Ask the Doctor: Exploring Mesothelioma Treatment With Dr. Nicholas J. Vogelzang

Nicholas J. Vogelzang, M.D., FASCO, FACP, is part of Comprehensive Cancer’s medical oncology team that provides world-class cancer care in a supportive and caring environment. Vogelzang leads and participates in multiple clinical trials in genitourinary malignancies and phase one mesothelioma trials. He also focuses on new therapies for patients with metastatic kidney, bladder and prostate cancer. We caught up with Vogelzang to discuss new advancements in mesothelioma treatment and the effects of the COVID-19 pandemic on his patients.

Q: This year’s ASCO conference was held virtually (due to the COVID-19 virus), yet still featured 90 education sessions and 300 speakers from across the globe. Did you attend or present at ASCO20?

A: I didn’t present anything. I had my name on two papers, two presentations, but most were in the world of prostate cancer. I didn’t have anything in mesothelioma this year.

Q: Your areas of special interest are genitourinary malignancies and thoracic and lung cancer, as well as clinical research, particularly phase one trials for all solid tumors. To confirm, you are still treating mesothelioma patients, correct?

A: Oh yeah, there just aren’t that many. So, you know, the number of patients that I have at any given time is maybe half a dozen or so.

Q: When the pandemic began, we discussed how your mesothelioma patients were being affected. At the time, this strain of coronavirus was very new, and everyone was beginning to adjust. Now that more time has passed, can you identify any routine changes you’ve noticed? For example, canceled appointments, treatments, restrictions, etc.?

A: Yeah, the biggest problem with the epidemic has been the fear patients have with attending the clinic. A number of patients have just not been willing to come see the doctors, so there’s been some video telehealth conferences. And we try to be as far apart on routine visits as we can get that I think is safe.

But, you know, the emphasis on mesothelioma has been immune treatment, and the new double immune treatment. Nivolumab and ipilimumab have really had a big influence on a lot of patients because they no longer have to deal with nausea, vomiting, diarrhea and the mouth sores that come with standard chemotherapy. The immune treatments have been quite easily tolerated, even in the elderly population. So, the need for follow up and monitoring of blood counts, etc. is less frequent. The immune treatment side effects, though, still have to be monitored. [Gastrointestinal] side effects can still occur, so they have to be monitored.

In general, immune therapy has been easier to tolerate for patients than chemotherapy. Therefore, immune treatments are given every either three weeks or, after the first four doses, every four weeks. Their need to come to the office is somewhat diminished, which has alleviated some of their fear. A lot of the mesothelioma patients, though, are out there still getting second opinions and flying to various other sites for opinions.

Q: There’s still a lot that we don’t know about the long term effects of the COVID-19 pandemic. However, with your extensive background in researching and treating rare cancers, what are one or two of your pressing concerns about how this novel coronavirus may have lasting effects on those diagnosed with mesothelioma and other forms of lung cancer?

A: That’s a very good point. I have a lady right now with lung cancer, very bad lung disease from years of smoking, and she developed COVID-19 during chemotherapy and radiation for her lung cancer. Unfortunately, she’s doing very poorly and is in the intensive care unit right now. So, it’s sometimes the straw that breaks the camel’s back. She obviously was very ill with multiple medical issues, radiation, chemo, emphysema, lung dysfunction (needing oxygen). Then COVID-19 comes in and sort of pushes her into a deep, deep, possibly not reversible event. So those are the issues.

Meso patients are in that same boat in that they already have underlying comorbidities, and they’re very fearful. But, you know, I explained to them that the fear of cancer is a bigger fear. COVID-19 is not that common. If you look at all the patients in the world who have had lung cancer, it vastly outweighs the number of COVID-19 patients. So, lung cancer is still a very serious public health threat, as is COVID-19. I’m not diminishing the impact of COVID-19, but lung cancer and mesothelioma patients have sort of a double level of concern.

Q: What advice and recommendations are you providing your patients to stay safe during the pandemic?

A: Risk in the time of COVID-19 is what a cancer patient deals with constantly. I had a patient who said, ‘Well, now the rest of the world knows what it’s like to have cancer.’ Because with cancer, you don’t know when the next problem is gonna rise. You don’t know when the next shoe is gonna drop. So, everyone with cancer has always faced this level of risk and uncertainty. As far as what you can actively do, you know some data says that masking is helpful and that social distancing is helpful. But, other data is suggesting that this virus is just going to play itself out.

No matter what anybody says, the older, elderly, and sicker folks are far more likely to get COVID-19 than younger and otherwise healthy patients. So our clients, our patients, lung cancer and mesothelioma patients are at risk. There is absolutely no question. How do you reduce it? Just like I said, mass handwashing and social distancing. I’m not sure if face masks are of any help. There’s nobody who has been able to prove that except in operating rooms.

