Dr. Suter: We're always looking for a cure. And so the first thing that I always tell owners is that if you're talking about curing a dog, you have to be willing to accept some of the toxicities that will occur from the total body radiation. Those toxicities are expected. We've learned through the years how to manage those very appropriately. And so it's important upfront for folks to understand that.
Dr. Venable: Welcome to the Veterinary Cancer Pioneers Podcast, the show where we delve into the groundbreaking work of veterinary professionals who are dedicated to advancing the field of veterinary oncology. I'm your host, Dr. Rachel Venable, and I'm thrilled to embark on this journey with you.
Dr. Venable: Hello and welcome to the Veterinary Cancer Pioneers podcast. I'm your host, Dr. Rachel Venable, and I am so excited today to welcome our guest, Dr. Steve Suter. Dr. Suter has a DVM and PhD and is board-certified in veterinary oncology. He did his training at the University of Pennsylvania as well as UC Davis. He has been part of the North Carolina State University faculty, and he's ran the world's only academic Canine apheresis and Bone Marrow Transplant unit and training specialists through a dedicated fellowship program. With that, so really interested to dive in deep and learn more about the bone marrow transplant program. He has over 60 scientific papers, book chapters, and a frequent speaker internationally and locally at different conferences. So also very excited with that. And he just started the Canine Transplant and Apheresis Center in Chattanooga, where he's going to be offering those services as well. So Dr. Suter, thank you so much for being here today, and I'm really excited to learn more about just your bone marrow transplant program and the apheresis is everything that you've been doing.
Dr. Suter: Well, thanks so much for having me, Rachel. It's great to be here.
Dr. Venable: Yeah. And, you know, I always like to start, which is kind of what led you into veterinary oncology. And certainly for you, what got you into bone marrow transplants?
Dr. Suter: Well, it was a pretty, pretty long journey, to be honest with you. And I sort of fell into it backwards. I ended up working on a PhD when I was doing my veterinary PhD at Penn, and the project involved the use of gene therapy in combination with bone marrow transplant to treat puppies with a severe combined immunodeficiency. The disease was called XSCID, and during that work, I had to dive into the transplant literature, which is all in the human side of things. So there's a ton of literature in the human field on bone marrow transplant, and quickly found out that dogs were used as a model for bone marrow transplants by mainly the Fred Hutch Research Center in Seattle for close to at that time, about 40 years and so about 60 years. And I had no idea that that literature was out there. I had no idea that you could transplant a dog. I had no idea that dogs were used as a model. And so it really opened my eyes during my PhD research that this was something that was possibly available for veterinary area. So again, I sort of fell into it backwards by working on another project that involved transplant. I had never been taught anything about transplant in veterinary school, as were still not, and I had no knowledge whatsoever of how to do it. I was really, a really a clean slate.
Dr. Venable: Sometimes, that's the best way to start, right? When you're not coming in with any preconceived notions, just doing it. So what would you say kind of comparing chemo with bone marrow transplant long term. But I guess, you know, can you just sort of walk us through the bone marrow transplant process, maybe just for some of our listeners that aren't as familiar with it. So when do we use it in dogs and when? So what diseases and at what point do you recommend it?
Dr. Suter: Yeah. So it's really a bone marrow transplantation is really a combination of chemotherapy combined with a bone marrow transplant. And so it actually is not one or the other. It's a combination. So it's a really I would consider it a pretty aggressive approach to try to treat dogs with lymphoma or leukemia or some other myelodysplastic disorders of the bone marrow. And so most dogs, all dogs who undergo a transplant have to receive chemotherapy first, which is what you and I do every day give dogs chemotherapy. And so the goal is to drive them into clinical remission with chemotherapy first. Hopefully we'd like to have that. And that's always the ultimate goal. So using chemotherapy for an amount of time and we can talk about that a little bit later to drive these dogs in remission, to decide to reduce them, to get the tumor burden as low as possible.
And most folks I would imagine, who are listening to this podcast are aware that we rarely cure dogs with chemotherapy. We can drive them into clinical remission, but we can't drive them into real molecular remission. And so that lack of a molecular remission is what gets dogs to become resistant to chemotherapy eventually. So we're really using bone marrow transplant to drive dogs into molecular remission after receiving high dose chemotherapy to drop them into clinical remission. So when a dog is in a clinical formation, they're still have some cancer cells floating around somewhere. We don't really know where, to be honest with you or how much, but they are clinically doing well. So that's really the combination of that. Any dog that gets into a remission with chemotherapy, is then a candidate for a bone marrow transplant because they been cyto-reduced as far as they can. Now, it's sort of depends on a transplant type, which you may we'll talk about in a little bit. But theoretically the best case scenario is a dog having a high grade lymphoma in clinical remission with chemotherapy. And then we're ready to go.
Dr. Venable: As far as getting them into clinical remission. Do you have a particular protocol that you like vets to use, or could it be anything as long as they go into remission, how do you typically recommend that beginning step?
