating older cancer patients. Patients have been treated with blood and bone marrow transplants (BMTs) for more than 40 years, but, initially, only younger patients were eligible. “There was a bar set as low as 40-years-old when this was a brand-new technology,” said Sarah Wall, MD, MPH, a James hematologist who specializes in treating patients with blood cancers. “Then it was 55 and 60 and 65 and now there is no official upper-age cutoff … it comes down to the individual patient.” In this episode, Wall explains the basics of BMTs. “There are two types, autologous, where a patient gets their own stem cells back, and allogeneic, in which we use donor cells,” she said. Improvements in the drugs used to treat graft-versus-host-disease (GVHD), which can occur in allogenic BMTs, have “really expanded the pool of donors for older adults who may only have siblings who are deceased or have had cancer themselves previously or some other disease that would make them ineligible,” Wall explained. “We have better drugs to prevent graft-versus-host-disease and to treat it when it does happen.” Several patients 70 and older have been treated with BMTs at the James. Wall said her oldest BMT patient is 80. “I have a [group] of the first three gentlemen 70 and older who I treated with a transplant all coming up to their five-year anniversary,” Wall said. “It’s a testament to them and to their families and caregiver support that they got through this. We’re the scaffolding they build this support on … and it’s very rewarding to be part of this and especially to open doors for people who thought they were closed.”

Pelotonia has changed Joe Apgar’s life. “I’ll never forget how I felt in the moment someone told me I had cancer,” the CEO of Pelotonia said in this episode. “You feel completely lost and by yourself and you don’t have answers to the questions running around through your head.” Apgar was diagnosed with testicular cancer while a student at Penn State. Pelotonia is the fundraising cycling event that has raised more than $285 million for cancer research at the James. Apgar first rode in 2011, soon after he moved to Columbus to work for Rockbridge Capital, a private equity firm that sponsors a Pelotonia team Apgar helped create. “I remember standing at my first opening ceremony [of Pelotonia] and how uplifted and excited and supported I felt … that’s when I could flip the switch on it and feel empowered by my own story and experience,” Apgar said of the start of his first ride and crossing the finish line. Apgar talked about his cancer journey, how he connected with a James physician for his follow-up cancer care, his Pelotonia experiences as a rider and leader, and the future of the event. Apgar also talked about the importance of the Pelotonia “community” and how it has helped connect members of the James team with riders, volunteers and donors. “I think [the Pelotonia founders] hoped that some of this sense of community would happen, but I don’t think anyone could have dreamed it would happen at the scale it has,” he said.

Because adrenal cancer is so rare, very few cancer hospitals have specialists equipped to treat patients and perform research and offer clinical trials for this type of cancer. “Very few physicians ever see a case in their lifetime and so there are a lot of physicians out there who don’t really understand the disease process,” said Barbra Miller, MD, the co-director of the James Multidisciplinary Adrenal Clinic. “I want to make sure patients get good, consistent and comprehensive and safe care and as a surgeon I want to make sure every patient gets the best surgery.” In this episode, Miller and Priya Dedhia, MD, PhD, a James expert in adrenal surgery and research, discussed this rare form of cancer and the wide range of screening and treatment options at the James, and their cutting-edge research. There are currently no screening procedures, such as mammograms for breast cancer or colonoscopies for colon cancer. This means adrenal cancer is often first diagnosed in the later stages when it has metastasized and spread. “We don’t know there’s a tumor until it’s quite large or has gone somewhere else, and another way we know is if [the cancerous adrenal gland] overproduces hormones,” Miller said. Some of the research at the James is focused on understanding how benign tumors in the adrenals can become cancerous. “We know colon cancer starts as a benign polyp,” Miller said. “We never thought this was true with adrenal cancer but now we’re at the stage where we think we can prove this is true.” Surgery is the primary modality for treating adrenal cancer, often followed by chemotherapy or, in recent years, immunotherapy. “We’re working to create new models for adrenal cancer treatment,” Dedhia said, adding that in her lab she has created “organoids” that “are like patient avatars and help us better understand and treat the cancer.” Organoids are masses of cells grown in the lab and can be used to test the effectiveness of new drug treatments, such as immunotherapy, prior to clinical trials in patients. “We’ve found two new pathways that kill these organoid cells and the next step we’re hoping for is a clinical trial,” Dedhia said. “We believe we’ve found a way to improve the immune response [of new immunotherapy drugs] and we’re very excited.”

A breast cancer diagnosis in 2011 changed the life and career path of Jessica Winter. “It was a really defining moment in my career,” said Winter, PhD, an Ohio State professor of engineering, and a member of the Ohio State Cancer Engineering Center. “I could have kept doing research and publishing papers … but now I really wanted to do translational work and take something from the lab to patients.” Winter is a leader in the growing field of utilizing nanotechnology for cancer science and treatment. “There are three areas where it can be applied – imaging, biosensing and drug delivery,” she said. Winter and her lab, and her collaborators at the James and the Ohio State Cancer Engineering Center are involved in all three of these areas. Nanotechnology has been used since the 1990s to deliver chemotherapy drugs. “Nanotechnology is defined as something between the size of one and 100 nanometers,” Winter said. “You can fit five million nanoparticles that are five nanometers in diameter inside a cell.” In her lab, Winter has developed what she calls “quantum dots” to improve the delivery of drugs to cancer patients. Another area of her research involves biosensing. “The COVID test is a biosensor and some of the earliest biosensors were home-pregnancy tests,” Winter explained. Winter and collaborators at the James are also working on a nanotechnology biosensing method to analyze solid tumors. “We came up with a method of erasable labelling,” she said of the method in which several different colors, or layers, of can be used to create a series of images. “We need better diagnostic tests to match the patient with the best therapy, this is personalized medicine,” Winter said. Her cancer diagnosis (she is in remission and doing well) continues to motivate Winter. “I love my job and what I do,” she said. “The idea that I can help people … and make real things for real people is very exciting.”