Q: As you know, once a patient is diagnosed with mesothelioma or another type of lung cancer, they begin researching and understanding their diagnosis and possible treatment options. One significant aspect of their treatment plan may include taking part in a clinical trial. For the patient who wants to understand what this means, can you explain what clinical trials are and what the advantage or appeal might be?

A: Each institution, each location can select its own clinical trial portfolio. Sometimes that portfolio is based upon National Cancer Institute trials. Sometimes it’s based upon the institutional trial. Sometimes it’s based upon pharmaceutical company trials. Many times it’s a mixture of all three. The clinical trials, in general, are slowing down during the COVID-19 epidemic, because they require more visits. They require a bit more intensity in terms of monitoring and X-ray frequency, etc. But I haven’t seen any slowdown in our clinical trial accrual. What we’ve seen is a number of companies that have restricted or stopped entry into their trials. The trial is always more complex than just letting your doctor decide what he wants to do, or what she wants to do, with your care. The clinical trial has more rigidity to it; it’s more regimented. Patients have their blood drawn a certain number of times and get X-rays a certain number of times. Many times it’s with a new drug that has to be monitored more closely. We encourage clinical trials, but for many patients it’s an extra burden. And not everyone wants to take on an extra burden, especially when dealing with advanced cancer.

Q: The randomized, phase three CheckMate-743 trial broke new ground in malignant pleural mesothelioma (MPM) by establishing that dual immunotherapy can prolong life without chemotherapy. How promising is this research, and what does this mean for patients diagnosed with pleural mesothelioma? Is this the new standard of care?

A: Well, I believe so. The new standard of care in my patients who walk in the door is the double immunotherapy with nivolumab and ipilimumab. They still have a significant risk that the cancer will come back with double immunotherapy. None of these treatments have a high rate of cure. There are some whose cancer goes away for long periods of time, but not a majority. So, although they may get immunotherapy first, the large percentage of our patients will still need other life-extending treatments. Those include chemotherapies, sometimes radiation, sometimes surgery, and sometimes clinical trials.

Q: Last year, Novocure received FDA approval for Optune Lua, a tumor treating fields (TTF) device designed to treat those with unresectable, locally advanced or metastatic MPM. Although TTF technology has been around for a while and was initially designed to treat patients diagnosed with glioblastoma multiforme, what is your opinion of this treatment option for mesothelioma patients? Have you recommended it to any of your patients who fit the criteria for its use? 

A: We’ve talked to the Novocure people, and they’ve been trying to get us to set it up. It requires a fairly complex system. It’s done mostly through radiation oncology, but there’s still many slips between, as the British say, the cup and the lip. You have to get it going, it has to have a billing code, insurance has to approve it, the patient has to copay a certain amount, and it’s only allowed as a first-line treatment with chemotherapy. So, if you’re going to do an immune treatment, the Novocure device is not an option. Once you’ve used immune treatment, your next up would be chemotherapy. The Novocure label indication is first-line and with chemo. That immediately presents a problem for the Novocure folks, because the new first-line treatment is immunotherapy. I think there’s going to be some folks that we’re going to try to get their insurance company to pay for it for their first chemotherapy, which would be the second treatment.

Q: As one of the rarer cancers, mesothelioma research and treatment is undoubtedly unique. What advancements are you hoping to see in mesothelioma treatment in the near future?

A: The biggest would be to find ways to make the current immune treatments more effective. There are a host of drugs that are potentially going to stimulate the body’s ability to respond to the immune treatments. For example, I’m working with a small company in Utah that was bought out by a Japanese company. They have a drug that alters the glucose metabolism within the cancer, which in animal models has made the immune treatments more effective. So, we’re giving this drug orally, first, and then the next step will be to administer it with the immune treatments and then measure the benefit thereof. But there are a whole bunch of these combinations of a drug and immune treatment. Many of them are working away through this clinical trial system right now. Now there’s also the long-held interest in anti-angiogenesis affecting the blood vessel growth into the cancer, and we have a positive trial.

We have a positive trial of chemotherapy with a drug called bevacizumab or Avastin, and there have been two of those. That one was from my colleague Dr. [Hedy Lee] Kindler at the University of Chicago, who was using platinum gemcitabine therapy, and the other was from Salzach in France. And that was using platinum olympic, with or without the bevacizumab. That was slightly favorable in terms of survival for the blood vessel inhibitor. So there are new and more powerful blood vessel inhibitors. That’s another angle that is being pursued in the mesothelioma world—so, ways to stimulate the immune system more effectively and ways to make chemotherapy more effective.