Advances in Lymphoma with Dr. Joseph Roswarski

On this DocTalk episode, we chat with Dr. Joseph Roswarski, the lymphoma/leukemia attending at MedStar Georgetown University Hospital and the Georgetown Lombardi Comprehensive Cancer Center. Dr. Roswarski’s medical career includes clinical care and research in hematologic malignancies, particularly lymphoma and multiple myeloma. 

For an interview with Dr. Joseph Roswarski, or for more information about this podcast, contact MedStar Georgetown University Hospital Manager Media Relations, Ryan.M.Miller2@Medstar.net. Learn more about Dr. Roswarski.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant, and insightful conversations about health and medicine happen here on MedStar Health Doc Talk. Real conversations with physician experts from around the largest healthcare system in the Maryland DC region. At MedStar Health, our malignant hematologic oncology program located at MedStar Georgetown University Hospital brings together world-class specialists and all types of blood cancers. When you're diagnosed, you need the expertise of an integrated team who has extensive knowledge and experience in caring for your particular disease. Part of the MedStar Georgetown Cancer Institute, we provide comprehensive, highly individualized blood cancer care using cutting edge technology and research, including clinical trials. Our research engine, Georgetown Lombardi Comprehensive Cancer Center, is the only national cancer institute designated comprehensive cancer center in Washington, DC. Through this partnership, we're dedicated to evaluating new and better ways to treat blood cancers by serving as principal investigators for phase one, two, and three clinical trials. Our research helps us better care for our patients, allowing us to translate our findings into effective treatment options. Welcome to MedStar Health Doc Talk. I'm Ryan Miller and I'll be your host for today's episode. I'm joined by Dr. Joseph Roswarski, lymphoma, leukemia attending at MedStar Georgetown University Hospital and the Georgetown Lombardi Comprehensive Cancer Center. His medical career includes clinical care and research and hematologic malignancies, particularly lymphoma and multiple myeloma. Thank you for joining us on MedStar Health Doc Talk. Thanks so much for having me here. Really excited. What do we mean when we say blood cancers? What are they? I'm not an expert, so you'll just want to dumb this down for me. Yeah. Loosely, what we're talking about are disorders of the blood cells, right? So that can be your leukemias, your lymphomas, and some other rare conditions of other types of blood cells. What is multiple myeloma? So multiple myeloma is a cancer of the plasma cell, which is another, again, type of white blood cell. How do you determine what type of blood condition or cancer someone has? Yeah, we have a various utility of different diagnostics that we can use depending on what the type of blood cancer we're looking at. So for a lymphoma that we might detect by imaging, either CAT scans or PET scans, we want to get some type of sampling of that lymph node, whether that's a needle biopsy or more preferably an excisional biopsy. So we're actually taking out part of that lymph node or the whole lymph node so we can dice it up and do special stains on it to figure out what type of blood cell is in it to comprise the lymphoma. If we're looking at more of a leukemia, we might be looking at the blood or at the bone marrow to again, do special studies on that to determine what the actual cancer cell is and be able to further refine from there. If somebody wants a second opinion, what is usually your advice to them? Yeah. So one of the main utilities of a place like Georgetown, which is a tertiary care center is to lend expertise to the surrounding community. So my expertise is in leukemia and lymphoma. So very frequently either patients themselves or referring providers from the community are reaching out to me to gain insights and expertise in either lymphoma or leukemia. And sorry, go. Ahead. Just to expand upon that, my general thought about second opinions is that they're invaluable. Blood cancers are not as common as the things that especially community colleges see every day like lung cancer, colon cancer. So these are rare diseases and to have people with specific expertise in them can be very useful. What led you to get into the blood cancer realm? Great question. So we all go through fellowship. I did mine at Walter Reed National Military Medical Center. When I was in my later years of fellowship, I spent time at the National Cancer Institute under the lymphoid malignancies branch and I really enjoyed working with them. I thought they were some of the smartest docs around. I thought whenever you're going into medicine, you want to pick out your mentors, the people that inspire you. Who do you want to be like when you're practicing on your own? And for me, when I was working with that group, I was like, "Oh yeah, that's the group of people I want to be like." So that led me to doing some extra research and lymphoma, spending some time at the National Cancer Institute, running a clinical trial in multiple myeloma. So I knew