Riding Toward a Cure for Cancer with Jessica Geiger, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Nearly 20 million people around the world will be newly diagnosed with some form of cancer this year. This ruthless disease attacks all over the body, and as we all know, it can be deadly. That's why medical researchers devote countless hours trying to find ways to beat cancer.

Some of that work is being done here at Cleveland Clinic, powered in part through our VeloSano Bike to Cure event. One hundred percent of the dollars donated through this global fundraising movement goes toward cancer research projects at Cleveland Clinic.

Today we're going to talk with oncologist Jessica Geiger, a past VeloSano research grant recipient, to learn more about her work regarding a potential vaccine for a type of head and neck cancer. VeloSano, by the way, is Latin for "swift cure." Now, let's see what progress we're making to achieve that lofty goal.

Welcome to the podcast, Dr. Geiger. Thanks for giving us a little bit of your time.

Dr. Jessica Geiger:

Thanks so much for inviting me, John. I'm happy to be here and talk with you.

John Horton:

Now, when people talk about cancer, they tend to talk about it like it's a singular disease. But the reality is that there are more than 200 different types of cancer, each with unique traits. In many ways when we talk about a cure, it sounds like we need 200 of them instead of just one. I'm guessing that's one of the reasons why this process just isn't an easy one.

Dr. Jessica Geiger:

You're right. Probably more than 200 — there's probably more than 200 different types of cancer depending on how far you break it down.

You're right. In its simplest forms, breast cancer is not the same as colon cancer or lung cancer or thyroid cancer, which is one of the cancers I treat as well. You have the different anatomic sites. I'm not even touching on lymphomas, leukemias, cancers of the blood, which is an entirely different organ altogether. But even between the different anatomic sites, then you can break it down to the different histologies within that anatomic site.

For example, I also treat thyroid cancer, as I say. But not all thyroid cancer is equal. There's papillary thyroid cancer, follicular thyroid cancer, medullary thyroid cancer — all based on what cell the cancer cell originated from.

And then, you can take it even a step further and look at the molecular level, so the DNA level, what the nitty-gritty is, the DNA background of cancer is. And so you can take a specific type of papillary thyroid cancer, for example, but it could have a specific mutation we call BRAF mutation, for which we have targeted therapy to treat that directly. A bunch of other different types of molecular mutations or gene fusions or other things, again, at the DNA level that really describes and explains the biology of what that specific cancer is.

You're right. It's multiple different cancers, probably hundreds and hundreds and hundreds when you really break it down to the different biologies of the disease.

John Horton:

Well, and that just really illustrates why it is just such a vexing issue when you're talking about finding a cure.

Now, I know your particular area of focus involves cancers of the head and neck, and I'm guessing that accounts for more than a few of those hundreds of types of cancer.

Dr. Jessica Geiger:

It does. I mean, the vast majority of head and neck cancers are mucosal head and neck cancer, so they're a squamous cell carcinoma that starts either on the tip of the tongue or somewhere in the oral cavity or the tonsils or the larynx, or the voice box is another name for that. The vast majority of those cancers are squamous cell carcinomas.

You're right. I treat dozens and dozens of different types of head and neck cancer. The vast majority of which by far the most common type is squamous cell carcinoma of one of the upper aerodigestive mucosal surfaces.

John Horton:

Well, tell us a little bit about your VeloSano research project, which I know is looking to tackle one of these cancers in the head and neck area. Tell us a little bit about what you found.

Dr. Jessica Geiger:

I partnered with one of our scientists, Dr. Natalie Silver. Dr. Natalie Silver is a good friend of mine, but a dear colleague as well. She's a head and neck surgeon. She's a surgeon, but she's also a scientist. She has a lab, and in her lab, she is developing treatments and vaccines specifically to help us treat advanced head and neck cancer.

One of the research projects that we have been working on, which, thankfully, was funded in part by the VeloSano grant, was moving from the lab, or the scientific research bench, and developing treatments that we can use and administer and actually treat real patients with real disease and improve on their outcomes, improve on their survival. And so that's what this particular research project was about. It was helping do some of that background research with Dr. Natalie Silver and her lab to develop this vaccine platform and to then develop it.

My part, and my role in all of this, is to bring it into the Clinic — so writing and implementing the clinical trial where I see a patient in clinic who is eligible for this study, for this treatment. And then, working with Dr. Silver, we get the treatment to the patient and hopefully, see a positive effect shrinking the cancer down, preventing it from growing and spreading to other places.