Dr. Suter: Yeah. The answer to that is is yes. So, you know, we all consider CHOP to be the best chemotherapy protocol because it's multi-agent and leads to the best results in a wide variety of study. So most folks will use CHOP. And it really doesn't matter to me what protocol is used as long as they do go into remission. Now, for an autologous transplant where we're using stem cells from the patient, we tend to be very careful with the amount of Cytoxan, cyclophosphamide those dogs use. That's the C in CHOP. Those dogs receive a very high dose of Cytoxan before transplant for a variety of reasons. And we don't want resistance to that particular drug. So we tend to leave out cyclophosphamide and just use HOP instead. For those dogs. But many times we don't know if the dog's going to make it to us or not. So I can't say that those dogs who have received Cytoxan do worse in a transplant setting. The dogs who don't. However, because of the issues of resistance, I tend to avoid that in the CHOP protocol. But any protocol is fine as long as they're in remission. In general.
Dr. Venable: Do you have a way to determine molecular remission? You know, you mentioned clinical and, you know, it's usually feeling lymph nodes and immature things. It's not real precise. But do you guys have a certain way that you're looking at molecular?
Dr. Suter: The only way we have is really with PARR, PCR for Antigen Receptor Rearrangements. So before the dogs undergo a transplant, we do run PARR on their blood. And if we have bone marrow, recent bone marrow is bone marrow to make sure we can't find any cancer cells in there. Now that depends of course of a dog has a PARR positive tumor when they're diagnosed.
And so that's always nice information to have is if they have a PARR negative tumor, then running that PARR at that stage of the game is really not going to help us. And then if they have a PARR positive tumor, we also run PARR on the a previous product, which we'll talk about a little bit to make sure that we haven't harvest any cancer cells. In a very recent project, which we need to obviously give back to them to themselves, which would not be good theoretically. So that's really all we have. It's a lot of dogs. We don't have PARR results or they have PARR negative tumors. So that's a little bit of a guessing game.
Dr. Venable: As far as PARR can not just be done on lymph nodes? Or would you want to bone marrow? Like if you have an owner that wants to do everything or you're you're hoping this dog can do a bone marrow transplant, should you do that in the beginning, or is that something they can do when it comes to you?
Dr. Suter: Usually we'll do it when they come see me. But we've really through the years I've been transplanting dogs since 2007. When I say we, I guess I mean me, but I always say we always have a big team to help, but we sort of backed off on PARR bone marrow or even analyzing bone marrow from the dogs who come to us in remission. Because in the beginning, when we did it, those dogs were we never found any disease in their bone marrow when they're in remission. So I sort it back on, backed away from that through the years. However, if I have a dog that I'm obviously worried about some disease somewhere, then we'll go ahead and do that. But we tend not to even do bone marrow on dogs anymore when they come to us when they're in clinical remission. So there's no obviously tissue to analyze at that point.
Dr. Venable: Okay. And how should veterinarians determine if a dog is a good candidate for bone marrow? Is it just after they go in remission of CHOP, or is there something to decide in the beginning?
Dr. Suter: No, there's really nothing. The main criteria is really dogs with high grade lymphoma, or whether B or T or leukemia, which of course is super high grade and nasty and scares everybody. And the fact that they have responded to chemotherapy and have gone into remission, that's really it. We do worry about comorbidities. So of course, these dogs, a bone marrow transplant, just like in people does stress the system a bit. And so we worry a little bit about other comorbidities such as advanced heart disease or other endocrinopathy or histories of seizures and stuff like that. Not that I wouldn't transplant those dogs, but we really want to know about those ahead of time so we can pay particular attention to them. And so many times dogs will come to us with, you know, grade three murmurs or something like that with no echoes, and we'll do echos on them to make sure that everything is structurally okay with their heart, stuff like that. If they have Cushing's, it's out of control. We'll try to get that under control, etc., etc. sometimes we just never know what we're going to get until the dog arrives and so we can be in for surprises sometimes.
Dr. Venable: You know, what should you or I guess what should we as the veterinarians, you know, kind of prep owners for, for doing a bone transplant. Like, what should they be prepared that okay, you're going to go to North Carolina State or Chattanooga and this is what's going to happen.
Dr. Suter: Yeah, it's actually quite an education process. So I like to be extremely transparent with everybody, including the owners and the referring veterinarians about what to expectations are. Number one is that we're talking about a cure, period. And that's the whole goal of this, life extension over chemotherapy alone is also possible. But we're always looking for a cure. And so the first thing that I always tell owners is that if you're talking about during a dog, you have to be willing to accept some of the toxicities that will occur from the total body radiation, because that's what we use for trying to kill every cancer cell in the body for an autologous transplant.
And there are side effects from that. And for any medical oncologist listening, those side effects are just exactly the same as the very high dose of chemotherapy. And so they can have GI toxicity. Some do, some don’t, some can be significant and some can. You never know. And bone marrow issues. And so those toxicities are expected. We've learned through the years how to manage those very appropriately.
But it is total body radiation. It is lethal without a bone marrow transplant. And I think we have a pretty good protocol now in place where we don't lose dogs. But there's always that potential. There's just a potential that something could go wrong and that would be lethal, quite frankly. And so it's important upfront for folks to understand that.
And then the other thing we always explain is that it's a process. It's a series of five different steps that are done sequentially, to get a dog through this. And so if something happens in that sequential process, there is a possibility that the transplant may not happen. Now, you know, it's very rare, but we always talk about everything that could happen bad. So everybody knows what's going on ahead of time. It's rare but it could happen. It happens to people when they go through a transplant process. So those are two really important things that I, I think folks should know, both referring veterinarians and dog owners.