pretty early on that that was the type of cancer that I wanted to gain more expertise in that I enjoyed taking care of and that I was passionate about. What type of patients do you often see here at MedStar Georgetown? So under the veil of blood cancer, again, I do mostly leukemia and lymphoma. So when we talk about lymphoma, that's a very, very broad umbrella. Roughly speaking, that's the Hodgkin and non-Hodgkin lymphomas. So those I see very frequently. So when we think about non-Hodgkin lymphoma, follicular lymphoma, the aggressive lymphomas like diffuse large B-cell lymphoma and Burkett lymphoma. Chronic lymphocytic leukemia is very closely related. Again, that's a leukemia, but it's of B-cell origin. Currently, I'm also working on some of the more acute blood cancers. So that's something like acute myeloid leukemia or acute lymphoblastic leukemia. So a pretty wide net within blood cancers. Are these common cancers or would you say they're rare? So on a whole, right when we talk about B-cell, so your non-Hodgkin's lymphomas and Hodgkin lymphomas, they roughly account for I think about 120,000 cases a year. So that's a sizable portion of new cancer diagnosis a year. Within that umbrella though, there are specific diseases that are quite rare. What are the symptoms to watch out for when it comes to blood cancers and is there any way to notice them? For some cancers, yes. For others, no. So certain types of symptoms that are sometimes more specific for blood cancers that don't happen as much in other cancers would be what we call constitutional symptoms or B symptoms. So these are things like fevers, night sweats, unintentional weight loss. These tend to happen more in leukemia and lymphoma. They can happen in other what we call solid tumors, but those are definitely things that when we see them, we start to think about blood cancers immediately. There are a lot of cancers though that are picked up incidentally, right? So a patient goes to their primary care doc and they've got an elevated white blood cell count, they feel totally fine and we will do further testing and they've got chronic lymphostatic leukemia. They would not have known otherwise because they don't to their disease. Other things related to lymphoma would be swollen lymph nodes or glands, right? So these can occur in the neck, the armpit, in the groin region. By the time it's noticeable, is it pretty far advanced? So yeah, that's a common misnomer. Most blood cancers we think about differently again than solid tumors. So we still use a staging system similar to solid tumors like breast cancer or colon cancer, but very often these are systemic diseases. We have blood all throughout our body, our bone marrow, our lymph nodes. For example, one of the more common low grade lymphomas, follicular lymphoma, very frequently stage three or four when we diagnose them. So this concept of catching it early, again, it's kind of a misnomer because at that time when they develop, they are systemic, right? They're all over the body by nature. Are there blood cancer screening tests that folks can do? I know there are things like Cologuard for at-home rectal cancer screening, but there's nothing along those lines for blood cancers, right? There really isn't. There are companies that are coming up with advanced diagnostics. The company GRAIL comes to mind, which can test for I think around 50 different cancers by a blood-based test, but know that technology is imperfect and leads to a frequent false positive rate, but there's no specific testing that is done to screen for leukemia and lymphoma at this time. What about minimal residual disease testing after somebody has beaten one of these cancers? Is that something you all do? Yeah, depending on the cancer, it can either be standard of care to do this type of measurable residual disease testing or not. It is becoming increasingly important both in knowing how good of a remission someone's in or are they in remission at all, being able to think about what additional therapies can be recommended for them. Currently have a clinical trial here at Georgetown for diffuse large B-cell lymphoma where after patients complete their primary therapy, they're offered measurable residual disease testing their lymphoma at all. If we can't, that's great. They're very likely cured based on that platform sensitivity, but if we can still detect it, could we act on that earlier and try to offer cure before they actually have a relapse? So this is the Alpha-3 trial that we have through AlloGene, which is a really kind of cutting edge clinical trial platform and design that I'm very interested in. And how do you let a patient know if they're a candidate for one of these clinical trials you're involved with? Yeah. So very frequently for our patients that we're currently treating here at Georgetown, we're bringing that up to them directly. I've had patients and their families reach out to us directly because they know the power of these tests and they want to get involved. So I had a patient that came because they had heard about this trial in particular and the fact that we were using very sensitive MRD testing and wanted to have that for their family member. What are the