Lung cancer innovations; TB's risks; bispecific antibody therapy: Upstate Medical University's HealthLink on Air for Sunday, Feb. 9, 2025

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a surgeon discusses what's new in lung cancer surgery.

Michael Archer, DO: ... Where there's cancer that's gone into lymph nodes, if we just stick with surgery, and we don't do anything else, our cure rates are lower than when we can include chemotherapy or immunotherapy. ...

Host Amber Smith: An infectious disease doctor talks about tuberculosis.

Elizabeth Harausz, MD: This is a very slow-growing organism, so it doesn't make you sick quickly. People generally, when they get sick, they'll have symptoms for weeks and potentially months. ...

Host Amber Smith: And a hematologist-oncologist tells how bispecific antibody therapy works in cancer and other diseases.

Krishna Ghimire, MD: ... When they bind to the cancer cells, they block the growth of the cancer cells. They attack and destroy them. That's how we are using these antibodies in the space of the cancer treatment. ...

Host Amber Smith: All that, plus a visit from The Healing Muse, after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, what's the difference between active and latent TB? Then we'll learn about the promise of bispecific antibody therapy. But first, innovations and updates in lung cancer surgery.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Dr. Michael Archer spoke recently at an American College of Surgeons meeting about innovations and updates in lung cancer. He's an assistant professor of surgery at Upstate and medical director of the lung cancer screening program, and he agreed to explain what's new in lung surgery.

Welcome back to "HealthLink on Air," Dr. Archer.

Michael Archer, DO: Thanks so much, Amber. It's a pleasure to be back with you.

Host Amber Smith: So what are the innovations and updates that you spoke about at the meeting?

Michael Archer, DO: The meeting that I went to was out in San Francisco, and it was a bunch of leaders in thoracic surgery talking about what's kind of the latest and greatest going on in the realm of lung cancer.

And two of the main things that we focused on were what we call perioperative chemotherapy or immunotherapy. So treatments that are for what we consider more locally advanced cancers, right? So Stage 2, Stage 3 cancers, where surgery still has a role but might not be the biggest part of the treatment algorithm. So we talked about that.

And then the other one was really focusing on some of the latest data revolving around surgery for lung cancer.

Host Amber Smith: Well, I understand the American College of Surgeons Commission on Cancer includes six operative standards for accreditation.

Michael Archer, DO: Yes.

Host Amber Smith: Can you explain those?

Michael Archer, DO: Yeah, it does. And so I've been actually really involved in that component of the Commission on Cancer and the American College of Surgeons. In fact, I'm on the education committee for the operative standards. Now, operative standards are a set of standards for surgeons. And what we're supposed to be doing from a surgery standpoint -- for not just lung cancer, but for colorectal cancer, breast cancer, melanoma -- is documenting in the patient chart in such a way that we are setting the standards for what is considered a good cancer operation, right?

So for melanoma and breast surgery, it revolves around margins and certain things you do in the operating room that the Commission on Cancer expects every institution that carries that accreditation to have in the operative note. So it's really telling patients out there that if you go to a COC-accredited institution, you're going to get an operation that should be standard across the country and meeting the certain oncologic goals, right? The cancer-related goals.

For lung cancer, it's interesting. It's not an operative standard, so it's not in my operative note, but it's what we do in the operating room and what we send to the pathologist. So it's not just important in the eyes of the COC, which is the Commission on Cancer, nor is it in most surgeons who treat lung cancer. It's not just good enough to take out the lung spot, right? Getting the lung spot out is inherently good. I tell patients this all the time. Taking out the tumor, definitely a goal of the operation. We don't want to leave any residual cancer behind. But what we need to remember, and what the COC standard really is honing in on, is that you have to take out the lung spot, but you have to assess lymph nodes.

And the reason why it's important to assess those lymph nodes is that's where we go from maybe taking a stage 1 lung cancer where all you need is surgery, to maybe having a stage migration to Stage 2 or Stage 3, which is a huge deal, right? Because if you end up having disease inside a lymph node, which is an area of your body that helps fight off infection in the lung, but if you have cancer, it tends to be one of the first places the cancer spreads to. If you get cancer inside one of those lymph nodes, then we know that surgery, isn't it, right? Surgery is an important part of treatment, but it's not the end-all, be-all, and we need to consider chemotherapy or other sorts of treatments.

So for the COC to set the standard that we need to take out lymph nodes from certain locations is telling us that that is an important part of cancer care because of the implications it could have related to treatment that needs to be given after lung cancer surgery.

Host Amber Smith: So if lung cancer has spread, it will go to a lymph node first? That's why you're looking at the lymph nodes?

Michael Archer, DO: That's exactly right. And we want to understand that as early as possible so we can get folks on treatment as early as possible because we know that that impacts survival and our rates of cure, right?

