Doctor Interview: Advancement made in Medical Oncology by Dr. Amit Agarwal

Sonam: Hello everyone, today we have on our panel discussion round doctor Amit Agarwal with us who is Director Medical Oncology from Fortis Hospital Shalimar Bagh. We welcome your doctor on board.

Dr. Amit: Thank you

Sonam: So to let you know about Doctor Amit. Doctor Amit brings with him an experience of more than 19 years into medical oncology and he is having a special interest in treating breast cancer, neuroendocrine cancers, and molecular oncology, Immunotherapy, and targeted therapy. He is also a member of the American Society of Clinical Oncology and the European Society of Medical Oncology and neuroendocrine tumors. So today we are going to discuss managing patients with medical oncology and the advancements we are having in medical oncology. So to start with the first thing I would like to ask is what exactly is medical oncology and what role does medical oncology play in treating cancers?

Dr. Amit: OK, so cancer treatment is complex and multidisciplinary, so there is no one set of doctors who does everything. Broadly speaking, there are three sets of doctors who will treat that. For example, there will be a surgeon. He will be called a surgical oncologist. Many patients will require radiation, and these doctors will be called radiation oncologists.

We are the doctors who treat their patients with chemotherapy, which are the chemicals for cancer treatment, and now the systemic treatment or updated treatment of oncology by us is not only chemotherapy, there are oral tablets available. Then there is a targeted therapy available that is more specific and more effective, and there’s a new class of drugs available immunotherapy which we will talk about. So we are the doctors who would treat the patient with chemotherapy, oral tablets, targeted therapies, and immunotherapy, we were known well for chemotherapy. And that’s how we were known as cancer-treating physicians. But now our scope has increased, so I hope that answers the question that what Medical Oncology plays a large role in the treatment

Sonam: So that is similar to what therapeutic advances we have in medical oncology. So we can say that not only chemotherapy, we have different therapies as well, like hormone therapy, immunotherapy, which play a role in medical oncology treating patients in medical oncology.

Dr. Amit: True, in fact, the role is becoming bigger than ever before. A large number of patients will be treated by chemotherapy. Their cancers would be analyzed by the lab and the lab would answer the question that is one kind of chemotherapy better than the other. Or don’t treat the patient with chemotherapy and avoid giving them toxicity or they would say that the tablet would suffice, or they would say that increase the immunity of the patient by specific drugs to kill cancer and lots of cancers can be treated easily better and some of them can be eradicated also. Whether innovations in medical oncology.

Sonam: So for treatment, what evaluation or what test is required to decide the protocol for the treatment?

Dr. Amit: There are tests to find out whether you’re dealing with cancer or not. So to establish the diagnosis, the most important test would be doing a biopsy these days in selected patients we may not do a biopsy. We may collect a blood sample in some subset and collect the cancer cells from the blood only and may be able to establish the diagnosis by what is called not biopsy or liquid biopsy.

So there are a lot of patients who do not want to get the virus. Not all of them, but in some of them we can simply do a blood test and tell them if it is a case of cancer or not. OK, sometimes, so that is an advancement in doing a biopsy, but still a large guarantee of patients would require buyers. So that is a test for saying it is cancer, then the second test that we need to know is how far is the cancer spread. For that, we have investigated X-rays, ultrasounds, CT scans, MRI, PET CT scan, PET MRI, and even the PET scan which is a highly sensitive tool for detection of the stage of her cancer, how far it has spread now. There are three or four kinds of pet scans available:

1. Basic pet scan.
2. PET scan specifically for neuro different team
3. PET SCAN which is perfect for prostate cancer and many other cancers.

So we are moving ahead and not just saying do one kind of a pet CT thing for you. The routine fed is not appropriate for you. A different kind of pet CT is more appropriate, that kind of thing. So there are a set of investigations. Now after the biopsies have been done or after the staging indignant that issue that we receive from the biosphere from surgeries analyzed for further testing. How best should we treat the patient? Does this patient really require surgery? Does this patient really require chemotherapy? Can I treat this patient with oral treatment only? Can I find out why the patient caught the Cancer? Can the patient acquire this cancer because of family history? Can the family also be investigated or like Angelina Jolie said that the family could be told that they can get cancer and they should start taking care of that? So a lot of new things are happening. So from biopsy for staging from many investigations. Finding out staging proper, telling about treatment and more information for better treatment including that other time.