And then who knows? We can talk a little bit more in detail about the specific patient population, but ultimately the goal is to use Dr. Silver's vaccine platform to treat any and all of our head and neck cancer patients. The salivary gland cancers, which start in your various saliva glands or salivary glands, we call them the parotid gland, there's dozens of histologies or different types of cancers within those glands. The possibilities are endless, and it's really exciting to think about the benefit that we hopefully will be able to bring to many different head and neck cancer patients in the future.

John Horton:

Yeah… Now, how was this vaccine developed? Was it building on something that's existing? Is it based on individuals? How did it come about?

Dr. Jessica Geiger:

Yeah, so when you say vaccine, what you're talking about is tapping into the body's immune system to either prevent disease or to fight off disease that is already there.

In the true sense of the word, when we say “vaccine” or we think about vaccine, or especially coming a few years out of the pandemic where it was all talk about vaccines, those vaccines we're talking about are to prevent disease from either happening or lessen the effects of the disease if the patient gets infected. That's important for head and neck cancer because the majority of head and neck cancer that we're seeing now — as tobacco smoking is on the decline, thankfully — we are seeing HPV or human papillomavirus-related head and neck cancer.

There is an HPV vaccine. It's been on the market now for at least 18 years, approaching 20 years. That is not the vaccine that we're talking about. That vaccine is to prevent cancer development before it even starts. What we're talking about when we talk about vaccines or cancer vaccines is the patient already has cancer. We're either talking about tapping into a little bit bits and pieces of the cancer they have, so it could be generalized. It could be generalized in, like for this project, we're taking bits and pieces of HPV itself, so human papillomavirus, and we're introducing an individual patient with HPV-related vaccine. We're introducing their body with this vaccine that has little bits and pieces of HPV to stimulate or to generate an immune response from the patient to recognize, “Oh, I should be seeing these bits and pieces as a bad thing. Oh look, there's a tumor there. It also has these bits and pieces, let's attack.” And so it's trying to reinvigorate or to awaken the patient's own immune system to do the work of treating the cancer.

John Horton:

That's really incredible. It's basically like teaching the body to go and fight cancer, to use that great system that we have to just attack the disease.

Dr. Jessica Geiger:

Right, that's exactly what it's doing.

And so at the beginning stages of this particular clinical trial, we're using something that could be a little bit more off the shelf, meaning it could be used broadly for all patients with HPV-related head and neck cancer. But the goal building from this is ultimately to say, all right, we have this platform that we could use in the lab to build a so-called vaccine. The bits and pieces I talk about, let's take a piece of tissue, a biopsy from this patient who has a completely different cancer altogether, but let's take some of that tissue, that cancer itself, take off some of the bits and pieces, load it into this vaccine to generate a completely personalized vaccine.

That is ultimately our goal, that's Silver's vision, for her lab and her work. I certainly would love to be able to have virtually any patient walk into my clinic and have me say to them, "Oh, yes, this is the cancer that you have. We're going to make a vaccine, a treatment personalized just for you, just for the cancer that you have at the DNA level but let your own immune system do the work of it."

John Horton:

That's just so incredible. Because when you see what cancer is and what's happening on that cellular level, it always seemed like something that just slipped through the cracks with our immune system. It somehow found a loophole and it got by it. It seems like you're helping the immune system out a little bit and going, "Hey, hey, hey, this is the bad guy. Let's go get them."

Dr. Jessica Geiger:

Right. Well, and the way that I describe it to patients, too — I think you hit the nail on the head — is, or at least started to scratch the surface, that the key ultimately I think to cancer eradication or complete cures of many different cancers across the board are somehow going to be tapping into the body's own immune system.

And so you're right. The way that I describe this to patients in clinic is all of us at any given time have individual cancer cells floating around our bodies. Those of us who-

John Horton:

…That's terrifying.

Dr. Jessica Geiger:

We do. That's just reality because a cancer cell is just a cell that, it's abnormally growing. It's not following the instructions completely. And that happens all the time. I mean, that's ongoing in all of us. But those of us who don't "have cancer," it's largely because our immune systems are able to recognize those poorly formed or badly formed cells in our body as being ... it's incorrect, it's a bad thing. And so the immune system takes care of those teeny-tiny individual microscopic cancer cells, and we're none the wiser.

There's already immunotherapy products and treatments that have long been approved and used in various cancers, including head and neck cancer, where it does that. Immunotherapy agents, checkpoint inhibitors, those describe some of the treatments that are out there that I use on a daily basis. That's what it does. It touches one small piece of the patient's immune system that has been blunted or been affected by the cancer. It's tapping into that to unleash the immune system on the cancer.