So what we know in this instance where there's cancer that's gone into lymph nodes, if we just stick with surgery and we don't do anything else, our cure rates are lower than when we can include chemotherapy or immunotherapy.

Host Amber Smith: Now, if I understand correctly, the Commission on Cancer quality metric had been to retrieve 10 lymph nodes from the chest at the time you were removing a lobe, but that changed.

Michael Archer, DO: It did change. You're right. And it's another one of these hot topics in thoracic surgery revolving around lung cancer care.

What we know is that for other cancer, say colorectal cancer, there's a standard that revolves around getting the number of lymph nodes out. But when we've looked back at using that number metric, looking at less than 10 lymph nodes or more than 10 lymph nodes, it tends not to be as predictive or as important, compared to when you look at where the lymph nodes came from.

So to get a little bit into the weeds, there's different parts of the chest, right? There's the part around the lung itself called the hilum. It's basically where the blood vessels are that are going to that area of the lung, and there's lymph nodes around there. And then there's another part of the chest called the mediastinum. It's a fancy word for the middle part of the chest. And so what we do in a lung cancer operation is we go into those specific areas, and we take out lymph nodes from those specific areas. If they're from what we call the hilum, we designate those as N1 lymph nodes. Or I frequently tell patients Level 1 lymph nodes, right? They're the first lymph nodes that the cancer could get into.

Then if they get into the lymph nodes in the middle part of the chest, the mediastinum, we call those N2 lymph nodes or Level 2 lymph nodes. And when those are involved, that takes us from stage 2 lung cancer, which is when they're around the lymph nodes in the hilum, and it takes us into stage 3. And so what we know is it's not whether or not we get 10 lymph nodes out, but it's that we physically went into those specific locations and took out those lymph nodes.

That's the really important part of this. If you only took out 10 lymph nodes, and they were all just in the N1 station or in the hilum, it's not as good. You need to go into the mediastinum and get those lymph nodes out to make sure you have the complete picture.

Host Amber Smith: Now, can you remove lymph nodes if the surgery is a robotic or a minimally invasive surgery? Or do you have to do open surgery in order to get lymph nodes?

Michael Archer, DO: No, we do all -- well, knock on wood, the last four years we've done all of our early-stage lung cancers, 100 percent of them have been robotic, and upwards of 90% of the time we are able to get lymph nodes out from all of those locations robotically. In fact, I would say as a robotic surgeon, doing minimally invasive surgery, it is safer, and I can get a more thorough assessment of all of those areas using the robotics platform compared to when we used to do open surgery, and it's just not as precise as it is when we use the robot.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Michael Archer about what's new in lung cancer surgery.

So let me ask you about early-xstage non-small cell lung cancers. How do you determine if a lobectomy where the entire lobe is removed is the best course of action, versus removing only a small portion of the lobe?

Michael Archer, DO: I love this question, because this is really where, in the last two years, we've had a seismic shift in lung cancer surgery. Just to give you some background, in 1995, a paper came out of Memorial Sloan Kettering (Cancer Center in New York) and it was the end-all, be-all for what we should do for lung cancer. So any lung cancer, early-stage, less than 3 centimeters, they looked at whether or not you should do a lobectomy or what we call a sublobar resection. So a wedge resection, which is like taking a very small pizza pie-type size bite out of the lung with the nodule itself, or doing something called a segmentectomy where you take out a little bit less lung.

And they looked at that, and the recurrence rate was higher in those instances where you didn't do a lobectomy. So at 1995, they said everybody should have a lobectomy. And what we know is that for years people were saying that can't be true. That can't be true, that we should just be doing lobectomies for these things that are just a centimeter or 2 centimeters. That just doesn't make sense that we have to take out the entire lobe.

And so in Japan and then here in the United States -- in fact, Upstate was a part of the clinical trial that was performed in the United States -- we asked the questions, as lung surgeons, can we do sublobar resections and get the same outcomes as we did when we did lobectomy, for early-stage lung cancer?

So in order to consider being a part of that trial and answering that question, we looked at only patients with early-stage cancer, so it had to be less than 2 centimeters for both trials. And we had to have a PET scan, which is a special scan we do beforehand that showed that there was no evidence of any lymph node involvement.

So, preoperatively, we said, "We're going to take all the patients with small tumors, early-stage cancer, stage 1 cancers, and we're going to randomize. We're going to say either you're getting a lobectomy, or you're going to get one of these sublobar sections." And what we found in both of those trials, not only in Japan, but here in the United States, was that there was no difference whether you did a lobectomy or a segmentectomy or a wedge resection.

So what this now tells us is that we can take out less lung and still give patients the same oncologic outcome, or the same cure rate, which is phenomenal. So in my practice, there are certain things that I look at to determine whether or not we should do a sublobar resection or a lobectomy, right? The classic way to determine who should get less lung taken out was breathing tests, right? Some people -- we know that smokers are very likely to develop lung cancer, or they're more likely than the rest of the population to develop lung cancer; that's why we have screening and all those things -- and so sometimes breathing tests or pulmonary function tests, the special tests we do to assess breathing, are poor in patients. And if we do an operation, we might make them worse off if we take out an entire lobe.

