Michelle Chen

Intern Mentor G/T

April 2 2019

Interviewee: ​Dr. Edward Heir

Title:​ Veterinarian at Bethany Centennial Animal Hospital
Date of Interview:​ April 4, 2019
Interview Type:​ In Person

Transcribed Interview

MC: Michelle Chen

ED: Dr. Edward Heir

MC: Ok. So my first initial question is where did you first hear about immunotherapy and what
were your first initial thoughts about it?
ED: Well, the first thoughts were very kinda exciting because the very first thing I heard about
was a way of treating canine melanoma. Canine melanoma, we encounter them here all the time,
in two different forms. The traditional pigmented nodules, that we often see, usually an oral form
that we’re talking about. And sometimes we see what we call amelanotic melanoma where it
doesn’t even have the black pigment, but it really is the same thing. You do a microscopic
analysis or the botanic histograph and it comes out being the same in the biopsy. And the
problem with a lot of these tumors is that they are often non-receiptable. There in a place in the
mouth where you can’t really do anything about it. And I personally lost two cats to oral cancer,
but neither one of them was a melanoma. But, I was aware of the difficulties. Even when you
surgically remove something and you get clear margins in the biopsy, they survive their life
being tube fed and things like that. So we didn’t have a lot of treatment options for melanomas.
Out came an oral melanoma vaccine, and the word vaccine is used in quotation marks. We
usually think of vaccines as being a thing we give in advanced basically to animals to keep them
from getting infectious diseases. But, the original canine melanoma vaccine is a totally different
concept and took the human plasmid DNA that expresses a gene which codes for an enzyme that
present in large amounts of melanoma cells. It had a narrow range and is only administered by
board certified specialists. It is administered at a certain stage of cancer, so they want a tight
control on the administration. We sent over some dogs for this type of therapy and over the
course of time its become a standard course of treatment for melanoma and has worked without
recurrences. The only issue is that we couldn’t figure out is if it wasn’t going to reoccur anyways
or was it because of the treatment. It did become another weapon in our tool box, especially
because the chemotherapy and radiation were not efficacious. They also had oral medication that
we could administer here, again to specific oral cancers that were inoperable, but we basically
got no response from the cats that we used it on. About two years later it was no longer on the
market, but it was another immune modulator that just didn’t get full FDA approval after its
failure. The most common immune modulator we use now is Cytopoint which is an monoclonal
antibody that blocks the itch signal and inflammatory responses for allergies. We’re very excited
about it and use it everyday and it seems to work , so that’s a summary on what I’ve come across
so far.
MC: And how expensive would you think immunotherapy for cancer would be?
ED: So the melanoma vaccine as I recall was a couple hundred dollars per shot, but each
injection was given in 6 month intervals. So it’s expensive, but it didn’t have to be given often.
We had one where we got dirty margins from the biopsy during the surgery and we went back
for follow up and they recommended the injections. The pretty much kept giving the injections
every six months for two and a half months. The dog did ok for a few years until it died for
different reasons.
MC: And then another question I had was, in what situations would you want to use an
immunotherapy or something like that over chemotherapy or radiation or surgery?
ED: So it depends on the kind of tumor you’re dealing with. Things around the head and the face
or the neck are very difficult to do radiation therapy. Even if you have a very narrow beam to do
the radiation, you still have to risk damage to vital tissue and brain damage. Certain tumors do
not respond to chemotherapy. Chemotherapy is a great therapy for lymphoma, for example. They
are purely for chemotherapy and target those tumors anywhere around the body. Some of the
glandular tumors, mast cell tumors even, we use a different combination of things. We may want
a multifactorial approach, especially if they’re a grade three and mestatize elsewhere in the body.
Distal extremities are difficult to get a two centimeter margin on, which can affect recurrence
rate, especially in areas like the hock or the metatarsal region where there just isn’t enough soft
tissue to remove. Sometimes you’ll give antihistamines or steroids to make it smaller, and then
try an immune modulator in combination to work against the tumors. Also, chemotherapy have a
lot side effects and immune modulators generally have a lot less side effects. We don’t have to