Sonam: Yes, Sir, it’s the talk about hematologic malignancies. So what exactly it is, what is haematological malignancy, and how does genomic analysis affect the diagnosis of hematologic malignancies?

Dr. Amit: So the simple answer is hematologic malignancies. What we call late-term cancer is called hematological malignancy in technical terms. Now the genomic analysis of blood cancer is equivalent to what I had been talking about analyzing cancer. When you analyze breast cancer that is called breast cancer genomics. When you’re analyzing a hematological malignancy like blood cancer, there is a genomic of that. Almost all cancer cannot be treated without a genomic analysis detail. The tumor needs to be understood. We don’t tell a patient that you’ve got blood cancer. We tell you ABV is a kind of blood cancer. This is not only that more information is achieved from genomics, and of course, a nice special treatment should be offered to individuals and that means blood cancers may not be similar to each other. One person’s blood cancer may be very different from a second patient, not cancer, and the same blood cancer looks like breast cancer. Maybe it is very different in two different individuals because they would have minute differences which we could not find out before and they can find out. So that’s the genomic advantage of analyzing blood cancers and other cancers.

Sonam: So we can say that it is again one of the advancements which we have made for treating cancers and it helps in providing more accurate treatment reservations.

Dr. Amit: It’s a precision medicine

Sonam: So, uh, if we talk about immunotherapy now, immunotherapy. People have heard this word, but they are not aware of what exactly it is. Is it because some people think it is a part of chemotherapy? Some people think that it’s a new therapy that has been invented, but they are not aware of exactly what immunotherapy is. So what exactly is it? And how does it work?

Dr. Amit: OK, it’s a good question. So the first question. The first answer to the question is that it is not chemotherapy. That is the first answer to your other question. Now when we get a cough or a cold or typhoid, or even COVID for that matter, the majority of us would recover because our immunity would allow us to kill that virus above the bacteria or whatever it is that we really don’t need to. In our own immunity, would help us recover.

That is why a family sometimes says that these two people don’t get an infection, these two people get recurrent infections. The people who don’t get infected there. their immunity must be very strong. That’s a common thing that we say. There is immunity that is supposed to kill the cancer cells also. OK, now somehow in the person suffering from cancer there is a lack of that event. Somehow cancer cells can paralyze immunity. Therefore despite the presence of immunity, it cannot do anything. Therefore cancer cells get an advantage and grow intensely. Now we know the mechanism in a substantial number of patients that what is going wrong. You can say that the switch is off. So cancer cell has been able to switch off immunity. Now, these drugs, go to the body near the cancer cell and they can switch it on. When they do switch it on, that means they allowed the cancer cell to get active, or they allow the immune cells have to get active. Now the immune cells close to the cancer cell can recognize this cancer cell and they bring back their own immunity to kill cancer. Because you’re only activating the cancer-specific immunity. Therefore, it is highly precise, highly specific in selected patients, very effective and the toxicity is very small. It is like telling your immunity what you should have been doing. You have forgotten that. Teach them how to use them back and they will learn it and they will treat cancer. OK, so you treat your asking you’re making your body itself strong enough to treat cancer. You’re not administering the chemicals toxic, potentially toxic chemicals to treat the cancer cell, but you’re asking your body’s own immunity to get up, Identify and kill cancer. It is not effective in all. It is effective in a fair number. You need to have an appropriate patient, appropriately tested, but when it works it can work like magic. I can give an example. So there is this gentleman from there are two of them. One is a doctor from An African country, Kenya, who had stage four liver cancer and this has been four years now. In fact, COVID has not come back in six months, and for the last four years, there has been no disease. Yes, at all. Another patient from the Iraqi area. He had metastatic cancer as well and this has been he came to meet me about one month ago during COvID times and there is no evidence of this is all gone. All gone and this within three years we would not have imagined. If you see two brothers sitting, you could not identify who is the patient because there are no TOXINS. Very similar in patients to whom you should give and it works its magic. Not all but some, but in whom it works its magic.