So that's kind of the first litmus test, is, do they have enough pulmonary function to tolerate a lobectomy? If they do, then I ask the question, well, where is the tumor located? Is it in an area where it would be easy for me to do a wedge resection or a segmentectomy, and do I think I can actually get the tumor out without compromising the margin? Now margin is just the idea that we need to have some normal lung between the tumor and where we cut through it. Otherwise, you might be leaving cancer cells behind.

So some of that comes down to judgment. I look at a CT scan, and if something's way out in the very edge of the lung, and it's something where I can easily pick it up, and I can get far beyond that and deep into the lung, then I'll consider doing a wedge resection or a segmentectomy. But if I think that I'm going to compromise my ability to actually get the entire thing out, as long as the patient has good pulmonary function, I still tend to use lobectomy in that scenario.

The other instances are if the tumor's bigger than 2 centimeters, we don't know whether or not you should be doing wedge resections or segmentectomy. So if the tumor's greater than 2 centimeters, we're doing a lobectomy.

The other thing is lymph nodes. So we talked about the importance of assessing lymph nodes. I said that you couldn't get into these clinical trials that showed that there was equivalence between the two, right? Segmentectomy and wedge resection and lobectomy, they were the same as long as the lymph nodes looked okay on the PET scan. What we ended up finding in the operating room, and in order to be included in the trial, you needed to take out lymph nodes from all these places we talked about before, in the operating room and in real time have them assessed. So if the lymph nodes were positive for cancer, all of those patients then fell out of the trial and they just had a lobectomy.

So what we do in the operating room is during the patient's operation for lung cancer, if we're deciding we're going to not do a lobectomy, we're going to take out less lung, we look in all of those locations for the lymph nodes, and we send them to the pathologist, or the special doctor that looks at the lymph nodes underneath the microscope, and if they call me back and they say, "Dr. Archer, all of the lymph nodes look good," then I say, OK, we're going to do the wedge resection, or we're going to take less lung out. If they call back and say, "There's cancer in those lymph nodes," then I do a lobectomy in that scenario, as long as the patient can tolerate it, understanding that when lymph nodes are involved, again, it means we've had a stage migration, and we're going to need to consider doing chemotherapy afterwards, or immunotherapy.

Host Amber Smith: Well, I've heard that you should seek a high-volume center for lung cancer surgery. What counts as high volume?

Michael Archer, DO: Twenty-five cases. There was an article published in 2023 that looked at volume-related outcomes, and they used 25 lung cancer cases as the threshold for what is considered a high-volume lung center.

So at Upstate, it's myself and I have two partners, and we do many, many more than 25 per year. And so, the upside of that is that this is what we do day in and day out.

The surprising thing is that if you look at across the country -- we're fortunate at Upstate that there's three of us here that do lung cancer surgery -- but if you look across the country, and you especially get into maybe some flyover-type states, a lot of the operations that are being done for lung cancer are still being done by general surgeons. When I was a part of this education committee for the American College of Surgeons to get the word out about this standard, what we realized is that we need to be educating...

You know, myself and my partners, we do lung cancer every day. So we kind of knew what the standard was, and we were doing it already before the college said you need to be doing this. But more importantly is if you're out in a rural community in Kansas and you have a lung cancer, it might be a general surgeon that maybe does five of these a year. And you got to make sure that those doctors are the ones being educated, so they know to get the lymph nodes out and give each patient a good cancer operation.

Host Amber Smith: Well, let me ask you about some more advice for patients once they're diagnosed with lung cancer. Obviously if they can come to a high-volume center, how do they go about picking a surgeon, and what should they be asking?

Michael Archer, DO: The first question that needs to be asked is, are we operable? Right? And that really can only be answered by a surgeon. So finding a surgeon that does volume, but that is also associated with a multidisciplinary team. I can't stress how important that is.

And, that meeting that I was a part of out in San Francisco for the American College of Surgeons the innovation comes from working with the medical oncologist and the radiation oncologist and the pulmonologist and all working together to figure out what's right for individual patients. But then asking the bigger questions about, well, what is the real best way that we should be treating lung cancer? And that's how we get all these great papers that tell us all these important things.

But I think when patients are trying to figure out where they should go, and where they should get treated, and who should be their doctors for these things, I think being surrounded by a great group of people and a multidisciplinary team is important because there are times where patients will come to me. At the outset, they'll have a tumor, and I'll say, OK, well this is what we need to do. We need to get your breathing test. We need to get your PET scan. We need to do the staging studies to determine whether or not you're operable and what stage we think we're at beforehand.

