Dedicated to Heme Malignancies
Jeffrey R. Schriber, MD, FRCP
A conversation with Jeffrey R. Schriber, MD, FRCP, of City of Hope.
MCMS: You are the Medical Director of Hematologic Malignancies for City of Hope in Phoenix. Do you support other City of Hope locations?
Dr. Schriber: I've gone to Atlanta to look at their program and help them a little. We do work as a group. It's a funny story how it came here. I developed the first transplant program at Samaritan Hospital, which eventually became Banner. It was actually with City of Hope. We developed that from nothing. This is back in 1997 and there really wasn't much of a transplant program anywhere. Mayo had a very tiny program, but this is where the bulk of the patients were. At the time, a lot of transplants were being done for breast cancer. So, the physician community said we don't want to send our patients to Tucson. We want them to be treated here. One of the medical radiation oncologists had worked at City of Hope and said, “Hey, you should call those guys.” They persisted and eventually formed a partnership, and I was recruited to help start the first unit. We rapidly built a successful transplant center. But it was just focused on transplant, which is a great thing, but it's like the cherry on top of a sundae. If you had patients with leukemia or patients who weren't ready for transplant because they failed, we didn't have the trials. Over time, Banner didn't want to work with City of Hope, so Banner started another program, and we didn't like what they were doing. So, we left them, and I started the program at Honor Health, but it was largely transplant. We did develop a leukemia program. But I wanted a bunch of people that were experienced in heme malignancies and part of the reason is that the heme malignancies, more than anything else, have changed dramatically over the last five to 10 years. Myeloma has the most new drugs for any particular disease and to keep up with that is really, really hard. I did a lot of speaking because that's how you become an expert. You got to keep up with these things. But it's hard. Myeloma treatment has completely changed. CLL or chronic lymphocytic leukemia has changed completely. It used to be all chemotherapy. You'd never use chemotherapy effectively now. For the first time since the 70s, we now have a new upfront approach for more advanced Hodgkin's disease. Just last week, there was a new approval for a therapy for diffuse large cell lymphoma that has changed what we've been doing for close to 20 or 30 years. Each of these fields has changed dramatically and yet, most of the physicians in Phoenix see everything. They see colon cancer, breast cancer, which are the common things and the heme malignancies, which together account for 30 to 40% of cancers, individually are small. There was nobody just doing heme malignancy. That's what I wanted to do. I came to develop that. And then as I was upstairs doing a consult and learned they had the structural capability to do transplant and it’s a part of a heme malignancy program. That ultimately came to pass, and then City of Hope got involved. So, this was a fabulous relationship and it's just accelerated because City of Hope is known for their heme malignancy program. They do other things, but their heme malignancy is one of the best in the world, if not the best in the world. They do more transplants than any center in the world. It's natural to bring that type of work here. And they have a plethora of clinical trials that is the next step for us. I came because I wanted to do not just the cherry on top. I wanted to do the whole sundae, as it were, and work our way up to this. I started seeing patients with myeloma and CLL and lymphoma, offering that expertise. It was also in the midst of COVID and for myeloma transplants, which is the most common reason we do an autologous transplant, a lot of places were saying the risk was too high. The risk, which is normally at1%, was up at 5 to 7%, so most people just deferred them. They would collect the cells, put them away, and say we'll do them later. Well, that worked out nicely for us because, by the time it was safe to do them, we were at a point where we were ready to start. We've done autologous transplants and we're now in the process of seeking accreditation. We've submitted all the required material and we expect to be fully accredited. My role is to really develop and bring talented people here who do heme malignancies.
MCMS: Talk about that a little bit. It's a big sundae to eat. How many other people do you need to be with you on the team?
Dr. Schriber: More than I have now. The first person that I was able to recruit was Dr. Jim Slack and Jim had been the director of the transplant unit over at Mayo for a long period of time and had just retired. I've known him for 20 plus years. We worked together at Roswell Park, which was my first job after fellowship. His kids are the same age as my kids. They're all best friends. We've added a few other people like Dr. Sara Park, who had just finished her fellowship and had gone to work at Saint Joseph's and then briefly with the Honor group but didn't like that as much and was having a baby, too. So, I said to her, “Hey, if you want to work part-time and you can deal with the baby and stuff, why don’t you come and help.” Dr. Jeremy Larson has just joined us, who was a myeloma guru at Mayo. He's been indispensable because we see a lot of myeloma. And then we've just recruited Dr. Tibor Kovacsovics from Utah, who'd headed the leukemia program in Utah. That's our next build to build leukemia. To have the full breadth, we probably need another couple of people. Now we need to get more patients to do that, but I think the philosophy with City of Hope is the Field of Dreams. If you build it, they will come. We're putting people in place saying this is what we need. We believe that as we do that, we will get the referrals because this is what we do, and we don't have to do this in a vacuum. It's true that the community oncologists are treating the bulk of these, but honestly the bulk of them can be treated by them and that's where they live. We're happy to see your patients as second opinions and then they get their patients back. We can follow with them for the complicated patients, like for the acute leukemias, we can take those over. And then if there's something unusual that needs to be done, be it a transplant or CAR T cells or by bispecific T cell engager cells, that's something we can do here. Just this weekend, I was at a meeting. There's a new leukemia drug – it’s an antibody drug that's a little complicated to give – and they anticipate it's going to be coming out soon. Two of the local oncologists were there and we were talking about the logistics of this for them in the community. Mostly, they're doing chemo locally. They don't have the ability to do complicated stuff. This drug causes some issues with red cells, so you have to transfuse them up beforehand, and then you have to be prepared that their hemoglobin might drop suddenly. They might need another transfusion. You've got to do this special pheno. It’s a pain in the… That's the type of stuff that we'll be able to do here in cooperation with them and say, “Do you want us to do the first few of these? We're happy to do that and send your patients back.”