Dr. Venable: When how long does this usually take? Like is it something where it's normally more local people that come and do this versus people traveling across the country, like, or is this something that takes a week? How long would the pet owner or the pet need to be there?
Dr. Suter: Yeah, so it takes the whole process takes about three weeks or so. The actual transplant itself only takes three days. And so if we can talk about the protocol now or later that dogs are right, we start the transplant process on a Monday. We're actually usually done Wednesday or Thursday. So that actual process of transplantation doesn't take that long.
What takes longer is for the dogs to go through the toxicities of the radiation, which is of course, as I said, GI. And really what we pay attention to a lot is bone marrow, because their bone marrow is essentially killed by the radiation. And we have to wait for the transplanted cells in the dog to start doing their job and making the cells they need. And that can take a week or two, kind of depending on the cell line we're talking about. So they end up being in the hospital around three weeks or so. The first part of the protocol, they're just receiving Neupogen under their skin, which is a drug that makes their white blood cell count go very high and drive stem cells from their bone marrow to their blood.
And that point, they're not in the hospital. So Thursday to Sunday, they're just getting twice daily Neupogen injections. And we're just checking their CBCs. And then they're admitted into the hospital on Sunday. We do the process to the bone marrow transplant process, which is usually done Wednesday or Thursday, kind of depending on a couple of factors. And then this becomes a waiting game. We put out brushfires, for lack of a better word, to support them with whatever medicines they need for their GI tract and give blood products if needed for their cytopenia post TBI. And once their neutrophils come up and their platelets come up, they go home. With that whole thing all strung together takes about three weeks.
As far as local versus national, we have have had dogs at NC state come from Canada, California, Florida and New York all over the country. Cleveland, we've actually had a lot of inquiries from overseas folks. We're working on a a dog from Spain right now at SeaTac. We've had a donor dog come from England for an outlook transplant to donate cells. So it really is turning into an international effort.
Dr. Venable: It's really cool. And and you just mentioned, you know, the allogenic. So can you kind of tell us the difference between the autologous and the allergenic transplants.
Dr. Suter: Yeah, it's actually quite interesting to me. This is why I find everything about transplant so interesting. And an autologous transplant, which is what's usually used for folks, for people who have had lymphoma and have relapsed, that people receive our chop. As you know, unfortunately, we don't have the R-CHOP, but those people have received our CHOP and relapsed. They undergo an autologous transplant. We use it in a little different setting in dogs. We use it in what's called an upfront setting. We don't wait for those doors to relapse. We do the transplant before relapse, as I explained earlier, and so on.
Autologous transplant, it's really where we just take the stem cells, the what stem cells from the dog using an apheresis machine after 4 to 5 days of Neupogen. And we harvest those cells. And then from the peripheral blood, which is why we run PARR as I said on the peripheral blood, to make sure that there's no cancer cells in there. So we take those cells out of the dog, which is actually quite easy because they apheresis machine and then they receive total body radiation. And that's going to obviously kill their bone marrow doesn't really kill it, but it certainly knocks it down hard. And we're hoping at that time the radiation will kill every cancer cell in the body, everyone. And that's a hard task. But it can be done. After that radiation is done, we just take the product that we harvested from the dog before the radiation and just put it back into them, and that's it. And so that's called an autologous transplant. Then, those stem cells come out of stem cells in their own blood. They go in the veins and they go into the bone marrow and say, oh, here's our home, we know this. And then they start making the cells that they need for the dog to stay alive. So that's an autologous.
And in an allogeneic setting, that's where we use stem cells from a from a match dog. And so again in humans there are public banks where you if I develop let's say leukemia. And I needed an allegenic transplant and you had donated cells and you matched me, then they would ask you to come and donate your stem cells using this apheresis machine. And I would use your stem cells would be donated to me, and then I would be transplant with your cells. So in that setting, that's called an allogenic transplant. Unfortunately, we don't have public dog banks for stem cell sequences. And so we have to do it a la carte is what I like to say. So for a person who has a dog who wants to undergo an allergy transplant, we have to find a match. It's called a DLA, dog-leukocyte-antigen matched dog to donate those cells.
And those all those dogs are usually littermates, or the bitch and the sire or the sire or dogs from that same mating pair. They all have a 25% chance of matching, and it's not additive. And so each dog has a separate 25%. But if we can find a match, which we we do most of the times, actually, if people have purebred dogs and you can track their progeny, those cells are then those dogs are, then you have a new pigeon. We harvest those dog cells, and then after that total body radiation, we put those bone cells into the dog with cancer.
