Dr. Andrew Pippas, Oncologist
Hello and welcome to another edition of Riding in Cars With Researchers. I’m Dr. Jeff Kingsley and I’m here today with Dr. Andrew Pippas, an oncologist and good friend of mine. Dr. Pippas has been doing research for quite a bit of time now and we get a chance to peek behind the curtains and find out what makes him tick. Dr. Pippas, I greatly appreciate you taking some time.
How long have you been doing research?
I began clinical research in 1995. I left Duke in 95 and I went into practice in central Florida and we did some clinical research there. Then the hospital began to do clinical trials in cancer and that really got me excited because we had a chance to do some good Phase 2 studies that led to the approval of several drugs and the hospital supported it greatly. That made me realize that you could do great clinical research away from academia.
Why do you take on that extra challenge of adding on research to practice?
I think, in some ways for an oncologist, it’s almost an ethical responsibility. Not to say that other forms of medicine don’t do things at the cutting edge. They all do. I mean cardiology clearly pushes the envelope. Infectious disease is always looking at new and better ways – every discipline does. But if you look at the strides we’ve made in oncology, particularly in pediatric oncology, all of those major strides have been made by patients committing to being in a clinical trial. And I think that it’s a fundamental responsibility for practicing clinicians to be engaged in research in some way. It’s part of your calling,
I’m wired the same way. There’s actually a journal article that’s on our webpage. It was in an ethics journal about the moral obligation of physicians to participate in research.
I think that if you’re taking care of patients, you need to focus on something that’s at the cutting edge. It may not be a thousand cutting edges, Jeff, but it’s got to be a couple where you are doing basic translational research, looking at new ways to treat people. I believe that fundamentally.
Why should patients participate in research trials?
If you look at the major guidelines in cancer care, the guidelines in the United States, the NCCN guidelines and the ASCO guidelines or even the ESMO guidelines. All of them recommend and say they believe that the best cancer care for a patient is enrollment in a high priority clinical trial. Best care, not good care, best care. So. when you have organizations like that, I look at it and think that the best care can come from enrollment. I think with the right clinical trials, everybody in some way should have an opportunity. They may not say ‘this is for me’. They may have biased against it, but at least the opportunity to say, ‘I was offered a clinical trial, I looked at it, I’m all for it, but that’s not the way I’m wired now’.
I think what you’re describing though is different from what we read in the lay press, in newspapers, not in medical literature. What I typically see or perceive is that research is when you run out of all other options, when you’ve tried everything else, research is your last choice. What you’re describing is the opposite.
It is, and I think that particularly with medical oncology; particularly for illnesses that are difficult to treat. Patients with the primary glioma, patients with an advanced malignancy where we may have some drugs that work very effectively. We need to look at those agents, look at those trials, and look at those situations and say, can we do better? Are there ways to do better up front? And even in the settings where we have established very good therapies. For example, in Stage 3 colon cancer or early stage breast cancer, there are nuances in the way that you treat those people. Not only the treatment part of that but even after treatment when you look at survivorship, late toxicities, the psychosocial, the emotional toll of treatment, those are opportunities for investigation. The NIH and JBACC are looking at quality of life and survivorship studies. We are looking at the toxicity studies (at how chemotherapy affects fertility, for example) in premenopausal women. And we’re looking at other studies that look at how we can modulate toxicities of treatment. So even in those areas, where we have established treatments, we can make things better.
What changes that you’ve seen in how we care for patients in oncology.
In the last five years, there has been a revolution utilizing what I call the third arm of treatment. The first arm is surgery, the second arm is chemo and the third arm is the immune system. And even though we’ve talked about and used immunity in some ways almost like a crude tool, now we’re using it like a surgical tool. Pharma and investigators have looked at that modulation of PD-L1 or other ways to modulate T-cell activity. We have drugs now that inhibit the break of the immune system and allow the immune system to begin to activate and recognize cancer as a foreign entity. We’re now beginning to realize that that modality works in a variety of tumors, almost all cancers, to some degree. We are looking at ways to predict to whom that’s going to be a treatment option, and if it’s going to be a useful treatment modality. But clearly, now with the activation of the immune system using inhibitors, there are ways to treat cancer that are non-chemotherapy based and the standard way we think about chemo that is highly effective. You look at a disease like melanoma, for example, where you see response rates in the 50% range or greater and durable responses even with single therapy at 30-40% at three years in an advanced setting, just based on monoclonal antibodies at modulating the immune system. So that’s where we are with those agents, and the challenge will be, in the future, learning how to couple those immune drugs with chemo or to couple them with other forms of biological therapy, like tyrosine kinase inhibitors, and make sure that those are tolerable and more efficacious in the standard of care. So that’s going to be a huge series of clinical trials, hundreds of clinical trials, that will begin to modulate the immunity even further.
