New Leader's Vision for Cleveland Clinic Cancer Center

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig phase 1 and sarcoma programs. Today I'm happy to be joined by Dr. Alex Adjei, Chair of the Cleveland Clinic Taussig Cancer Institute. He's here today to talk to us about his vision for cancer care at Cleveland Clinic. So welcome, Alex.

Alex A. Adjei, MD, PhD: Thanks, Dale.

Dale Shepard, MD, PhD: So maybe just start out, give us a little bit of an idea of the scope of your role here.

Alex A. Adjei, MD, PhD: Yes. Thanks, Dale. So the scope here at Taussig is that Taussig Cancer Institute is where we have hematology oncology, radiation oncology, as well as palliative medicine here on the main campus. And then we have our regional centers, about 18 centers. Not all of them have radiations, but all of them have hematology, oncology, some radiation. And so I have oversight of all the regions through outlined. So in charge of their cancer services and their finances and their research. So practice research, educational all bundled together. But one of the more exciting parts of the role is working with all the other institutes that touch cancer to make sure that we coordinate cancer care across the Cleveland Clinic Enterprise in northeast Ohio. And then, as you know, we have cancer in Florida and Abu Dhabi and we have an advisory role. So I work with those areas so that we streamline our services and patients who touch any Cleveland Clinic location is getting the same excellent quality of care.

Dale Shepard, MD, PhD: Excellent. So you've been here for a few months now. Why Cleveland Clinic? What drew you to Cleveland Clinic?

Alex A. Adjei, MD, PhD: When we think about cancer in the nation and we think about the big cancer centers, people may have heard of the National Cancer Institute Comprehensive Cancer Centers. And when you are labeled as such, it means that you provide research, education and care of cancer patients. But that program is particularly focused on research. And so you have a lot of research programs and population sciences and when it comes to clinical care from the National Cancer Institute standpoint, they don't really delve into the quality of care and they're more interested in clinical trials and the number of patients you put on clinical trials. But we all know that cancer is such a deadly disease. We are making progress by saying a lot of work that needs to be done. And so the research we do should really directly impact cancer care, the here and now, and in some of the cancer centers, particularly the university research based ones, that there's a lot of tremendous research.

Some of them are really cutting edge, but sometimes those are relatively basic. They're important, they're going to be important in future, but not now. And as a clinician investigator, I've always been interested in doing something that affects cancer care of our patients now. And so Cleveland Clinic is probably one of the few places that provides a model where you can merge the two together. You can have some of that research, but we have exceptional patient care. And so you can do all of them together, good patient care, the clinical trial piece and the basic and translational research that's going to influence patients' lives now. And so for me, that's what attracted me to Cleveland Clinic rather than some other academic place.

Dale Shepard, MD, PhD: And so we'll talk about what your thoughts are on clinical trials and research for the institute and for Cleveland Clinic as a whole, but what are your primary research interests?

Alex A. Adjei, MD, PhD: So personally, all my career I've been in drug development and so this is what some have called early phase clinical trials. And because of my background in pharmacology, I've always been interested and focused on the basic sciences, finding a molecule that looks like it might be good for cancer, working with them to do all the preclinical studies that shows that the drug might be really good for cancer and is, at least in the preclinical models, in the animal models is safe.

And then working with them to bring it to their clinic to test it initially in cancer patients and if it's promising, move it on to later lines of study and eventually hopefully get it approved for cancer patients. So my focus has really been in drug development. And then along the lines, I remember my department chair just asked me to see lung cancer patients and help bring new treatments to lung cancer. As you know, 15 years or so ago, lung cancer was uniformly deadly. There were no new treatments. And so it felt like the way to move forward is to bring some novel therapies to lung cancer. So I was asked to see lung cancer patients as well. So I also treat lung cancer and do clinical trials in lung cancer patients.

Dale Shepard, MD, PhD: So very much like you talked about the very practical aspects of bringing those trials to patients and patients come to us and they're looking for options. Unfortunately, a lot of patients don't participate in trials, but what's your view and what's your vision for how we sort of intertwine standard patient care with those clinical trials?

Alex A. Adjei, MD, PhD: Yes, I think the lack of participation of patients in clinical trials is twofold. One is where us oncologists and so on and cancer administrators and so on, sometimes in our minds separate out clinical trials from standard of care, so that sometimes even when it comes to resources, we put resources into patient care and then we think of research as different. But if you think about it, if you're a patient and you have this cancer and you come to Cleveland Clinic, you want the best care, the care that has the best possibility of prolonging your life. And because cancer is so difficult to treat, the number of cancers where a lot of times for that patient the best care is a clinical trial because the standard of care doesn't work very well. And because of the advances in the science that is helping us understand cancer more.

A lot of times that clinical trial is testing a new treatment that's really affecting a protein that's important in that cancer. So the patient has the chance of doing the best with that treatment. So I think all of us, our job is to take a step back and in our minds, not just separate out a clinical trial from standard of care, but any patient who comes in asks the question, "What is the best treatment for this patient at this stage of their cancer journey?"