Now with a allogeneic transplant, we use less radiation. So auto dogs usually get 10 to 12 break, which is just like a prescription of a drug in allogeneic dogs we get eight gray, only eight gray. It's still is really tough on the bone marrow. And it's really not designed to kill cancer cells in the body. Some of them, but not that higher dose with an autologous transplant. We just want to make space in the bone marrow for these new foreign cells coming in. We want to provide some level of immunosuppression until those aloe cells, those new cells and get into the bone marrow and say, oh, here's our space. But it's not really our home. It's the new home. And what we're going to do is put these dogs on cyclosporine, which is an immunosuppressive drug, so that the growth is not rejected. But we want graft versus host disease. The reason we want to graft versus host is these that match the graph, the tumor saying to the host, I don't like you very much. That's a bad thing. But in the setting of lymphoma or leukemia, it's actually a good thing because you get secondary graft versus tumor effect. And so that's the first form of immunotherapy that's never ever, for lack of a better word, invent it. And that's extremely powerful. And so we want some graft versus host disease. But we also want to make so much that it makes a dog ill or possibly dies. Because graft versus host can be very difficult. But we want that because we want a good level of graft versus tumor of that. And that's why this is such an interesting process. And we're sort of walking this knife Z edge, for lack of a better word, using immunosuppressive suppressive drugs like cyclosporine to keep the GVHD down, but not enough that it's not going to get graft versus tumor effect.
So we kind of play this game between graft versus host disease making a dog ill. But we also want graft versus tumor effect. And the the point of that is so you say, well why in the world would you do an allo when you're talking about all this crazy cyclosporine and graft versus host disease? Because it's extremely powerful. And so the cure. So even in the earliest studies that I've done with small numbers of dogs or over double for an aloe transplant, they been auto. And so that's why it's used in people, because you can cure a lot of people who relapsed after receiving. Also, you can cure a lot more people with an aloe. Again, people live for a long time. And so you have to worry about rappers as host and people. Nevertheless, it's a very powerful form of immunotherapy that I'm really excited about. Actually.
Dr. Venable: It does sound like you have a lot of moving parts when you're doing all this. It's a lot to keep track of, but it is really fascinating. And I never really realized with The allogenic that you wanted some graft versus host that you were saying getting that immuno response to the tumor. So that's really fascinating. So but like you said, really the only option with that in dogs is if you know the mating pairs like so for purebreds, because otherwise just, you know, if you got a dog at a shelter or rescue just trying to find another match, is it almost impossible?
Dr. Suter: Yeah, it's almost impossible. Yeah. So we always shoot for an allo, and if we can't do an allo, then we'll go backtrack to an auto. The other really interesting thing is, is there's no way you could transplant, let's say, a golden retriever with a Siberian Husky cells. You can't go across breeds because these breeds are such genetic islands that it's at this point would be virtually it's impossible because you would get such massive graft versus host disease. You could never control it. We as humans were all mutts. And so we have a lot of intermixing. And so it's not that hard to find a match. It usually takes about two weeks and people may be three. But in in our world of purebred dogs, it's really, really pretty much impossible. So you're right, you need a same breed and you need to be able to track down those those pups in the bitch, and the sire. And if you can't then and I'll, I'll relay at this point is not an option.
Dr. Venable: Yeah. That's really fascinating and it sounds quite the process but really interesting on how you know, all the different steps you have to go through. So I'm assuming that this is pretty expensive. How do you balance cost or what do clients or a lot of them using insurance. How does that whole process work?
Dr. Suter: Yeah. So it is expensive. And so I remember back when I started in 2007 and one of our cases had $20,000, and I was like, it's just, oh my God, I can't believe how much money this is costing people. But as it turns out, at least our chemotherapy here at NC state is kind of on the cheap side. But in in private practice, you can spend 10 to $15,000 on chemotherapy, especially these days. Those things are a little bit crazy, of course, really easily. So you can spend a lot of money on chemotherapy for a protocol that works. It really does work. Chemotherapy really extends dogs lives, but it does not cure them. And the vast majority of them relapse, of course. I mean, everybody who does medical oncology knows that. So it is a very pricey item. It's pricey at CTAC. We're a startup. And so we're quoting people 50 to $70,000. That's a lot of money. The good news is that it is covered 80 to 90% by most major insurance companies. Way back when I started all this, it took me about, I don't know, maybe 4 or 5 years to convince Trupanion at that point that that was not experimental. That was your only their issue is that they're not going to pay for something experimental. And finally, I convinced them through sending them papers and talking to them, papers that I published, that it was not experimental. It's actually clinical. And they started covering it. So a bunch of other insurance companies sell online. Now, most of the major insurance companies pay for bone marrow transplant. I hope that continues and we'll have to see. But so that helps a lot. Obviously, a lot of people have used social media to raise money, also, which has been really nice to have a bunch of help using social media. And so people have seemed to be able to come up with the money many times to do that.
We have a third party, a vendor at CTAC, who was supplying folks with money is sort of alone. I don't know the details of that because I'm on the medical side of the of the company. But we do have a third party that is helping people with their finances and also so it is expensive, there's no doubt about it. And it's certainly not for everybody for a variety of reasons.
Dr. Venable: But that's great that you've got insurance to help, you know, cover this and people using social media and other groups. So and good for you for being persistent with insurance. And that that could be a challenge. So thank you for already doing that for the rest of us here.
Dr. Suter: I always say to folks who if you have a purebred dog, which, you know, a lot of people do and you get insurance, they want, you know, you get insruance day one, because you and I both know that we see mainly treat dogs in our cancer clinic. That's for sure.
Dr. Venable: Yes, yes, we definitely do. And you know with all this and like you said, it's not it's not for everybody, but it's certainly still a good option. Do you have any kind of stories that stick in your mind of different cases that you remember doing? Or I'm sure that first case you did was probably pretty memorable.