MCMS: Is that approach well received, one that you're not trying to poach the patients and hold onto them?
Dr. Schriber: At first, there's always a lot of caution and I think that's legitimate. For a new patient, we’re convenient for them. Our philosophy has always been we're here to work with you and to help you. We'll see your patients and you get them back. Even if we're doing a transplant, we'll do the transplant. Then you get them back. Because if you don't do that, they're not going to refer to you and I don't want that. For most weekends, I'm there intermittently to give direction or to give the patient some reassurance, but colleagues are doing the bulk of it. They’re doing it all correctly. It's not like they need me to teach them how to do it, but sometimes with subtle things or clinical trials. It helps to reassure the patient that they’re getting someone and that this is their focus. I'm the last person you want to see for colon cancer or breast cancer. Today, I was at a meeting and they're texting me that someone’s there for a one o’clock. I didn’t have a one o’clock, but I go down and sure enough, it's on a different schedule. I went in and this person has ovarian cancer. Now there's a doctor here named Scribner, who is a GYN person. And I said to her, “You do not want to see me for this because I know nothing about ovarian cancer.” But we just had a clinical trial using the latest and greatest CML drug, where we were able to get early access for some of our patients and gained some experience. That's the type of thing we have that others may not.
MCMS: At this stage in your career, it sounds like you are, in part, a mentor. Is that a comfortable transition that you've made over the last 5 to 10 years?
Dr. Schriber: We're mentoring but a few of us are old. We've got a great group of APPs. We've got our administrative team. When you do heme malignancy stuff, it really is a team. I always talk about transplant as being the ultimate team sport, but heme malignancies are like that, too. I just saw someone and then I usually go right to my nurse coordinator and say, “Hey, this is the type of stuff we need to do. In two weeks, we’re gonna see this guy. We need this scan.” All of those types of things. You have to be very involved and a part of that is teaching your team members. Part of it is saying to the referring doc, hey, I've got this new study for this. Part of it is figuring out which studies you want to do. I'm learning from them, too. Trust me, they know how to do much of these logistical things way better than I do. Both the nursing staff here and the local physicians. They do a terrific job. So, my goal is to be someone who's an asset to them, not someone who's trying to poach. That never works. I might get a bunch of patients at the beginning but I'll never get anyone from them again, and nor would I deserve to, frankly, if that's what I'm doing.
MCMS: You've been in the City of Hope family for a while. Can you try to think back to why you came over to City of Hope?
Dr. Schriber: Well, it depends which time you mean. Back in 97, I was at Roswell Park in Buffalo, which is a major cancer institute. I was doing the traditional academic things, like assistant professor, senator in the Buffalo Senate, all these other silly little things. I had a nice career going. I was getting some publications and I got a call from Dr. Steve Foreman. Steve is a god in transplant. I thought he was calling for somebody else because I had someone who was going to do a fellowship and he said, “No, I want to talk to you about starting a program in Phoenix.” I remember talking to my wife at the time and saying, “Look, there's no way I'm going. It's tumbling tumbleweeds, but it’s Steve Foreman. I gotta go out.” And I've known Steve for a long time. So, I came out and the idea was an interesting one. They wanted to start a new program that wasn’t being done really in Phoenix. There was a tiny program in Mayo. They were doing maybe 10 transplants a year. It was not a popular thing. And our growth ultimately spurred Mayo’s growth. So, this was a good thing for both.
MCMS: Dr. Foreman helped to convince you to go?