But there's probably more we don't know about the immune system than what we do. There's different avenues to try to generate an immune response to try to stimulate the body's immune system to reinvigorate the immune system.

John Horton:

As I was researching this ahead of our talk, one piece of information that jumped out at me regarding, was it oropharynx cancer, or cancer that we're talking about here, involved the age of people who are being diagnosed with it. It seems that many of those that you're seeing with this cancer are younger people who are in good health overall, which just is not who you think maybe would be having these issues. What's happening here? What's driving these numbers?

Dr. Jessica Geiger:

It's HPV.

Historically, when you think about head and neck cancer 30 years ago, the patients are going to be older, more frequently male who have been smoking two, three, four packs of cigarettes a day, often combined with very heavy alcohol consumption as well. Those are the standard tobacco-related, carcinogenic-related head and neck cancers.

But you're right. About 20, 25 years ago, maybe even longer than that, certainly before my career as a head and neck medical oncologist, we started seeing these younger, healthier, fit patients in their 40s or early 50s often who had never smoked before, or very light smokers, maybe did a little bit when they were in college in their younger years, but were never considered a regular tobacco user, and they're very healthy. These are young, healthy patients who develop a neck mass, and then they ultimately get diagnosed with HPV-related head and neck cancer.

And so hopefully, in decades to come, we'll see a decline as more and more children are being vaccinated with the HPV vaccine that's been on the market for years and years. But that's going to take decades for that to happen. I probably won't see the effect of that vaccine in my lifetime. Again, that vaccine that we're talking about is different than the one that VeloSano has funded for us. This vaccine is to prevent HPV infection altogether.

Do I have a moment to just explain what HPV is?

John Horton:

Yeah, I was going to ask. Yeah, please do because I think HPV is one of those terms that people have heard, but you might not know exactly what it pertains to.

Dr. Jessica Geiger:

You may not know exactly what it is. If you do a Google search of HPV, you're going to go down a rabbit hole pretty quickly, and it can be ... what I say to patients is, part of my job is to educate and de-stigmatize what's going on.

John Horton:

That's why we're here to educate, too. Lay it out for us.

Dr. Jessica Geiger:

Basically in a nutshell, HPV or human papillomavirus, this is a very widespread virus in our Western society.

Essentially for all intents and purposes, almost all of us have been infected with HPV and were infected with HPV at a relatively young age. It is a sexually transmitted infection. It can be transmitted in other ways, but by and large, it's transmitted through sexual contact. We are infected acutely with HPV at the time that we have our sexual debut.

Now, the vast majority of us, over 90% of people, our immune systems — again, going back to the immune system and the importance of an intact immune system to prevent cancer — thankfully, clear this virus from our bodies, and we are none the wiser. It usually happens within a few years of being infected. When you have an acute infection with HPV, you have no symptoms. There are no symptoms related to it. You don't even know that you're carrying the virus. Thankfully, after two or three years, your immune system likely will get rid of this virus for good, and you don't have anything to worry about.

John Horton:

I feel like there's a “but” coming on now.

Dr. Jessica Geiger:

There's a “but,” that's the next part.

For reasons we don't completely understand, there's about 7%, maybe 8% of the population whose immune systems just aren't able to clear the virus at all. And so HPV, the virus itself, lies dormant within specific cells and tissues of the body. These cells and tissues, for example, are tissues of the oropharynx, so the base of the tongue, the tonsils, the posterior pharynx in men and women, and in cervical tissues in females. And so over time, this virus, again, years down the road, can make changes within the DNA of those cells and tissues and ultimately lead to cancer development.

Ideally, if you want to prevent cancer, you vaccinate to prevent a disease. And so that's why with HPV vaccines that have been out for now many, many years, they're very safe. They're not used enough. People don't vaccinate their children enough or accept the vaccine for themselves enough. But there's vaccines, the most common one being Gardasil®. It's FDA-approved for males and females ages 9 to 45. But ideally, you are vaccinating before exposure. That's why pediatricians are integral to preventing head and neck cancer and cervical cancer and genital warts because they are providing the vaccine to children ages 9, 10, 11, 12 before they have any sexual contact.

I have a 4-year-old and a 6-year-old. They're not old enough yet, but absolutely, they will be getting it.

John Horton:

It sounds like that's the key with that HPV vaccine to get it early.