Dr. Suter: Yeah, I have about 157 stories, you know, that's how many dogs I've transplanted. And so these families are really unique. Situation. The first dog that you mentioned was the dog named Tina. She was a chow and she was 12 years old, and she was owned by a gentleman who was in the medical field. He sold medical equipment. So he was actually quite well aware of the whole scene of transplant scene. And I sort of talked to him and said, you know, she's 12, she's a Chow. You know, this is a this is a big ask for her and his previous Chow Chow had lived to be 16, which is great for Chow Chow. And so he was all in from day one. He just wanted to do it. And we transplanted her.
And I was beyond nervous because it was the first dog we were in. Our old hospital. We we had to sort of make an isolation ward out of the runs. It was a little bit ghetto, but that's okay. We transplanted her and she actually did great. She grafted beautifully. She only bit me twice, which I thought that was pretty good for a for a chow. I'm pretty sure they were love bites. And she left, then went home and she ended up unfortunately developing liver cancer about I think it was 12 months later or something like that, and then succumbed to that. But she didn't die from lymphoma and obviously she didn't make it to be 15 like his previous Chow, but he was really happy about it and felt that she had a great quality of life at home. So that was sort of nice. And there have been a lot of other great stories. There's so many. We had dogs who one dog who's still alive. We know she is the service dog for an autistic woman and he knows how to read sign language, actually. And so he developed lymphoma. He's a big old mastiff and as sweet as can be. He went through allo transplant and is still alive to this day. And so he's still doing his service for his owner. So I think that's pretty fantastic. He's an interesting case. We've really never been able to get him all cyclosporine completely. We usually leave them on cyclosporine for about a month, and then we just stop and sort of see what happens. And every time we lower his cyclosporine dose, this has been almost four years now. His liver enzymes start going up. So that liver is one of the GVHD organs in dogs. Our alkaline phosphatase is really the one we look at and total bilirubin and other chemistries. So every time we lower dose they they go up again. He still feels fine. But as an indication there's a little bit level of GVHD there. So he'll probably be on cyclosporine low dose for the rest of his life. But he doesn't care. And his owner certainly doesn't care either because he's still with her. So that's always been a really heartwarming story. also. Probably the last one that I'll mention out of all of them is it is the dog who is Owen Millie on by a very nice couple in California, and we found a donor, but the donor lived in England and so they brought the donor, the owner and the dog to the States here. And she stated they met here for the first time. We lots of pictures and got to know each other. And so Millie was, transplanted with I forgot the dog's name from the UK, unfortunately. And she's still alive to this day, living in California. And so that was really kind of fun. This would be something like that. And that's, you know, these people are so darn dedicated. It's amazing. So you can imagine what would into what into all that, not only the money but also the effort to find a donor and then figure out how to get the donor here. And this. It was a lot. And these folks are just my heroes, to be honest with you. They are so dedicated to the pets.
Dr. Venable: Now those are amazing stories. I love that those those are great and just all the different ways they come together and and how well they're doing. One thing that did come to mind, you know, you have been talking about cyclosporine, and I understand the use of that for the graft versus host. But I also, you know, I feel like there's always a warning label with cyclosporine that potentially could cause other cancers. Or normally I'm careful with it. So why is it, I guess that you guys aren't seeing any issue? Is maybe that warning of it causing other cancers? Maybe not totally found dead? Or is it just because you're doing bone marrow transplants? So it's totally different than if we were using cyclosporine in a different pet with cancer. What what are your thoughts on that?
Dr. Suter: Yeah, I know that warning for sure because it always worries me. But typically these dogs are on a very short course of cyclosporine. So usually they're on for a month. That will leave them on a month post-transplant. And then once they're fully engrafted and they go home, we'll stop it and sort of see what happens. As I said, the GVHD organs in the dog or the skin and the liver. And so if we stop it and there's no liver enzymes and there's no skin crusting and scab, it's scabbing usually around the eyes and everything, then we're good to go. If they start having elevations in liver enzymes or t billi and skin issues, then we'll put them back on that for a while and then try to wean them off that in a slower process rather than stopping, which almost always works.
Dr. Suter: And so it's a very rare dog that needs to be on cyclosporine for a long time. I do worry about because he's been on cyclosporine for a long time, but it's a super low dose. It seems to control him. And so, I mean, he has a fatal cancer. And if he if he relapses with the disease, he's he's done. And so I think it's worth the risk. Any of the allo dogs we've done most of them are off cyclosporine fairly early. So I don't really look at it as really a big risk, to be honest. We too, in those dogs and the dogs are on a really long time. I worry about it. But again, what's the alternative?
Dr. Venable: Oh, that's very true. And that is fascinating. But it's interesting to for me to hear that you haven't seen any issues. So that is interesting. Just using that drug. And so I'm curious about the group in Tennessee. So what made you open a branch in Tennessee?
Dr. Suter: Well, it's a little bit of a dicey story, I guess the transplant program here was shut down, unfortunately. And so this was basically my my whole career here at NC state has been research related to lymphoma, but also on the clinical side has been transplant. So I’ve been transplanting dogs for a long time, since 2008, actually, with a couple breaks in between. And it was just an administrative decision to shut the unit down. I was after a very, very difficult case of a dog who had acute myeloid leukemia. Anyway, that dog ended up dying in the hospital and the decision was made that the unit should be shut down. So I was quite upset about that, quite frankly, because that's crazy, crazy talk. But that's the way it is sometimes. And so I ended up when I had a transplant unit here, I trained fellows, as I’ve mentioned earlier, and so I had seven fellows who came, but initially was one year. And then we made it into a two year fellowship, and I was a fellowship and apheresis and bone marrow transplantation.