Sonam: So what all cancers are treated through? Immunotherapy means basically it works in which all cancers, cancer types,

Dr. Amit: many cancers, head and neck cancer, lung cancer, kidney cancer, and skin cancer are excellent examples, but that doesn’t mean we have never cancel when it works. But there are different districts. There’s not one drug there, at least five or six drugs. OK, so it’s not like 1 drug is there as in immunotherapy. There are five drugs available in the country to users in the country. So head and neck cancer, lung cancer selected very few breast cancer, liver cancer, even stomach cancer, lot of kidney cancer. They’re a very effective treatment for kidney cancer. There’s a particular kind of skin cancer called Melanoma, which is a black color of cancer. These are very, very sensitive to immunotherapy but more cancers than this are also sensitive to this treatment. Not all, selected patients, work.

Sonam: So are there any kind of side effects? Also in immunotherapy?

Dr. Amit: Not very very few of your immunity that gets stimulated is not only the cancer immunity. If your immunity gets stimulated which is not supposed to be stimulated. This happens in about 2% to 3% of the population. Then the things can go wrong, but it’s much worse off than much better off than chemotherapy with toxicity is not limited to 2% with the toxicity can happen in 40% fifty percent 60% of people. There’s no hair loss. There is no nausea. There is no vomiting. There is no city. People keep on working. There is no skin. Happen, but generally, it doesn’t happen after a month or two. Very few patients would have toxicity and you can’t identify their message.

Sonam: OK, so there is also hormone therapy, so how hormone therapy is different from immunotherapy?

Dr. Amit: Some of the cancers, particularly breast cancer, ovarian cancer, and uterine cancer. And prostate cancer. These are hormonally driven normal tests. These are the tissues that are actually made to function by normal hormones in the body and abnormal hormones or tissue depending on less hormone level is one of the critical factors. Why these cancers develop or progress? But if or and or injectable hormone therapy and brings the hormonal altered status back to normal, then many of these cancers can be cured. Or altered or control for long periods of time with only these treatments. Change the hormonal abnormal pattern brings or hormonal pattern back to normal and then cancer responds very well to that. Sometimes it is curative but many of our prostate cancer patients can easily live on. Hormonal treatment for a long period of time, even five years or 10 years. It’s a bad disease. They can be controlled providers in years without giving them a signature. They some hormone therapy or oral, hormone therapy injectable. But the answer is if you can make your bad hormone status into a good normal status. Some of this cancer can be very well controlled.

Sonam: OK, so now I see talk about relapse multiple myeloma. So what exactly it is? And what are the treatment options for treating relapsed myeloma?

Dr. Amit: So, one of the most important treatments for myeloma is a Nautilus BMT, and so I don’t know whether the patient undergoing a transparent before or not. But in my myeloma, there are quite a few drugs. There are targeted drugs available, this specifically killed my myeloma health and there are some. Chemotherapy is also available patients who relapse after a long period of time can be reoffered, autologous bone marrow transplant, also other elements which are available for Myeloma depending on what they received before is usually quite-Effective. I hope that answers your question. If you want the name of the drug, that doesn’t help, but my number had only one line of drugs available 15 years ago. Now we have five or six lines of drugs available, so that is not. Not a very common cancer, but this is 1 canceled. With the advancement has been very rapid, we can offer them four or five kinds of treatment one after the other. A lot can be done for these patients

Sonam: And similarly if we ask about the advancement which medical oncology made for treating cancers like leukemia, lymphoma, they have a similar kind of treatment.

Dr. Amit: There’s a new treatment happening in the USA, and I think Tata Memorial Hospital just released it yesterday. It is yet to reach India inadequate strength and which is taking the patients’ cancer cells out and bringing out the immunity outside and then teaching them that advancement much more, but I’m trying to say is that trying to stimulate the immunity is becoming a great advancement and particularly group of them home and leukemia more than immunotherapy is going to be offered. Within the next six months, nine months, or year time, even if you have failed in the therapy, more drugs will be available. Great time ahead. For treating cause cancer patients likely we could cure more patients than ever before.

Sonam: That’s really great. So if we can find out such. Research, so if we talk about during this pandemic, what measures can be followed by patients cancer patients basically. To avoid worsening of their symptoms or to avoid worsening of their diagnosis.