cancer therapies that are currently available at MedStar Georgetown for leukemia and lymphoma? At this time, we have a wide array of treatment modalities. I think anything that's considered standard of care specifically in leukemia, we do offer allogeneic stem cell transplant for our lymphoma and myeloma. In addition to standard of care chemotherapy and novel targeted therapy approaches, we have things like bispecific antibodies, which we are using regularly. We have CAR T-cell therapy both for our lymphoma and myeloma patients. So anything that's considered standard of care cutting edge is something that we have here at Georgetown, which is excellent. In addition to that, going beyond standard of care, we offer a diverse clinical trial portfolio, which is asking what is better, what is newer, what is going to be the standard of care in the future, right? So patients at Georgetown have access to tomorrow's medicine. That's incredible to hear. When we talk about targeted therapy, what is that and how does it work? Especially lymphoma, this has been a revolutionary class of medications. So the first one actually was developed for chronic myeloid leukemia. So when we think about the initial drug there, it was called imatinib or glibec. So that's a targeted molecule that inhibits the pathway survive. Turning that from a fatal disease into one that is very manageable with just a pill. So that's the power of targeted therapies. Geez. Yeah, it's incredible. So that was revolutionary in the early 2000s when that drug got approved. The advent for that in lymphoma started to happen with the BTK inhibitors. So the first drug being ibrutinib. And since then we've had numerous others that target the pathways within B cell malignancies. Again, a lot of the non-Hodgkin lymphomas So these are often pills. They have a different side effect profile than traditional chemotherapy and often they're more effective. How do you approach giving a patient bad news? So when I was in training, my mentor told me, if you've got bad news to share, never go into the room without a plan. You always need to be prepared for delivering the to pivot to, I've got something. Solution to the problem. Solution to the problem. So I've taken that to heart. And so anytime I'm thinking this is potentially bad news, I'm going to share. I'm doing my homework and making sure that I'm thinking about what is that next best option or first option so that we can focus the conversation, not on the bad news, but about what are we going to do about it? Exactly. And is that the most common question you get from patients? What next? Depends on where they're at in the disease process. Very frequently for the newly diagnosed patient with a blood cancer, a lot of the time we're clearing up misconceptions. People have a thought in their head when they hear the word cancer and it's usually doom and gloom. They're thinking the worst and sometimes that's just not the case at all. So really setting expectations and trying to educate them about what does this actual cancer mean for them specifically, that can be a lot of the conversation, right? Before even getting to what's next and what are we going to do, you really need to educate and make sure that they understand what this means for them. I can't emphasize that enough. Most people do not have a lot of understanding or education about cancer. So what gets dramatized on TV is a lot of doom and gloom. Right? And that's not always applicable to them. A lot of these are manageable cancers. Very much so. Why should patients choose our malignant hematologic oncology program? The reason to come to Georgetown for malignant hematology is that we have specific expertise in these diseases. That really does set us apart from a lot of other centers, again, that are trying to treat every single disease at the same time. That is a very difficult job. So our job here at Georgetown is to have specific expertise in what we're treating. With that, we know what is the best standard of cares for these cancers. And again, this is a rapidly evolving field. We have access to cutting edge therapies to include bispecific antibodies, CAR T, allogeneic stem cell transplant, the newest FDA approved therapies, as well as the clinical trials, again, which can be hugely important in blood malignancies. Can you tell us about the malignant hematologic oncology with MedStar Georgetown's stem cell transplant and cellular immunotherapy program? Yeah, we work together hand in hand every day and we kind of overlap in some ways. We are frequently identifying patients that need these types of cellular therapies or stem cell transplant and working with our colleagues to get them established so we can get them rapidly those therapies when they need them. We're also doing our own clinical trials in the cellular therapy space trying to become principal investigator on a new CAR T product that targets two different antigens at the same time. This is a novel construct that looks like it might be better than our existing standard of care CAR-T products that are commercially available. So yeah, we work hand in hand with our cellular therapy team. Some of us are on the cellular therapy team as well as doing