It is a lot easier for me to turn to a colleague in a meeting who is a radiation doctor or medical oncologist and say, "OK I saw Mrs. Jones a week ago, and this is what her PET scan looks like. I think we need to do maybe chemotherapy or immune therapy before we do an operation. What do you think about that?" And having that teamwork and that connectedness really is just, honestly, the best thing for the patient. Finding a surgeon who does minimally invasive surgery is important, I think, just because we want patients to bounce back and get back to their normal life, right?

This getting diagnosed with cancer is a lot emotionally to go through. If we can get people in and out of the hospital quick -- you know, on average we keep people in the hospital about two days after these operations -- and then within a couple of weeks people are back doing what they love to do. So when you use minimally invasive techniques, you're more likely to have that course.

If you have the old school surgery with a big operation and spreading the ribs in the old-school way, that can be a little bit more to overcome.

Board certification is always an important thing. When my parents are asking who they should see, figuring out whether or not somebody cuts the mustard from a board standpoint is always important as well. So I think, finding the right team is, at the end of the day, I think the most important thing, though.

Host Amber Smith: Well, that's very helpful information. Thank you. And I appreciate you making time for this interview, Dr. Archer.

Michael Archer, DO: Yeah. Well, you're very welcome, Amber, and I always love chatting with you, and I hope this helps folks out there that are thinking about what needs to be done for lung cancer. And, we're always here to help, and happy to chat with you in the future about anything related to lung cancer.

Host Amber Smith: My guest has been Dr. Michael Archer, an assistant professor of surgery at Upstate and medical director of the lung cancer screening program. I'm Amber Smith for Upstate's "HealthLink on Air."

Tuberculosis continues to be a worldwide concern -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

When you consider infectious diseases worldwide, tuberculosis remains a leading cause of death. Today I am talking with an infectious disease doctor who specializes in tuberculosis, Dr. Elizabeth Harausz. She's an assistant professor of medicine at Upstate.

Welcome back to "HealthLink on Air," Dr. Harausz.

Elizabeth Harausz, MD: Thank you. Thanks for having me.

Host Amber Smith: So what is tuberculosis?

Elizabeth Harausz, MD: Tuberculosis is a mycobacterial, which means it's a type of bacteria infection. It's an infection that mostly affects the lungs, meaning that it causes pneumonia. It's an unusual infection in that in most people who are infected with tuberculosis, they will never become sick, and therefore they'll never be contagious, meaning able to spread the infection to other people. And this is called latent TB.

With latent TB, the person's immune system is controlling the infection. And about 90% of people with normal immune systems who are infected with TB will never develop any symptoms and never become sick and spend their whole lives with latent TB and absolutely no symptoms.

However, in about 10% of people with normal immune systems, sometime during the person's life, often years after the initial infection, the TB germ will escape the immune system's control, and the person will become sick with bad pneumonia. This is called active tuberculosis, or active TB.

However, these symptoms have a slow onset over weeks to months, and these symptoms steadily progress. The symptoms don't come and go like cold or allergies or something like that. And untreated, active tuberculosis only has about a 20% survival rate. And people with normal immune systems, and people with significant immune suppression, will not survive without treatment.

Host Amber Smith: But you said latent TB, so a person could be infected with this and have no knowledge that they're a carrier?

Elizabeth Harausz, MD: Correct. Yep. In latent TB, people have absolutely no symptoms, but it could in the future,come back and cause, and kind of rise up and cause symptoms.

It's not entirely clear if there's really, truly kind of living bacteria in all those people. In some people maybe the immune system killed it and it would never come back. But there's no way to know what people's immune systems have completely eradicated or which people it may come back. But being infected by tuberculosis and not having symptoms, we just call all of that latent TB.

Host Amber Smith: And if you have latent TB, you're not contagious with it? You can't spread it to other people?

Elizabeth Harausz, MD: Correct. Not with latent TB. People have to be sick with symptoms to be able to be contagious.

Host Amber Smith: What is going on in Kansas City, where they're reporting a significant outbreak of tuberculosis?

Elizabeth Harausz, MD: Over the past year there's been a large TB outbreak in the Kansas City area. There's not a lot of details that have been given by their Department of Health, but one could say that, in general, larger outbreaks occur when someone who is quite sick with TB -- and that's usually someone that's unable to get medical care -- spends a significant period of time in a closed space with a large amount of other people, for example, homeless shelters or prisons.

There's really no need to panic. The risk of being infected with tuberculosis is very low for the general public. Tuberculosis is not very contagious, not nearly as contagious as the other respiratory viruses. So you really, to be at risk for becoming infected with tuberculosis, you need to be a close contact of someone actively sick with tuberculosis. And this is generally defined as being in an enclosed space with an actively sick person for at least four hours per week.

And remember, this just means you may develop latent TB, not that you immediately develop active TB.

Host Amber Smith: What is being done to get this under control?

Elizabeth Harausz, MD: So again, it comes back to having a good and well-funded department of health. So with all kind of contagious infections, it comes down to department of health.