Can you envision a world where chemo goes away completely?
I can. I think chemotherapy will always have its place in some ways. I think that chemotherapy is still an extraordinarily effective modality for many forms of early breast cancer and colorectal cancer. It’s still an active modality in other forms of GI malignancies like pancreatic cancer. It’s still an effective modality for a variety of GU tumors like testicular cancer and even in lung cancer, which remains the leading cause of cancer death in the United States. Chemotherapy still has a role. but how we modulate it, or connect it with immune therapy, is going to be the next series of great big clinical trials. We already have answers like that in lung cancer.
What about CAR T cancer therapy?
CAR T is an important way to modulate signaling through the CD 19 receptor. It’s a way to dramatically activate T-cells to recognize an idiosyncratic cancer cell in cancer patients. Clearly it’s come to the market and is active in forms of leukemia, in certain forms of relapsed lymphomas, and it’s being studied in multiple Myeloma. It will be, in certain settings, a form of curative therapy for people who have exhausted other options. It’s efficacy in solid tumors has been looked at and being studied, but clearly in the hematologic malignancies. it’s going to be an effective treatment.
Can you imagine CAR T pushing into the community setting?
It’s been confined to mainly transplant facilities that are familiar with the toxicities of re-infusing CAR T cells. When that happens, patients get something called a cytokine release storm which can be difficult to manage. I do think it will happen in large community centers. JBACC is part of a large community system and a large hospital system, and we would look at potentially being affiliated with a system that does it more frequently than we do down the road.
What advice would you give to oncologists that today aren’t actively engaged in clinical research?
I would encourage them strongly to look into it. I would encourage them to begin to think about incorporating it in their practices and then realize the only way we’re going to fundamentally be able to answer questions is to get everybody involved. That’s everybody, and we hold it at JBACC as a mark of pride that we’ve been doing this for a long time. We think it differentiated us in years past from other centers near us. We think it’s a mark of quality care and we believe that strongly.
Any advice to oncologists on how to set themselves up for success, doing clinical trials?
The thing I would tell you is get involved with an organization that’s done it so they can educate you in how to get involved in clinical research. You could be successful at it, but don’t go at it alone. And make sure you have somebody who’s done it, who has as a history of clinical research to help you.
I think that oncology is booming in the variety of trials that we have available and the number of questions that we have to answer, and immunology (immunotherapy) is going to be increasing geometrically. I think that the combination of immune therapy and chemotherapy is going to be looked at more closely in a variety of cancers. I also think modulating immunity and adding drugs to the current drugs that we have available to make them either more responsive, to restore response for people who’ve had a response and have lost it; it’s clearly an area of interest for us as we have a trial looking at ways of resurrecting or restoring the immune system.
I think coupling biological therapy with immunotherapy is going to be huge. Again, the other thing I worry about in that setting are untoward toxicities or unknown toxicities. The learning in oncology is booming. The number of trials that are coming out in oncology is humongous. I think that if you look at the number of trials in oncology, and if you could combine the other disciplines or a couple of them, we still eclipse them. Oncology is more than 50 percent of all the research happening on the planet. We just need our doctors, our hospitals, and our patients to be aware that these are the questions that are out there – they’re important questions. We believe that being involved in research is going to not only potentially be better for you but be better for the folks that come after you to try to answer some of these questions. I think that’s the responsibility we have as clinicians – always looking, always asking, is there a better way to treat this patient? Is there a study for this patient? And having the ability to have those studies right here in Columbus.
Everything happens faster. The more participation that we get, we can answer these questions faster. And it’s important. I think probably there’s a good portion of the audience that doesn’t understand oncology research is so much more than just researching new ways of curing cancer. It’s diagnosing cancer earlier and more effectively.
It’s treating the symptomatology that goes along with chemotherapy and radiation. Radiation therapy is so much broader than that. It’s finding better ways to diagnose cancer with a blood test. It’s finding out ways to image the breast better, maybe less frequently, more proximally and maybe we’re not using mammography correctly. The treatment style is very relevant and then toxicity studies and then after that, quality of life after treatment. How do we get people back on their feet? How do we get people back working? Those are things that we need to look at.
The NIH has taken an interest in these quality of life studies, as well. We, fortunately, have those available through our CTSU and CTF affiliations. I think all of that is very relevant. For me, a successful patient is somebody that got into one clinical study, may have done well with it, goes onto another clinical study, then maybe a third or fourth clinical trial. That, to me, is a successful outcome of therapy or course of therapy for somebody. Those types of studies need to be available through the continuum of cancer, cancer care, diagnosis, screening, treatment radiation, if they need it. And then survivorship and long-term care.
Well sir, I greatly appreciate it. Thank you for sharing your impressions. Thank you for helping us revolutionize research and change how patients and physicians interact with researchers. It’s so essential.
Thanks for riding along!
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