primary clinical work for patients with blood cancers. Dr. Rosworski, you are a decorated military veteran who has received numerous awards during your time of military service as a medical officer. How has this valuable experience and complex cases been an asset for your patients? I think my military time was invaluable to shaping me to who I am today. Being in the arms services instills in you a sense of duty, honor, and responsibility and I bring that to patients and I bring that to patient care. Sounds like that shaped your philosophy of care. Yeah, 100% it did. I want to make sure that I'm doing right by my patients, making sure that they're getting the best of what I can give them with my time, with my expertise, with my compassion. Again, I feel very much duty and responsibility bound to them. That's wonderful to hear and I know they're lucky to have you as their doctor. Can you break down phase one, two, and three? So clinical trials are done in phases for a reason. As we're trying to develop new therapies or combinations of therapies, we need to first establish that they're safe. So that's a phase one trial. Just establish, are the drugs or this new novel platform, is it safe? Once we've established that and we know we have a safe drug, then we move on to a phase two study. So when we get to phase two studies, what we're trying to establish is what is the efficacy of the new regimen generally but not always these are non-randomized studies where we're just trying to see how efficacious is this new platform. Once we've established that and it looks like this is potentially a promising drug, then we move to phase three where that is generally a randomized study against what's considered a standard of care. So new platform, new agent versus today's current standard of care. So those are generally randomized studies and those are the ones that generally will lead to FDA approval for new drugs. Thank you for that. Is there a specific clinical trial that you're most excited about? Yeah, there's a trial that we're currently enrolling on right now that I'm very excited about. This is a partnership with Memorial Sloan Kettering in New York and our consortium partner in New Jersey at the John Thur Cancer Center. Here we're looking at using a bispecific antibody called mosinatuzumab and frontline meaning patients that have not been treated before follicular lymphoma. This trial is not being done at a lot of places. Again, this is just three centers that are doing this, including Georgetown. We know that this antibody, bispecific antibody works incredibly well in follicular lymphoma. It's currently approved in the third line setting and when anything works as well as most edutuzumab did and in the third line setting, the question is, should we be moving it up? Should we be taking it to second line or first line therapy? So again, this is a first line study. We've already enrolled a lot of patients on it. Patients are responding well to therapy. The current standard of care in first line follicular lymphoma is chemoimmunotherapy, so chemo plus antibodies. So with this trial, we're asking a question which is how does a bispecific antibody, so not utilizing any chemotherapy, how does that work for patients? And the results that we've already published at the American Society of Hematology are incredibly encouraging with response rates and complete response rates very similar to chemoimmunotherapy. So I've had many patients from the region ask about this trial. Sounds like a game changer. Yeah. I think most of us in the lymphoma field are starting to think that are we entering in a future where chemotherapy is kind of a wayside? We're getting there and it's trials like this, follicular lymphoma, especially where we're starting to ask those questions, can we start to pivot away from chemotherapy? There are cancers where we've already done that, right? In chronic lymphocytic leukemia, again, we're using these targeted therapies almost exclusively for patients because they work better than chemotherapy and these types of concepts are moving to other B-cell malignancies in rapid fashion. Dr. Rosworski, how do you feel about the future of blood cancer care? Hearing you talk about those clinical trials, it sounds like there's a lot of reason for optimism. There is a ton of reason for optimism. It's just getting better and better. I frequently will tell patients when I'm meeting them for the first time, depending on what the cancer is, right? There's no better day to get diagnosed with this blood cancer. That's a great attitude to have. So for certain cancers, our cure rates are already very high. The future is that we're going to push those cure rates even higher. There are some cancers we cannot cure, but we hope to change that, right? I think we're developing the tools where we can start to cure more and more blood cancers. Well. The future is bright. I've been talking with Dr. Joseph Rosworski at MedStar Georgetown University Hospital in Washington, DC. Thank you for sharing your expertise with us today on MedStar Health Doc Talk. Thanks, Ryan. It's been great to be here. For more information about our malignant hematology oncology group, please call 202-444-5209.