Dr. Schriber: I was still relatively early in my career, and transplant was a pretty new field back then. I had been the first transplant fellow at Stanford. I was maybe #251 of all transplanters in the world. When I finished fellowship, I was asked to start a program and I knew how to take care of patients, but I had no idea how to run a program. I'd only been out in practice probably three or four years. The problem was how you deal with the finances and all that stuff. But I knew that City of Hope was there to support me, and that was appealing. I convinced another fellow from Stanford to join me. People thought this was a good opportunity. So that's why I ended up coming. Also, the City of Hope philosophy is one that I very much believe in. Their philosophy is, “There is no profit in curing the body if in the process we destroy the soul.” You need to not just help the patient but help them move on and continue to do the things that they want to do. That's a philosophy that is ingrained. People sometimes say, well, if I don't do this, I'll die. And it may be true, but if you do it, you can also die. You must be sure that it's the right thing to do for the right reasons with the right purpose for the individual patient. I might see two patients with the exact same disease, but their goals are different. And you may choose a different approach based on that.
MCMS: Was there something in your background or in your training in Canada that may have led you to City of Hope? Something tied to the philosophy or vision that speaks to you.
Dr. Schriber: One of the mentors that we had in Toronto was a guy who talked about how to give bad news to patients. In Canada, there was a fair amount of emphasis on how you talk to patients. How do you have a conversation to ask about goals. He was ahead of his time because that's talked about now but, 20 years ago, that was not talked about. As Canadians, I think we rely a little less on labs and CT scans. Here, everybody and their mother has an MRI. In Toronto, which is a major city, there are probably two. You had to make do. When I order a test it's a question of what I will take from that and how that will change things. If I'm not going to change anything and just doing it for the sake of doing it, it's not something that I like to do. We tend to do a little less, I would say, defensive medicine and you're relying on your history taking, your physical exam, to try and lead you. That's not to say that one's better. I would say that approach is perhaps a little bit different, the idea of trying to compassionately help someone.
MCMS: Let's talk about communicating. You try to incorporate genetic testing, immunotherapy, new techniques, and data from clinical trials. How does that translate complex information to patients and their families?
Dr. Schriber: Well, we try and make sure we do what’s appropriate. I'll give you an example. With CLL, we want to look to see whether a specific gene is mutated or not, because it gives you some prognostic information. It doesn't change how you'll treat them. We look for a couple of different proteins that might alter to some degree how you're going to treat people, and you can incorporate that in. And then you tell patients we're doing some special tests and share this is what the tests show. They may confirm something or, in some situations, help to establish a diagnosis. In Waldenström's, there's a thing called MYD88. If you have it, you’ve got Waldenström's. If you don't, it's unlikely you do. So, we would order it just as anybody else would but it’s more innate for us. And then there are times where you look at stuff and say, well, do I need to do it? A lot of people are doing what we call MRD testing, looking for very low amounts of disease. And there's a disease called CML, which is well established. We know if you can achieve a certain level for a certain period of time, you can actually stop the drugs they're on. And CML is a fascinating disorder because, when I started, the only cure for these patients was to go for an allogeneic transplant. As people understood the science of it, there's a chromosome abnormality that causes a protein abnormality, which produces a specific kinase. That's the problem. Someone asked, “What if we just block that?” and that was the origin of all these TKIs. You can now take a pill and live a normal life rather than going to a transplant and potentially dying, so it's completely evolved. Not only did it evolve with the patients, but there are also at least four different companies that have drugs in this space, all of whom are profitable for a disease with maybe 3,000-5,000 people a year in the U.S. It supercharged looking for molecular targets, those type of things that allow us to change the face of not just human malignancies, but every cancer. Again, I know nothing about lung cancer, but there now are markers. If you have those markers, you can see it on TV. In CML, we initially thought you're on these pills for life. Well, it turns out if you achieve an incredibly good response, you can stop. We've done trials where you can say if you achieve this response, you stay in it for a period of time, you can stop, and half of those patients will stay up and it never comes back. From a disease where over a three-and-a-half-year period, untreated everyone died. That was the natural history. That's an amazing accomplishment.
MCMS: And that's information that patients can understand?
Dr. Schriber: Yeah, and I'll show them and say, “Look, this is the target. If we get here, you can live a normal life. If we get to this level, I can actually stop this drug.” CML is not uncommon in younger patients, many of whom want to have families and you're not supposed to have families on these particular meds because they can be teratogenic. For them, there's a big motivation to be off these. You can use that to say you have got to take it every day. It's not like flossing where you can kind of catch up a little bit. But that model can apply to other things. We’ve got great measurements but what they mean is a little bit hard to tell sometimes, so a lot of people are talking about measuring MRD for myeloma. Although we think we know what it is, we don't know definitively. I was telling a patient today, and we have a number of patients who are 20-year survivors of transplant in myeloma, which is pretty good. Half of those patients still have a marker. I don't know if I have to get rid of every single last cell. Is it okay to kind of put them in a quiescent stage? You sort of stay in your corner and don't cause trouble. I don't routinely do those tests because I don't know for sure what I'm going to do with it, but I think as we understand the science of it, we're better able to treat the patients. We have a lot of people on what we call maintenance therapy, and they’re on it forever. I always tell patients on maintenance that they’re doing it for two reasons. One, you may get bad side effects we don’t want, and two, we don't want your disease to come back. I hope you're always on this. I would like there to be a third option, that I've determined you don't need meds and all the potential side effects that may come down the road. We don't have that yet, but we’re getting there, and I think that's going to be exciting as we move forward.