Now, you said you can get it up to age 45, but I take it, are there issues as you get older and you are sexually active and that kind of stuff has started?

Dr. Jessica Geiger:

Well, so step one, yes, it's approved up to age 45. Regardless of past relationships and whatever your behaviors have been, your lifestyle has been, if you are under the age of 45 and you have not been vaccinated, I still strongly recommend that you do for a couple of reasons.

Number one, there are various strains of HPV. The most common strain of HPV that causes cervical cancer and head-neck cancer is HPV type 16. But that's not the only one that causes it. There's other subtypes, and so then you can look into ... at least right now, we would never do this to say, “OK, well, what subtype were you infected with way back when?” But theoretically, you could have been infected with one subtype, but another subtype you can have a later infection. It definitely makes sense if you haven't been vaccinated and you fit within that timeframe to get it.

But also, and I don't have solid data or evidence, there's preclinical in the lab and there's hypotheses, that even if you have been exposed and chronically infected with HPV, later on getting the vaccine still within that age range can then generate an additional layer or level of immunogenicity or immune response against that cancer. You can still derive benefit from it.

John Horton:

Get the HPV vaccine if you have the opportunity to, especially if you've got young children. It sounds like it's a very good preventative measure that can be taken.

Dr. Jessica Geiger:

It's a no-brainer. It's a no-brainer for me. I mean, of course, talk with your pediatrician, talk with an internist or your PCP to make sure that you're not at any risk of side effects and things like that. But it is a very safe and well-studied vaccine for sure.

The caveat, John — and here's where there's another “but” that comes into the conversation — is while you're absolutely correct that the key to HPV head and neck cancer is to prevent it from happening with the vaccine, the reality is we are not going to see the effect of that vaccine, at least in my lifetime as a head and neck oncologist. In the meantime, it's great. I will do all the advocacy and education I can to prevent this cancer from developing.

Please, I would love to be put out of business of what I do. I guarantee you, do not worry about me, I will find something else to do. If there are no head and neck cancer patients in the world, I would love that. The reality is that it's not going to happen in my lifetime. We still need to continue to fund research and to develop treatments to treat those patients who unfortunately develop head and neck cancer.

John Horton:

Now I want to bring our conversation back to the vaccine that we started talking about. We went on a little detour there on the HPV vaccine, which is the preventative measure, but the vaccine that you've been working on in part with the VeloSano grant is after you already have this cancer.

I want to see what have you found with that. I mean, is it working as far as taking those cancer cases down and just helping people get through everything?

Dr. Jessica Geiger:

Two parts to this answer.

Specifically, for this clinical trial, so we're still working on this clinical trial to get it off the ground and get it into the clinic. There's what people may or may not realize is the amount of work and behind-the-scenes efforts on many individuals that it takes to write and open and run and develop clinical trials and implement clinical trials and see patients on them.

For example, I am still seeing patients who were treated on a clinical trial from a decade ago, and we still don't have the results for it. Because you treat patients and then, you have to follow for a long time to see how things will play out and what the benefit will be.

I don't have real-time data to tell you, “Well, we've treated X amount of patients with this vaccine and this is how they're doing.” We will earmark that for another podcast down the road hopefully, I'm sure.

John Horton:

We'll have you back on, yeah.

Dr. Jessica Geiger:

But what we have seen is in the lab, Dr. Silver using tumor tissue and looking at things in a very controlled environment because that's what you do first. You test things in the lab with cells to make sure that the science on paper makes sense in vivo or in a test tube, essentially. It's a little bit more complicated than that, but that's what you do first.

But we know from prior clinical trials and from standard treatments, immunotherapy treatments included, for head and neck cancer, that there are subsets of patients who can respond beautifully to the immunotherapy treatments we already have on the market. But it's only about a quarter of them. If you are a head and neck cancer patient who unfortunately is not cured of your disease and you develop recurrent or metastatic disease, meaning the cancer has spread to other places of your body like your lungs or your liver or your bones, you're on a timeline. The clock is ticking to some degree because we don't have a cure for most patients.

There are some patients who are cured with standard immunotherapy agents that are out there, something that I couldn't say a decade ago when I was still in fellowship training before immunotherapy was approved and on the market. Now I could rattle off a list of patients I have who were, had technically, incurable metastatic disease who are treated with standard immunotherapy and had a beautiful response. Those are in the minority. The majority of patients with metastatic head and neck cancer, unfortunately, at some point, will succumb to this disease.