So what they do is, when a person with active tuberculosis is identified, they provide treatment for that person and then they also what we call contact tracing, which is to get the names of the people who have been in close contact with that person, and then evaluate those people for active or latent tuberculosis, and then give the correct treatment for that.

Host Amber Smith: Did this happen because of a lack of immunizations?

Elizabeth Harausz, MD: No. We no longer give immunizations for tuberculosis in this country. And most what we call Western countries no longer, and many countries in South America, no longer give that vaccine. It's not a great vaccine. It's It really is just given to infants in countries with high tuberculosis burden, so usually the low-income countries. And it protects children from the more severe forms of tuberculosis, like tuberculosis meningitis. But it doesn't protect against tuberculosis infection, doesn't absolutely protect against tuberculosis infection, and usually it's effects, it's not a great vaccine. We don't, unfortunately, don't have good vaccines. It's effects and protection wears off by about early adolescence.

Host Amber Smith: Do we have any idea what percent of Americans might have latent TB?

Elizabeth Harausz, MD: It is hard to say, because lots of times people don't seek attention for it. because they don't have any symptoms, they wouldn't necessarily know. But it's fairly low, maybe about 3% of the population has in the United States -- to make that very clear -- in the United States has latent TB, meaning they've potentially been infected with tuberculosis sometime in their lifetime.

Host Amber Smith: So if I understand correctly, in America, the way a person might find out they have TB is when they develop a pneumonia and they end up in the hospital or a doctor's office, and testing is done, and that's how you discover, oh, you've got TB?

Elizabeth Harausz, MD: Yeah. Although in this country, having active tuberculosis is fairly uncommon.

The rate of active tuberculosis, of people becoming sick in this country, is only about three people per every hundred thousand people in this country. So, quite rare. So people generally presenting with active tuberculosis would come in quite sick and then be probably diagnosed in the hospital.

Latent tuberculosis, much more common, but probably more often diagnosed if people have potentially known risk factors and have a screening test done, or have a known contact with somebody with active tuberculosis.

Host Amber Smith: Well, where in the world is TB more of a problem?

Elizabeth Harausz, MD: Active tuberculosis, the countries with the highest burden with people becoming sick with tuberculosis are generally in Africa and Southern Asia. However, Eastern Europe, although it may not have the absolute numbers of those countries, has quite high rates of drug-resistant tuberculosis, which makes treatment, more difficult.

Host Amber Smith: How is it treated?

Elizabeth Harausz, MD: Treatment is long, a bit longer than you would think, but it's 100% curable. So the standard treatment for tuberculosis, active tuberculosis, is four antibiotics for two months, and then take two antibiotics for six months. There's actually a new regimen, which is four antibiotics for two months, and then three antibiotics for two months.

So the problem is this is a very slow-growing organism, so it doesn't make you sick quickly. People generally when they get sick, they'll have symptoms for weeks and potentially months. But it also therefore kind of takes a long time to kill. But as I mentioned, the treatments are very effective, and a person can be expected to heal completely if they take all of their medication.

And for the most part, these antibiotics are specific for TB, and they wouldn't be antibiotics that you would generally be getting for other infections.

Host Amber Smith: Now, is active TB very contagious? Would the person need to be isolated?

Elizabeth Harausz, MD: Yes. So if somebody does have active tuberculosis, they are put on isolation until we start treatment on them. And then once they are treated, probably much quicker than two weeks, but kind of the rule is after about two weeks, we retest the sputum cultures to make sure the organism's no longer there. And if it's not in the sputum, the person still has the infection, but it's not contagious.

And as long as they're on their medicines, then they don't have to be isolated anymore.But it's not that easy. I mean, it is contagious, but it's actually not that easy to get tuberculosis. It is an airborne infection, meaning that it spreads when a person who is sick with active symptoms, therefore having active TB, coughs and then the germ spreads into the air and another person breathes it in. But it's not nearly contagious as all the respiratory viruses and the colds and such.

To be at risk for becoming infected with tuberculosis, you need to be a close contact of someone who's actively sick. So not somebody with latent TB, but somebody that's actively sick. And this is generally the rule is kind of that being in an enclosed space with a person actively sick for at least four hours per week. And as you may remember, this just means that you may develop latent TB, not that you will develop active TB immediately after being exposed.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host Amber Smith. I'm talking with infectious disease specialist Dr. Elizabeth Harausz, who has expertise in tuberculosis.

TB was the leading cause of death in the United States in the early 1900s. How was it diagnosed and treated back then?

Elizabeth Harausz, MD: Back then, it was treated based on clinical symptoms, and then chest X-rays, which they had around, kind of developed around the turn of the century.

And alsoin, like, the late 1800s, they actually discovered which germ was causing tuberculosis, and they found they could see it under a microscope when looking at sputum. So that was kind of the early diagnosis. there was no antibiotics to treat it, actually, until the 1940s, and they discovered like one or two. And then a few more antibiotics were discovered through the 1950s, 1960s, 1970s.