And if you have a promising clinical trial where the initial results suggest that it's better than standard of care, you're going to put them on the clinical trial. And if you don't have a great clinical trial, then you are going to give them the standard of care. Now if us, the oncologist, nurses and so on start thinking about cancer treatment that way, then the way we present the clinical trial to our patients will even be different. We've given it to them as something that might actually be the best chance of prolonging their lives. So they probably are more likely to enroll in that trial, right? Because even the way you present the study sometimes determines whether the patient will decide to enroll or not.

Dale Shepard, MD, PhD: Yeah. I mean sometimes in those discussions with patients, they'll say, "Well, I could do a trial, but we don't know if it works."

Alex A. Adjei, MD, PhD: Exactly.

Dale Shepard, MD, PhD: You have to refocus and say, "Well, I can give you something that's approved and I still don't know if it's going to work."

Alex A. Adjei, MD, PhD: Exactly.

Dale Shepard, MD, PhD: How about in engagement of our regional sites and how we're going to get more of those patients engaged in some of our research opportunities?

Alex A. Adjei, MD, PhD: So what I find, talking to our colleagues in the regional sites, visited some of them, not all of them yet, there are a few to go. I find that uniformly everybody's interested in clinical trials and everybody's interested in enrolling patients in clinical trials. Clearly one of the reasons talking about barriers to clinical trial participation on the physician and nursing side and so on, one of the reasons sometimes is that it takes a little bit more effort to put a patient on a clinical trial. If you see a new patient and you are going to give them standard of chemo, you explain it to them, you send them off to get their treatment. If it's a clinical trial, you are going to run through the eligibility and make sure they're eligible, talk to them. Sometimes there are special tests you need to do and so on before you sign them on for the trial.

So sometimes in the region where you are very busy and you don't have enough research nurses and coordinators and so on, it might take you twice as long to put somebody on a clinical trial as opposed to giving them the standard of care. So what we need to do is, one, select the clinical trials that will serve the kinds of patients they see, the ones that are easy to enroll patients on. And then one of the strategies we can use is where if there's a location where they're interested in clinical trials, the volume is not such that you can actually put a research coordinator there all the time, create a system where they see the patient, they're eligible for a trial, refer them to main campus where we have more resources and we can enroll the patient on that trial and then they can go back to the region and continue their treatment there.

I think that's going to be one of their approaches that will help. The other approach is, so I talked about sending patients to main campus, but it may be that we could identify one central location, maybe just one, or one on the east side, one on the west side where they'll be fully resourced to do all this work and then regionally they could refer the patients there to be enrolled and either come back to the region where the patient started off, if that's feasible, or if it's not and it's convenient for the patient, they can just get their treatment there. So maybe thinking about how we develop sort of a hub and spokes model where there's the main campus and then there are regional centers where we have enough resources and so on, and some of the patients might come there, but we need to think about new ways of doing it, things like that.

Dale Shepard, MD, PhD: We certainly want to have great research programs across the board for all of our patients. Are there particular areas that you're more interested in kind of beefing up earlier than later?

Alex A. Adjei, MD, PhD: Yes. I think the first starts with something you are very familiar with there, which is phase one trials or early phase trials. And the reason for that is back in the day, phase one trials were drugs that typically didn't really work. We didn't understand the science. We had only a few drug classes. So every new agent that came in belonged to a class. So you talk about alkylating agents and for a while in a new drug that comes, it's also an alkylating agent. So if you have a patient who's had cyclophosphamide or something like that, it was unlikely that giving them another alkylating agent was going to be effective. So phase one was not very attractive responses where low patients didn't benefit. But we've come a long way where we have a number of studies that are basically targeting specific genetic subsets where they're going to do much better than if they got the standard treatment or they're focusing on certain pathways where now, because we understand the pathway and we can select the patients, they're more likely to benefit.

So when you start that, then that's going to be the group where either you have patients who have no other options and typically you throw up your hands, but now we have drugs for them so they can come and go on a study or we have patients, there may be other options, but this is the best option and this is the early phase of testing this new drug. So when you beef up your phase one program, you're going to bring all these drugs in and find that, okay, maybe this drug is ideally suited for breast sarcoma and melanoma.

So after the phase one is going to go into these diseases, and so as you beef up your phase one program, you're going to find that you're going to have novel agents that can now trickle down to all the other disease settings. So as it were, you get a pipeline, where you bring new drugs in and hand them off to your different disease groups. So our robust phase one program is going to feed all our disease groups. So to me that's kind of the way to start where you build up all your other programs and more importantly then you get to a situation where all your phase two and phase three studies are with agents that you've already studied in the institution. Your nurses know about it, the physicians know about it. So it's kind of a win-win for patients as it were, you're getting from the ground up and an institution like Cleveland Clinic, that's what we should be doing.

Dale Shepard, MD, PhD: And considering that the interest in having trials that actually help people as best they can, oftentimes these are patients coming and say, "My doc said there's nothing left."

Alex A. Adjei, MD, PhD: Exactly.