MCMS: What would you say are some of the hurdles to practicing oncology today?
Dr. Schriber: One is the breadth of knowledge. It continues to explode, which is why we developed into just doing heme malignancies. There's no way I could do what some of these guys do, which is treat all these cancers. I couldn't keep up. It's great because there's this explosion of knowledge, but it's figuring out which are the important things and making sure you can stay on the cutting edge. That's a challenge. I think the other challenge we face is regulatory and insurance, where we may have something I want to treat, but I can't for whatever reason. We need to do a better job at trying to break down some of those barriers. I don't view insurance companies as enemies. The patients are in the center and we're all trying to do the right thing. The insurance companies want to make sure they do the right thing at the right place and not do extra stuff that doesn't need to happen. I want to make sure I move things quickly, but there can be partnerships. One of the things we need to get better at is realizing we're all working together. How can we make things better for the patient? For instance, when you try and start a transplant program, you have to get this FACT accreditation. To get FACT accreditation, you need to do a certain number of transplants, but if you can't get insurance, it can be complicated. We've been very fortunate because of the groups and people we've brought on board we've been able to do that, but that's a barrier to get in the space. Maybe that's good because you make sure people know what they're doing, but it can also be complicated. You have to find ways to break down those barriers while maintaining the appropriate guardrails.
MCMS: High barrier to entry but it helps to make sure the quality is high enough.
Dr. Schriber: You have to make sure quality is there. Quality can't be compromised for this.
MCMS: My last question is what motivates you each day to care for patients. You've been doing this for quite a while. What gets you going these days?
Dr. Schriber: It's funny. I talked to my kids and said, “You want to find something you really like, that you enjoy and you like the people, you like what you're doing because then it doesn't feel like a job.” I really like what I do. I love it when I can go see the patient and say, “Hey, I just saw your scans. We’re five years out. We can talk about you being cured.” I like the fact that things have evolved. For Hodgkin's disease, there's a new medicine and it took a while to get there. I think in 2019, they produced their first data from a two-year follow up and it was the first time something appeared better than the standard for Hodgkin's disease. It had been the same for 30 years. People said the trial was flawed but, just this year, that study matured enough that you saw survival advantage. Once you see a survival advantage, you can't ever catch up. That's the better therapy. Helping to be part of some of the studies. Being someone who talks about these drugs and then see where it goes, that's incredibly exciting. This field never did. I tried to convince my daughter she should go into oncology. She went into endocrine, and I kept saying to her it's different all the time. What I'm doing now will be different than what I'm doing in five years. What I started seeing 20 years ago is completely different. The first growth factor had just been developed. A typical transplant patient was young, about age 40. They were in the hospital for about 40 days and the mortality was 30 or 40%. That's for a simple autologous transplant. Now, median age for a myeloma transplant, who no one would have ever touched back then, is probably 72. Pre-COVID, I could do half those patients completely as an outpatient. COVID has changed things a little bit. And the mortality is closer to 1%. Patients are much older, it’s much safer, and fewer come into the hospital. The field changed because we got better antibiotics, better supportive care, better ways of using stem cells. When I was at Stanford, we published the second article ever on the use of peripheral blood instead of bone marrow and that’s remained the standard since then. You get to watch these things completely change. It's never boring. And watching the patients who get to that next level, that's why you do this. In the old days, some of these patients would have died if you hadn't done this. I talked about CML patients. I have a guy I remember very fondly. I told him he couldn't do a transplant. He had a bad fungal disease. I said I'll kill you. He came back and found a way to get an antifungal from the sort of AIDS underground back then. We ended up transplanting and, sure enough, he died from a fungal infection. 10 years later, maybe six years later, he never would have had to have a transplant. I look at that guy and he had a young child who was the same as mine at the time, and I wrote him a letter way back in the 90s and said, “You may not know your dad, but I wanted you to know some things about him. He did this for you.” I look back and think if we had been able to delay stuff, this guy would be alive taking the pill. You’re driven by the patients to get better, to push forward and find better ways of doing it. You're driven by your team because they're fun to work with and you like to make things move forward. And you're driven by building with a group like City of Hope, which is so incredible saying we can build something here that will be a legacy for folks in Arizona. All those things drive you. You don’t have to be that motivated. It's incredibly fun to do this stuff. I feel very lucky.
MCMS: Congratulations on the effect you've had. Thanks for your time today.
Dr. Schriber: Sure, happy to speak with you.