But before antibiotics, many people, hopefully, if you were lucky, you were able to go to a TB sanatorium for treatment, which were kind of hospitals out in the country, where the treatment -- they didn't really have antibiotics -- was basically clean air, rest and good nutrition.

Host Amber Smith: Is that how TB was eradicated, with a combination of the various antibiotics and the sanitariums?

Elizabeth Harausz, MD: Well, so it's not eradicated. It's just in low numbers in this country. So it's still one of the I think actually the No. 1 infectious disease killer in the world. COVID took that title for about a year, but TB is back at the top, unfortunately. But yeah, I mean, the sanatoriums did help. I mean the air back then, it was really in the cities was filthy. So being in clean air and good nutrition and rest, you know, helped improve people's immune system and helped to whatever degree it could to fight the tuberculosis and perhaps be cured. But what really helped was public health and social welfare measures had most of the initial benefits. So programs to combat malnutrition and improve living and working conditions. So the numbers there of active TB started to fall with that.

And then followed by treatment for active TB and treatment of latent TB, with a health care system that had the money to do so. So it really was the departments of health that were the heroes in decreasing the rates of TB. And by finding people who had active TB and by treating people with the active TB and finding those who had been exposed and treating them for latent TB and therefore preventing further progression of illness.

Host Amber Smith: Well, getting back to TB in America today, I just wanted to talk about the prognosis for someone who is diagnosed with latent TB who has a suppressed immune system. Does that put them at higher risk?

Elizabeth Harausz, MD: Yes. So somebody with a normal immune system has about a 10% chance in their lifetime of progressing to active tuberculosis. But somebody with a suppressed immune system has a much higher rate. And it really depends on how suppressed their immune system is, but if your immune system is suppressed, you can't control the tuberculosis as well.

What we see, really, in this country is people who are going on immune suppressive medications, like certain rheumatological medicines. They'll be screened for tuberculosis before they start those. Even though the rates of tuberculosis in this country are quite low, they'll be screened for latent tuberculosis and treated if necessary just because it's something that's easy to treat and would be bad if it wasn't caught and treated.

Host Amber Smith: Now if someone is discovered to have TB and it's treated, does that offer them any immunity from developing TB again?

Elizabeth Harausz, MD: Yes, to some degree it does. Although, there are people who, if you have very high rates of exposure to tuberculosis, it can reoccur. But those conditions generally don't occur in this country. I'm talking about, like, miners in South Africa and that sort of thing with very, very high rates of tuberculosis and very poor lung conditions.

So it is possible to get it, to have a reinfection. I mean, if you're treated, it's not going to come back, treated correctly and take all your medicines, but you could be reinfected. But again, being exposed to tuberculosis is fairly unlikely. So being exposed a second time and with whatever kind of increased immunity that you have, so it's pretty unlikely to ever have it a second time.

Host Amber Smith: Well, here in the U.S. and in developing nations, what can people do to reduce their risk of getting TB?

Elizabeth Harausz, MD: So really the best defense against becoming ill with TB, is knowing when you have been exposed to someone with active tuberculosis and getting the appropriate preventative treatment. And the people who do this -- meaning people who keep track of active cases of TB and treat people who have been exposed -- is our Department of Health.

And that's why it's so important for a whole host of reasons to make sure our departments of health are well funded and well functioning.

Host Amber Smith: Good to know. Well, thank you so much for making time for this interview, Dr. Harausz.

Elizabeth Harausz, MD: Oh, you're entirely welcome.

Host Amber Smith: My guest has been Dr. Elizabeth Harausz. She's an assistant professor of medicine at Upstate, specializing in infectious disease. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- bispecific antibody therapy for cancer and other diseases.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Bispecific antibody therapy has generated excitement among cancer researchers in recent years as a way to treat certain cancers. Today I'm talking with a doctor who will help us understand the promise of these bispecific antibodies. Dr. Krishna Ghimire is an assistant professor of medicine at Upstate specializing in hematology and medical oncology.

Welcome to "HealthLink on Air," Dr. Ghimire.

Krishna Ghimire, MD: Thank you for having me, Amber.

Host Amber Smith: I'd like to start by asking you to tell us what antibodies are and where they fit in with cancer therapies.

Krishna Ghimire, MD: Well, that's an excellent question, which is a very relevant nowadays in terms of treatment for cancer patients. An antibody is a type of protein produced by the immune system in response to the presence of the foreign substance, what we call antigen in medical terms. So these antibodies, or protein, are a key part of the immune system defense mechanism, which are primarily produced by the white blood cells in our body.

And in terms of where they fit with the cancer therapies, let me take you a little bit to the basics of how this protein looked like. They look like a shape of a Y, the English alphabet's Y, where the tip of the Y binds to the foreign substance, for example, cancer, and the stem of the Y attaches it to the immune system and helps the immune system to recognize them and activate them.