worry about anaphylactic reactions or drugs going outside of where they’re supposed to go. The
consequences can be deadly. Some drugs are done intravenously and if they get outside of the
vein it can be fatal. Also handling them can be dangerous for the veterinarians handling them and
you have to worry about them getting on you or in you.
MC: What are some of the side effect of immune modulators that you know of right now?
ED: The only real effect that we know of is a lack of efficacy. There is a debate over if they
really work. There are no disasters like gene mutations, because they’ve already undergone a lot
of trials before they get to the veterinarians. We always have the standard worries of reactions at
the local injection sites like inflammation or pain at the injections site. There can even be
sensitivity because the vaccine is cold and of course if there is an allergy. It’s still so much less
than the chemotherapy that if killing a large number of cells.
MC: And, how effective do you think chemotherapy is in comparison to immunotherapy.
ED: It depends on what cancer you’re talking about. Most B-cell lymphomas respond amazingly
well and the life span of a dog is over more two years what was predicted. Chemotherapy is
basically useless in mast cell tumors, and this is where immune modulators are a huge advantage.
They can kill the specific cells there and targeting the fast reproducing cells.
MC: And, do you see yourself incorporating immunotherapy more in the future here in you
practice.
ED: For general medicine, we’re just beginning to touch it. The Cytopoint, we use everyday in
our practice. For oncology, maybe not so soon. The oncologists right now have protocols that
still use a combination of things, the multimodal approach, that gives you the best chance to treat
cancer. It’s uncommon right now if we had a case of melanoma that we’re only going to treat it
with the vaccine and not other methods as well. It also matters it it's the right stage and it its
mestatized outside of the original area, because it becomes less effective if it has moved. I do see
more and more of these coming along. If they’re available in an oral dosing form and they’re
effective, they may start to become more common in general practice. The research is still going
in that direction.
MC: Do you think most people will be able to afford it? Even when it becomes more common?
ED: The oral drug was moderately expensive, even the one that was no longer available. But, it
wasn’t prohibitively more expensive. We have many drugs that are more expensive. I think
people pay more for Apoquel now, for allergies than they do for the immune modulating drugs.
If there's something that treating a cancer we see a lot of, there's more likely a chance there it
will be mass produced and be more available. The drug manufacturers know that people are
willing to spend a lot for their dog and cat, and right now they’re not going to sell a lot of it, so it
will be more expensive. If sometime ends up in general practice, it will be a lot less expensive
than what an oncologist or an internal medicine specialist will use.
MC: I guess my final question is can you describe the perfect candidate for someone to get
immunotherapy. What type of cancer, age, breed, anything that you think would make the perfect
candidate.
ED: Well, most cancer patients are older. Not all of them are always old, there's no steadfast role
for age. The ideal patient is any patient with a cancer that has limitation of what you can do with
current treatment therapies. Even better, where we don’t have to deal with the side effects. We
can deactivate the genes that cause the cancer with immunocytochemistry, the lab tests are still
expensive. It costs four to six hundred dollars and we’re starting to get that. The ideal patient is
any patient that can afford and care to have the cancer treatment. And it comes down to
insurance. It hard to believe that you get this puppy or kitten and you’ll need this oncology
referral twelve, thirteen years down the road. But, you can afford it with the insurance and as
these therapies develop, it may encourage more people to get this insurance.
MC: Ok, thank you so much for doing with interview with me.
Reflection:
Dr. Heir was a very reliable source and gave me insight on how immunotherapy is used
day to day in a clinic, and how it’s being view and updated. The interview gave me a new
perspective on different reasons as to why immunotherapy is helpful. I never realized that
immunotherapy could be used for cancers that are in inoperable locations on the body. The
interview also gave me a real estimate on how much influence immunotherapy has in a vet clinic
and how much it would cost an owner to go through with immunotherapy. To understand the
financial and biological associated strains with treating cancer really helped me see how
immunotherapy could impact canine oncology in the future.