And so my goal of all of this was always be in education, because that's what I had to I had to be educated to learn about all of this, and I do it myself, which is really a pain in the you know what? Because I didn't know anything. So my goal also was always to train folks to come to NC State and learn this and then go out and transplant dogs. I mean, I can transplant, what, 24 dogs a year, maybe 30 tops, because I got so many other things to do as far as being an academic. And so I always wanted to train tools and go out, have them go out and then start transplant units, or at least educate medical oncologists, you know, all veterinarians and owners about this as it turns out, one of my transplant fellows name is Dr Alexandra Gareau. She was here for two years. Then we kept her on for a medical oncology residency for three years. And then she was on faculty for a year. So we had her for a long time. As it turns out, she took a job in Tennessee at this practice and is also, it turns out, is we had a radiation oncologist resident here named Jason Strasburg who works there also. So that means they have a linear accelerator there. We for obviously for transplants, you have to have an accelerator and a radiation oncologist for TBI. And so she went there, Jason was there and everybody started talking. And as it turns out, there was, a couple there who owned the Pullen Cancer Center, and they were became very interested in transplant and apheresis for recess.
And so that's where the germs sort of started to grow the seed. I should say seed, not the germ. And and so then I got involved because I got very excited because I've actually always wanted to expand this beyond NC state. And so that's how the whole thing started. And it took a long time, probably about a year and a half or so negotiations and trying to figure out what to do. And we literally started with a big giant room. There was just a big giant room, huge room, and we built it from the ground up we added isolation wards, runs in a freeze. We had to buy it in a previous machine and all that, so it cost a fair amount of money and we started accepting in cases in January. We have our first one on April 24th I believe. So we're just getting started. So it's quite exciting and I'm really happy to be back in the game, for lack of a better word. It's a little awkward because I'm still here at NC state and I don't live there, but I've been involved in building a unit and advising the group on, you know, the protocols and all that. So I'll be there for probably the first five transplants, just oversee everything. And, Alex was well trained because I trained her. Haha. And so she should be fine. Yeah. So we're all quite excited about it. But it's a it's a startup and we have to make some money to stay open. So we'll see how that goes.
Dr. Venable: Well, it is exciting and it is exactly like you said, fulfilling for you just because you always training people and this is what you're wanting to do and really getting to see it come out right, you know, and you can help kind of oversee in the beginning and things. So that that sounds really exciting. Are there other areas just that you are aware of in the country that do bone marrow?
Dr. Suter: There's only one. There used to be quite not quite a few. That used to be about four. But there's only one lab is Dr. Ed Sullivan in Bellingham, Washington. He's been transplanting dogs as long as I have. Actually, he started before I did, and he had the first paper way back in 2006, where there were his group, which is a private practice in Bellingham, transplanted a dog with an allo transplant, T-cell lymphoma, way back when. That was a long time ago, and the dog was cured of his disease. So he's been a pioneer also. And I talk to him all the time. And we'd worked together on these transplants a lot. So he's got the West Coast covered, and I've got the East Coast covered so far. Yeah. So that's the only other option. So I've been we still get a lot of requests for transplants or at least to talk about transplants here at NC state over the past two and a half years that I've been close. So I've been sending all those cases out to the West Coast. Well that's it, there's only two.
Dr. Venable: Yeah, well, at least they're on opposite ends of the country, so that does help a little bit.
Dr. Suter: They are. Our goal is to get this up and running and then open some other sites, either across the country or across the pond, as they say. We'll just have to see how it all goes. But we'd like to have more than just one site because as you know, there's thousands and thousands of dogs coming down with lymphoma every year across the world, probably tens of thousands.
Dr. Suter: And so hopefully we can help those. And that's what this is all about, helping those dogs.
Dr. Venable: Yeah. So I've definitely heard some big numbers like 70,000 I mean no nobody quote me here because I, I can't remember the source. But yeah. So there's a huge amount every year that are diagnosed with lymphoma so. and you know, a lot of how we treat it hasn't changed much in the last few decades. You know we're people are looking into things.
Dr. Venable: So it is exciting to hear about other options. And if clients are interested in this or, you know, as a vet, if you're thinking you have a pet, that would be a good candidate for this. How do you go about this? Do you call the clinic? Is there a website? I guess you know, what is the way to kind of get things, you know, started?
Dr. Venable: If you think that pet would be a good candidate for a bone marrow transplant.
Dr. Suter: Yeah. The easiest way is to go to the CTAC website. It's just CTAC. It's on CTAC Tennessee, and that'll come up and there's a portal there for veterinarians and for dog owners to ask question, ask that they want to be contacted. We really, really, really like talking to owners and veterinarians. And so we always like to talk to them first and make sure they understand the whole process, make sure that they understand the money involved.