Piggybacking on your earlier comments, some of these patients are younger and otherwise healthier. You're absolutely right. It's different to some degree telling an 80-year-old or a 90-year-old that you have incurable cancer. It's very different when you're talking to a 50-year-old and saying, "We have good treatments that may work well for a period of time of a couple of years." A couple of years to a 50-year-old is not the same as a couple of years to a 90-year-old. And so that's what we're really trying to do to improve and move the needle forward.

John Horton:

Well, and it sounds like slowly but surely we are moving that needle forward. Looking at that, how much of a difference do these VeloSano grants make when it comes to doing research like yours and unlocking some of these mysteries?

Dr. Jessica Geiger:

I mean, the funding received from VeloSano over the years in what hopefully will be years to come is absolutely integral, especially to Cleveland Clinic, especially to our scientists and our clinical trialists like myself, to be able to do studies that we may not otherwise be able to do.

The only way, at least in cancer care, really, the main way that we can move the needle forward and improve outcomes — and when I say improve outcomes, I mean cure more patients, increase the of longevity patients and improve overall prognosis of a potentially deadly cancer diagnosis — is to do clinical trials, whether it's a late, what we call a phase three randomized trial.

Oftentimes, these VeloSano grants and VeloSano funding, they're providing the funds and the money necessary to do the very early, very promising but very early, studies where we wouldn't be able to do it otherwise. This is pertinent to my study with Dr. Silver as well. We wouldn't be able to be where we are with doing this clinical trial, which again, hopefully, is the springboard to personalize vaccines for all the cancers that I treat. And not just me, but all of my colleagues as well.

And so it seems, sometimes, that it starts very small, but it has such a direct, meaningful impact on day-to-day patients. It really is profound the impact that VeloSano has had at Cleveland Clinic and within our cancer center.

John Horton:

To give people an idea, in the first 10 years of VeloSano, it raised more than $51 million, and that money went toward more than 240 different cancer research projects. There's incredible work being done and advances being made.

I've ridden in the VeloSano event, and I have to tell you, it is just a truly amazing experience. You realize while you're there, just how vast cancer is and how many lives it affects, not only the people who have it, but their families, their friends. It ripples out, and all of us have an experience with somebody with cancer.

Dr. Jessica Geiger:

The VeloSano event is spectacular. I have not ridden in it myself directly, simply because again, my kids are 4 and 6. Over the last seven or eight years that I've been on staff at Cleveland Clinic, I've either been pregnant or had a newborn, or it was COVID.

But I will tell you, my husband is an avid cyclist even before all of this. He is not a physician. He works in the business sector, and he has formed teams within his companies, which are completely separate from Cleveland Clinic. Just by that, I mean, there's a lot of people, a lot of businesses, a lot of companies that are looking for ways to give back or to do things that are not within their general area of expertise or what they normally do.

It's such a fun event. The Friday night before the race is just a spectacular event to mingle and to meet people. I've been involved in all of those. Even just the atmosphere of standing at the finish line, ringing the cowbell when people you don't even know … but everybody's working toward a common goal, I think that is really, at the end of the day, what really highlights VeloSano and what we're trying to do. It is a big community of people all across walks of life, all across what they do in their day-to-day lives from being a cancer survivor, whatever they were doing or actively treating their cancer, going through cancer treatment, or having a friend or a loved one do it, all the way to our bench researchers and scientists who are trying to develop the cures.

We're all riding together, we're all celebrating together, and it really is coming together like one community, one family, all working toward one goal of eradicating cancer.

John Horton:

Yeah. Well, on that note, let me say thank you for all you're doing to protect us from cancer, Dr. Geiger. I know we've seen so many advances over the years because of the work being done by you and so many other researchers.

I know there are no guarantees, but it's hard not to feel optimistic about the future and where we're going with all this.

Dr. Jessica Geiger:

Thank you. I can't imagine doing anything else. You try to capitalize on the successes and always push forward and learn from what has not worked, and also keep the memory and spirit alive of all the patients over the years that you've treated.

John Horton:

Well, I look forward to having you back on in a few years when you have absolutely fabulous results to share. Thanks for giving us some time, and I look forward to our next chat.

Dr. Jessica Geiger:

You're welcome. I'll hold you to it.

John Horton:

Can cancer be stopped? That question remains unanswered, but we're slowly chipping away at the disease thanks to innovative research at Cleveland Clinic being done by Dr. Geiger and others through VeloSano grants. If you'd like to help the cause, visit impact.velosano.org to see how you can make a difference.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.