So these antibodies, when they bind to the cancer cells, they block the growth of the cancer cells. They attack and destroy them. That's how we are using these antibodies in the space of the cancer treatment.

Host Amber Smith: So these antibodies, our bodies make these normally?

Krishna Ghimire, MD: That is correct. The antibodies are made by the bodies normally. They're normally called polyclonal antibodies. So they have ability to attack different infections, different foreign substances. But some of the antibodies that we use in the therapies are called therapeutic antibodies, which are designed in such a way that they attack to particular targets, for example, cancer. In some conditions they can attack, too, some autoimmune conditions like rheumatoid arthritis, there may be some particular targets. So these are, in a way, very focused and, in a way, laser-guided type of approach, where those antibodies are produced to attack certain targets that we want them to attack to and minimize the other off-target side effects.

Host Amber Smith: So let me ask you this. If a person has cancer, is their body making enough of these antibodies on its own?

Krishna Ghimire, MD: Our immune system is designed in such a way that when somebody has a cancer, there's a mechanism for our body to kill them by the immune system.

When somebody develops the cancer, while they are developing it, that mechanism is not working anymore. Somehow that system is inactive. So we try to use our body's immune system and make them more active, make them recognize the cancer and kill the cancer with the help of the antibodies.

Host Amber Smith: Now I've also heard of something called monoclonal antibodies. What is that?

Krishna Ghimire, MD: Monoclonal antibodies are produced by a type of a cell, what we call clonal cells, that is only one type of the cells. Those monoclonal antibodies are very specific antibodies we target to specific targets, for example, cancer. One example, let's say if we have monoclonal antibodies for lung cancer, it's going to work only for the lung cancer. It's not going to work for the colon cancer, for example.

So these are very uniquely designed proteins to target the specific type of the cancer, which is more of like a personalized cure for our patients. Specific cancer patients get a specific type of antibodies, and that antibody cannot be used for other type of cancers.

Host Amber Smith: So what is a bispecific antibody?

Krishna Ghimire, MD: Oh, that's even more interesting. Bispecific antibodies are a special type of antibodies where there are two different types of antibodies binded together. So they have two different arms, in a way. So one arm is going to attach, or bind, to the cancer cells. The other arm is going to bind to the immune cells. So those immune cells then get activated. Those activated immune cells attack the cancer and help them to destroy the cancer.

Host Amber Smith: So are the bispecific antibodies made with the help of real antibodies from the body? Are they then worked on in a lab?

Krishna Ghimire, MD: So these bispecific antibodies are designed in the lab. They are designed in such a way that they have those specific targets that we like to attack upon.

That's why those specific antibodiesare manufactured in the lab, and they are shipped to our cancer centers where we can infuse to our patients and help them fight those specific type of cancers.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Krishna Ghimire. He's a hematologist-oncologist at Upstate.

So how many bispecific antibodies have received FDA approval for use?

Krishna Ghimire, MD: As of now, when you and me are talking, there are more than a dozen of antibodies, already approved by federal drug regulation agencies so far. There are many, many more in the pipeline as well.

In terms of the numbers of antibodies I just mentioned, there are hundreds of those in the pipeline. They are in the early stage of development. And they have to go through the drug approval process and different phases of the clinical trials. We expect that those clinical trials will mature and, hopefully, they'll have good results, and those treatments will be valuable for our patients in near future.

Host Amber Smith: Do bispecific therapies work on solid tumors or blood cancers?

Krishna Ghimire, MD: Bispecific antibodies can work for both solid tumor as well as blood-related cancers. And as well as there are other conditions besides the cancers where they have also been used for autoimmune conditions, bleeding-related problems, and also in some diabetes-related complications.

So its use is growing day by day, and it's a very exciting time in this field, especially in the cancer field, How these therapies have evolved over time and how remarkable the response we have seen while going through these therapies for our patients. We have seen multiple, multiple, multiple lines of therapies in the past.

Host Amber Smith: Do you have patients who are treated with bispecific antibodies?

Krishna Ghimire, MD: Absolutely. We do have patients who have undergone bispecific antibodies for blood-related cancers as well as solid tumors.

And these patients have been through many lines of chemotherapies in the past, and their outcome remains very dismal after so many lines of therapies. The promise that these bispecific antibodies has given to our patients with the minimal toxicity and manageable toxicity is very, very promising.

Host Amber Smith: What do you say to someone if they're considering taking a bispecific therapy? What do they need to think about ahead of time?

Krishna Ghimire, MD: I think it is very important to consider them ahead of time so that you can plan accordingly. Some of the therapies do take time to bring it to you, to the cancer center.

So, first of all, we need to discuss with our peer providers whether or not somebody's eligible to get those bispecific therapies. And for someone who qualifies for the bispecific therapy, there are a few things that we need to consider that will help us to navigate the treatment process.