Dr. Suter: We actually have a really nice owner handbook that we like to send to owners. So there's a ton of information they're written down, so it's nice to read something. I'm still old school, so I still like to look at a piece of paper, but it's web-based also. So they we send them the handbook. We have a handbook for donors for that, for potential donors also, so they understand if their dog does match what's involved in the donation process, which is benign. But it's still a big deal for dog owners. And so we have that handbook also. So we send that to them. We have the owner handbook we like to send to veterinarians also. So we would send that to let's say you. So you could look at that and go, “Oh what the heck is this? Like what's cyclosporine all about?” You know, so just general information. And so we just start a communication process first. And that's extremely important that everybody understands, what expectations are set. And then if the owners are interested now if they say, oh I know where there's, you know, five siblings, they live right down the street. Well, of course, then we'd say, all right, well, let's get a good blood for them if you're interested, and we'll get there. Let's sequence. Was the DNA sequencing done? We still do it at the Fred Hutchinson Cancer Research Center. That can take a while. So we'd like to get on that right away. And so we just start that whole process there. Yeah. If it's not going to be an allo transplant, then we start talking about approaching it quicker because I'm a paranoid oncologist, which you probably are too. And I always worry about relapse, especially with T-cell dogs. And so and auto we tend to get on much quicker because we all have to wait for the owners to find potential littermates, and we don't have to get the matching process done. That whole process can take many months, many times with an auto where as long as the dog is on chemo and and either in remission or getting post remission, we really like to get on those quickly. My initial data show is pretty clear, which is exactly opposite of people. The dogs who who have relapsed with disease don't do that well with an auto transplant, which is really interesting. So the upfront transplant, upfront auto transplant is actually not used in people at all, because you can cure 60 to 70% of people with a with a R-CHOP. So you never put a person through the transplant, which really stresses the system. It has a potential for death when you can cure that higher rate. With our job, it's been exact opposite in my experience. However, again, my manuscripts were not 400 dogs, which is what we really need. You know, mine were, you know, 15, 24 dogs. And so again, that's another point of having multiple sites is to get a database. We're actually building a database. So try to say this is the cure rate for dogs with high grade B-cell lymphoma using an auto and an allo transplant. The rates that I published I don't know if they'll stand. I hope they do, but I don't know. We haven't transplant enough dogs, so we're in the process of building that database to be able to say with more certainty of the benefits of this or not. I think there are benefits, but, you know, we want them now. That was a rather long winded answer to your question.
Dr. Venable: Totally fine, totally fine. And I was just going to ask, what are those cure rates and benefit rates? What are you guys seen so far?
Dr. Suter: Yeah. So for dog that's high grade B-cell lymphoma transplant, and with an auto transplant the cure rate is defined. You have to remember most of the studies in the veterinary field don't follow dogs for years in the studies they're now one year survival tier etc., etc.. So the cure rate and dogs is defined as living greater than two years past transplant. Why did I pick two years? Because it seems that the dogs have been doing this long enough. Now the dogs who live two years post-transplant don't relapse, and then people, that's really that line of sort of five years. And so again, everything happens quicker in dogs and so two years for dogs who have diffuse large B-cell lymphoma transplanted with an auto, transplant that is around 30 to 40% somewhere in that range. The first manuscript was 30. I published the second one using this other immunotherapy. That not important to what we're going to talk about that was 40. So it's somewhere between 30 and 40. So that's cure. Those dogs go on to live a normal life with an allo transplant. The publication that I have in VCO, it was 90. Now that's a lot. And that's fantastic. But that was you know, again, it was a smaller number of dogs. But if it holds up after transplanting 200 dogs, that would be fantastic. But I don't know if that number is going to hold. But even if that 90 drops to 70, that's still way better than chemotherapy alone, which you know, is zero ish to maybe 2%. So that's a B-cell T-cell still remains a problem. It remains a problem for you and me with chemotherapy and everybody else out there. So the cure rate of dogs with high grade T-cell lymphoma with an auto is down around 20%. And one could argue that's not worth the money. And I've heard that argument before and I don't know if that argument is valid or not.
But I can tell you, if you talk to those those 20% of families whose dog is still alive, who are given a death sentence when they found out that the dog ate T-cell lymphoma, they're pretty happy, you know? So, I mean, I guess it depends on how you looked at a glass half for glass half empty. We haven't published our data on allo transplants yet. We're looking at that. I think it's going to be around 50% for dogs with high grade T cell lymphoma at first look, but I'm still collating that data. We have a couple dogs we're waiting on to hit that two year mark. Right now, it looks like if those dogs make it, it's going to be around 50%, which would be fantastic. And so those are the numbers we have at this point. And again, we just need a lot more dogs to really say definitively what this is going to be.
Our experiences with acute leukemias have been difficult because it's hard to get find a matched donor before the disease overtakes the dog. And that's really the one problem we've had with acute leukemias is that the disease progresses so rapidly. As you know, they're trying to find a donor and get the dog. Donors here can be really difficult. Having said that, we have transplanted a couple of acute leukemia dogs who have done very well. One was cured of this disease. There were some debate about that manuscript. But anyway, that dog's home happy and healthy. One thing I wanted to point out to the listeners is that even if their dog is not cured, many times they have life extension over chemotherapy. And even if their dogs died, and I've asked every owner this about their feelings about their pets not making it, and to the T, all of them has said, “You know what? We've tried virtually everything that is known to help our dog with this terrible lethal disease. And it just didn't work. And we go to bed at night, sad that our pet died. We go to bed at night knowing that we did everything that we could possibly do for them.” And literally to a T, everybody says that nobody's coerced them into doing this transplant process. They know ahead of time. So again, we're very transparent and they just feel that they tried and it didn't work. Unfortunately, it's the same in people. It doesn't cure all people either.