Dr. Amit: So avoidance of COVID is important. There’s no doubt about it. Cancer patients are more prone for, Not getting COVID, but if they get COVID then their problems are higher than the normal population because cancer patient is suffering from many symptoms. Immunity as such is not because they have cancer. Cancer itself decreased immunity considerably. All precautions to avoid COVID should be taken. Cancer patients with or without treatment should be taking the vaccination. There is no contraindication to take vaccination is as COVID whatever vaccination is available should be offered should be given. Some people also thought that cancer patients will not raise response to vaccination, but that’s not true. The data suggests that is the vaccination is taken on time appropriately. Then these patients respond to vaccination as well as any other person would normally do, so that’s a safe drug to take and an effective drug to take. Uhm, cancer doesn’t listen to COVID. that means. Many people are trying to avoid taking opinions and taking treatment that doesn’t stop there. Cancer.

Sonam: Does COVID play a role inversing cancer?

DR Amit: No, CoVID doesn’t play a role. People are apprehensive about coming to the hospital which is understandable, but nobody wants to go to the hospital these days. But there are many diseases which are chronic like joint problems. You could wait. But if somebody has a chroma, he cannot WAIT, somebody has a heart attack. He cannot wait. Somebody has a CANCER. He cannot wait because this cancer is not going to listen to it is going to increase only. So think I think the point here is that cancer cannot wait. OK, the problem with cancer is people coming late today. Somehow, we see more late-stage cancers because patients are trying to avoid the situation. Let the COVID go away and then we will do it. But that is an app and the second they may or may not be powered by the third way. So if somebody has confirmed cancer. I understand people are scared of everybody. But I think cancer cannot stop cannot be stopped by getting SCARED. It has to be treated.

Sonam: Sir, how means recently the UK launched a 5-minute breast cancer treatment. Jabs called Phesgo, so to treat all stages of HER-2 positive breast cancer cases in combination with chemotherapy. So how effective is it in curing breast cancer?

Dr. Amit: So thank you. Contains a drug called Pertuzumab Artisanal is available, but this man was being given as an accepted was being given as an infusion injection and that includes an injection that needs to take about four to five hours of admission time in the hospital. Now they have released a combination of these two drugs as a subcutaneous injection. Likely give insulin. OK, so the advantage of that is that the patient does not come to the hospital for too long. Hopefully, get the injection done, doesn’t stay in the hospital for five to six weeks back home. It is equally effective to what injectable drugs are available to us before, so this is not an advancement of a drug. It’s an advancement of a drug delivery method. If I have a drug for which it takes 24 hours admission, and if I can get that injection one minute into opening, it saves so many things for the patient. Sooner or later this drug with a delivery system will be launched in India. But because of COVID time, it will be not happening in two months. IT may happen in INDIA this time. But that will make patients’ life very easy. We will have to just buy the drug and get it injected into OPD and within half an hour 45 minutes they can go back home. And it is a great combination of drugs, whether as a threat or as a new submitters injection. But obviously, subcutaneous injection is going to be a better, better thing for the best, definitely.

Sonam: So now my last question is that after cancer treatment or after completion of chemotherapy cycles, what role does a follow-up plan, please?

Dr. Amit: Immense importance. whenever we are treated the patient. There is a guarantee that cancer will not come back in that time period where cancer can come back. Not in all of them is approximately 5 years. We normally ask the patient to keep in touch with us regularly. Follow up with us in five years. Let’s say somebody was treated in 2016, then 2021 will be the last five years, and then we may say in 2021, you’re done. You’re cancer-free. You don’t need to come back in 2021, so follow-up is very, very important, because if something goes wrong, how will they pick up? And we don’t want to? Well, we don’t want to have cancer coming, but if it is going to come back, we want to do it as early as possible, because earlier we picked the disease coming back, we can still hear it. Not in all but some, but if the answer is delayed either in the initial diagnosis or as a recurrence is obviously we lose the plot. Right?

Sonam: So that was I think my end of questionnaire is my end of this, so it was really helpful for our viewers. And it was really informative. It will definitely help us. Many of the patients you know getting an idea about what exactly are the advancement of what is exactly as treatment options they have for treating their cancer. I would request you to have, say, a few words on as an ending note to a discussion

Dr. Amit: so I would start by saying that cancer is much easily treatable detail. Cancer can be cured in many patients. should be picked up early should be prevented in subset we should not be scared of cancer we have got better tools machinery and support to teachers they come and we will fight cancer together and they will definitely keep Should be picked up early. Should be prevented in the subset. We should not be scared of cancer. We have got better tools, machinery, and support to treat it. They come and we will fight cancer together and they will definitely kill. Thank you,

Sonam: thank you very much, Sir. Thank you.

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