Dale Shepard, MD, PhD: And now we have something. You're absolutely right about the durability. I mean, we have patients on phase one trials for 50 or 60 cycles, which would've been unheard of for some of our genomic therapies. So I guess switching gears a little bit, all patients that come in, whether they're on trials or not, some of our patient support services for instance, are really important. What sort of things are you interested in doing in terms of helping patients for some of our support services?

Alex A. Adjei, MD, PhD: There are two parts of the patient support services, one part is the whole area of patient navigation. A lot of our patients who come, particularly patients who come from the rural regions and so on, a big place like the clinic, they come and they're overwhelmed, they don't know where to go and so on. So having navigators who greet them and show them where to go and so on, it's so important. So that whole area of navigation and so on is important for our patients. The support services we give on our ground floor where for instance, we have a shop for wigs and so on, for particularly the ladies who are undergoing treatment who have lost their hair, which again, I always say that a lot of times for us physicians from our standpoint, because we see the devastation of cancer and so on, we always think we have a good drug and it's going to shrink your tumor, who cares about your hair?

But a lot of women care about that, and it's not all cosmetic. Part of it is the fact that somebody sees you and they know there's something wrong with you because you have this lovely blonde or brunette hair now is all gone and so on. So it's almost like a marker of cancer and it can be very devastating. So having services to take care of all of that is important. And then the other part of it is that we are so fortunate to have palliative medicine as part of Taussig. A lot of cancer centers' palliative medicine sets in another department. So it's so difficult getting their help.

So having palliative services there who can address their stress, their anxiety, their fear, and particularly something we do so well at Taussig that a lot of places don't do is the support for the caregivers. We forget that a lot of times with cancer, and I'm sure, Dale, you've seen it where the patient themselves are at peace with the disease and their treatment, but now there's the family. And let's say they don't have close family nearby and it is just one person or their spouse, the stress on them, sometimes it's physical, they have to help them to the bathroom and so on, they have back pain and so forth. And the psychological stress is intense. So the fact that we have massage therapy, which is not just for the patient but for their caregiver and we have all these services on our ground floor for caregivers, I think is huge, and something we should just build on and expand.

Dale Shepard, MD, PhD: And then tell us a little bit about patient outreach and serving underserved populations. And we've had some wins there, but what are some of the other things you'd like to do in that area?

Alex A. Adjei, MD, PhD: Yeah, I'm glad you brought this up. So in terms of patient outreach, it's really simple. If you have an institution like Cleveland Clinic where we get patients from all over the country, all over the world, of course it makes sense that we should serve the patients in our community. And if we are not serving them, that we're doing something wrong. And so I think a lot of good work has been done. I applauded Kim Bell, Kim Sanders for getting this up and going. So you find that there's great community outreach. We are getting patients to screen for colon cancer, for breast cancer, for prostate cancer, and it's really grown. So we are doing well there. We should just continue doing what we are doing because it ain't broke, so no need to fix it. But where we are still lagging behind is that when we screen and we find the cancers, a lot of the patients are not actually coming here to Cleveland Clinic.

And so what I'd like us to do, what I'd like to see going forward is how we strategize in building trust and visibility so that we don't screen the patients. They get cancer and they go somewhere else to get their care because they can get good care everywhere, but this is probably the best care in the world. And if people travel from all over to get their care here, if they're here in their Cleveland metro area and they get cancer, they should be coming here. So to me, the next step is how do we get underserved population with cancer to come to Cleveland Clinic or one of our regional sites for their cancer care?

Dale Shepard, MD, PhD: I guess sort of dovetailing on that, the last thing I'll ask about is those who aren't in our area, what about telemedicine and delivery of care? What are your plans in that arena?

Alex A. Adjei, MD, PhD: So one of the things we are thinking about seriously and we want to spend some time on is almost like clinical engineering. I call it innovative care delivery. So how do we put ourselves in a situation where both of our clinical trials and regular clinical care, we are able to reach as many people as possible. And thanks to COVID, telemedicine is here to stay. I mean, they are regulatory issues, but at least if you are in the state of Ohio, we should be able to reach everybody through telemedicine. If you are outside the state and you come here for an initial evaluation and so on, you should be able to do your follow up. So we are going to spend a lot of time, and in my mind what we are going to do is take some of our early phase trials because those are, a lot of times, the best care for the patient who has no other options.

And sometimes they can't participate because they have to drive four hours and a lot of these studies require weekly blood tests and so on. So take a few of those as a pilot and see how we can get home blood draws, maybe electronic consent so that we do everything and the patient comes here, gets their treatment, go home. We do follow up there. We use telemedicine for weekly visits and they come down here or to one of the regional centers for let's say their monthly or every three week treatment.

And if we are able to work out all the kinks and the workflow with the early phase studies because they are the most complex, but usually it's not a lot of patients, so you can't really pilot something like that, then we can roll it into other clinical trials and hopefully to our regular standard of care so that we are set up for telemedicine and can really service patients from all over. And I think it's going to be really important in patients from the rural communities who are far away from the main campus and some of the other areas in the country that honestly are underserved in terms of cancer services.

Dale Shepard, MD, PhD: Very good. Well, I appreciate you joining in and sharing your vision. It looks like we have some great things to look forward to.

Alex A. Adjei, MD, PhD: Thank you.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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