Dr. Venable: Yes. And it those numbers are exciting though to hear. I mean, those are, you know, much better than what we're seeing with chemo alone. So yeah, that's really exciting what you guys are seeing and I do agree it's all about perception. Everybody's a little bit different. I know all the conversations I've had with people over the years with various cancers. Some people's reactions are completely different than the room you just got out of, right? So I can see where you run into that too. When it comes to is it worth it or not? You know, I think that's always a question. Anything in vet med, but that's good to hear too, that clients that do this, you know, because like you said, it's very committed people, very people that are just wanting to know they did everything. At the end of the day, they still feel good that they did everything they could because they really did. I mean, if you do a bone marrow, you've done everything you can in my mind.
Dr. Suter: Yeah, I would agree with you there. It's again, not for everybody. It is expensive. But I tell you this, this story, if you have just if we have a minute, the story that really got me, got me hard in my heart was an owner in California when I was doing my residency at Davis. And I went in and gave the, you know, the lymphoma talk. We should have a tape recorder to just play it or something like a little podcast just for the owners, as we've said it so many darn times. And I did my talk and he looked at me and my right, my eyeballs and said, is that all you got? That it? And I, I said yes at that part at that point.
And that's really stuck with me through this whole process. Even, you know, in the beginning, when we lost a few dogs in the hospital, that's what's always driven me, is that that's all we have. And it's not good enough for some people. So let's see if we can develop something else that could give these dogs hope. And so that's always been a really like, that guy has always stuck with me.
Dr. Venable: So I think that's a great sentiment and kind of where sort of wrapping up a little bit here. So just lastly, I always like to ask, is there any emerging technology or anything on the horizon that you're excited about that maybe some people might trickle down to dogs or something going on and dogs?
Dr. Suter: Well, I think we're all aware of immunotherapy and the human space being revolutionary at this point, although there are more toxicities, I think, than people imagined in people that were thought because they're more targeted therapies. But I'm hoping a lot of those will trickle down. We have a lot of, as you know, TKI and kinase inhibitors that are becoming available. We have a monoclonal antibody against PD1 now which is a new checkpoint inhibitor. So there are some stuff starting to trickle down. And I hope that those will make a difference. I again, we're not probably talking about curing a dog. So I've always been so, so laser focused on curing a dog. I would say transplant right off the bat, but it doesn't cure all dogs. And again, it's not for everybody. So these products I think hopefully will really help dogs in the long term. I think we're all still trying to figure out how to use them, how to combine them, etc., etc. as as is and people. So I think the whole field of immunotherapy will make some changes for sure in our future.
I'm getting quite old. I'll probably be retiring in the next 4 or 5 years, so maybe I won't get to see the benefit of that. Maybe I will. But anyways, I think that's going to be pretty exciting for sure.
Dr. Venable: Then I always like to ask, who would you recommend to be a guest on this podcast?
Dr. Suter: Well, that's a biggie. I don't know anybody who's doing something that's unusual. You know, I stuck my professional neck way out when I did this, and I didn't invent transplant. I just took it from a research setting, put it in a clinical setting. But it was, you know, there's a bit of a gamble, I have to say. And so I would say that anybody out there who's putting their neck out a little bit and saying this would be, you know, this is something that can work. And so, you know, Cheryl London's been doing it for years, like, Thamm, Phil Bergman when he came up with The help, the Sloan Kettering with, on DNA vaccine for melanoma. Those are folks who decided if something needs to be done and more involved in developing some alternative strategies. Like you said, we've been using Chop for oh my, how many years now? My whole career, which is 22 years and is probably used for 40 years or so. And so these are all folks who have been involved in trying to make a difference. And so any of those folks would be quite interesting. I think it's you know, it's never a as they say in science, never. It's really never a eureka moment. You know, it's very rare. You go, “Oh my God, I'm changing the world.” That's really science. Building on science, building on science and kind of grudge, you know, hard lab bench science to try to make a difference. And so it's nice to acknowledge those people.
Dr. Venable: Oh, totally agree. And I think this conversation has been so interesting. I love learning more about the transplants and what you guys are seeing. And I'm definitely excited to see how this transforms, especially in the public setting in the private practice setting. I mean, it'll be interesting to see how all this grows, so we'll certainly be watching closely.
Dr. Venable: And thank you again, Dr. Suter, for being on this podcast.
Dr. Suter: Yeah, I truly appreciate it. Thanks, Rachel.
Dr. Venable: Well, that's it for this episode of the Veterinary Cancer Pioneers podcast. If you enjoyed this episode and gained valuable insight, we would be so grateful if you could share our podcast with your friends and colleagues. And it would be even more wonderful if you want to give us a five-star rating, positive review, or any kind of feedback on Apple Podcasts or wherever you listen. The Veterinary Cancer Pioneers Podcast is presented to you by ImpriMed.