First of all, understanding the treatment. So we encourage our patients to ask the providers how the therapy works, why it is used, what are the benefits of using those therapies, and what are the toxicities, what are the risk and what are the alternatives of the treatment? And also we need to know about the side effects, the common side effects, of those therapies and how to treat those side effects when somebody does develop those side effects.

And also, it is very important that supportive care is also equally important in those patients who have planned to undergo bispecific antibodies -- staying very well hydrated, eating well, having a good rest, and having both social support as well as physical support is very, very important. So having those supports ahead of time, when you plan early, would be a lot easier to manage. And also it's very important to look for some clinical trials, also some financial assistance programs, insurance coverage, all those things sometimes can be a hindrance for timely therapy. So that's why it's very important to look for those things early on in the treatment. And you can get the treatment on time when you need them.

Host Amber Smith: So is the treatment intravenous, or is it through, do you take pills? How does it work, in general?

In general, those bispecific antibodies are intravenous therapies, but recently there have been some approval for injections, subcutaneous injection medications, as well. So far, there is no pill available as a bispecific therapy. Hopefully with the advancement in science in the future, hopefully we will like to see those pills as well, which will be a lot easier to administer, for the health care provider as well as to our patients as well.It sounds like bispecific antibodies are not the first-line therapy. Are these generally saved for people who've already tried some other treatment for their cancer?

Krishna Ghimire, MD: So some of the bispecific therapies have been moving to the earlier and earlier lines of therapy as well, in some of the blood-related cancers.

But in solid tumors, they have been on later lines of therapies. So it all depends upon what type of the diagnosis you have and what type of therapiesyou are going to get. So most of the bispecific therapies have been used in later lines of treatment so far, but because the patients are getting such a good response to the therapies, and the toxicities are much more manageable than the other chemotherapy drugs, so they have been moving to the earlier and earlier and earlier lines of treatment.

Host Amber Smith: Are they considered potentially curative?

Krishna Ghimire, MD: So it's very interesting. Bispecific therapies so far is not a curative treatment. But with the treatment we can control the disease and control the growth of the cancer and also potentially get a deep remission, hopefully a longer period of time. But so far it is not a curative treatment.

Host Amber Smith: How do you expect these therapies to evolve over the coming years?

Krishna Ghimire, MD: I think some of those therapies have some potential side effects, obviously. So, having more and more therapies, newer therapies, more effective therapies, with less toxicity, that we're hoping. And some of the therapies are given for a long duration as well, and we are hoping shorter duration therapies and longer interval in between the therapies. So these are some of the things I think, as the science evolves, hopefully new drugs will have those qualities we just discussed about.

Host Amber Smith: Well, Dr. Ghimire, I appreciate you making time for this interview. Thank you.

Krishna Ghimire, MD: Thank you so much for having me.

Host Amber Smith: My guest has been hematologist-oncologist Dr. Krishna Ghimire from Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from registered dietitian Heather Dorsey from Upstate Medical University. What's the healthiest way to navigate a buffet?

Heather Dorsey, RD: When you're faced with a buffet, you're going to have plenty of protein choices, lots of starchy choices, and probably some minimal vegetable choices. Hopefully we want more vegetable choices than not. But we also want to look at some of the protein and the starchy choices to make sure that they have some things that are beneficial. Like, look for things that have nuts in them or brown rice or wild rice or even beans. Those things are going to increase your fiber, and they're going to keep you more satisfied and will make it just more enjoyable and healthy for you.

Host Amber Smith: You've been listening to registered dietitian Heather Dorsey from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: David Ram is a poet who lives in Massachusetts. He sent us a poem that contains all the heartache, all the love, all the rich history that exists between a mother and son dealing with the mom's Alzheimer's. Here is "Follow-Up Visit with My Mother," dedicated to Mary G. Ram (1923-2001).

When I see in the phone my silhouette

reflected in the photo of a store

display, I remember your instruction

about a common childish frustration:

we cannot be in two places at once;

lacking the power of bilocation,

your words, we must choose between here and there.

Ages later we're sitting side by side

in your neurologist's waiting room,

when out of the blue, you say, "People who

don't know me don't know I am not myself."

I know you. I know you are both here and

someplace far beyond my understanding,

a place from where you will never return.

Sitting across from the doctor, he asks

where you are. You tell him confidently

you are here. When he asks, following up

where here is, you sigh, then slowly, as if

for a little child, enunciate,

"I am here, and you are there," gesturing

both hands at this innocent, getting schooled

in logic by his Alzheimer's patient.

He goes on, asking who I am. You shrug

silently. He repeats his question.

Looking at me, you say, "He's a good guy."

You may not know where we are or our

relationship, but you know here and now.

I'm a good guy. What more, Ma, could one ask?

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

This is your host, Amber Smith, thanking you for listening.