Q&A with James Armitage, M.D., Kearney native who launched UNMC's renown programIn 1982 Nebraskan, James Armitage, M.D., launched what is now one of the most successful bone marrow transplant programs in the world.
In 1982 Nebraskan, James Armitage, M.D., launched one of the most successful bone marrow transplant programs in the world for the treatment of blood cancers. The first bone marrow transplant was done on April 1, 1983.
What have been some of the contributions of UNMC's transplant program for lymphomas?
We've made contributions in a variety of ways. When I came here I intended to build a lymphoma study group. When we started doing transplants, I wanted to have a program that focused on lymphoma. We started doing a new thing which is autologous transplants - where you take normal bone marrow cells from a patient, give them intensive therapy for the lymphoma, thaw out those frozen cells and give them back to reestablish the function of their bone marrow. That's what we started out doing primarily. For a time I think we were doing more transplants for lymphomas than anywhere else in the country. Our first transplants were mostly auto transplants for lymphomas.
At that time no one knew if it could cure lymphoma or not. There were a number of publications in the 1980s that showed that did work. We showed you could predict for whom they'd work based upon if the patient's lymphoma was in remission, how well they were, and if the patient's cancer was still responding to traditional therapies - that led to a paper in the New England Journal of Medicine back in 1989.
Anne Kessinger showed that we could do the same thing with blood-derived cells rather than bone marrow derived cells. You could argue that we did the first blood-derived autologous transplant successfully. There were people who tried to do it five, six, seven, eight years before but it did not work because they did not get enough cells. There was a group in Adelaide, Australia, a group in Germany and our group that at same time in the same year, published papers that showed the transplant could be done and that it worked. We were the first team to do an allogeneic blood cell transplant for leukemia. So we helped show you could do this for lymphoma and cure it. We showed that you could use blood-derived cells to do the same thing, which has become, after working out all the technical issues, the standard way to do it.
What are some of the biggest changes in transplants?
The biggest change in transplants has been the technical things; that is, learning how to do blood transplants efficiently, learning more about graft versus host disease, learning more about typing for allogeneic transplants so patients do not get as much graft versus host disease. Learning how to do things better has made a real difference. And then learning who benefits from the procedure and who does not (i.e., what diseases benefit, what sort of patient will benefit, and at what time in their illness is the treatment most useful).
The world for lymphoma has changed unbelievably. We did not know what the disease was. Our team has been one of the places that have worked out ways to classify lymphomas - to put them into groups so that you are treating real, coherent groups. It is hard to find a cure for something if you think this is a disease but it's really a mixture of several diseases. A treatment might work for one but not the others.
What other ways has UNMC changed the landscape in transplants?
We've been involved in testing a variety of new drugs, some of which have made differences. For example, antibodies have made a huge difference in treating lymphomas. We showed that you can cure lymphomas with certain treatments -- that you don't have to treat people so much to cure them if the treatments work.
How far have treatments come?
When I started treating lymphomas, for example, if you had diffuse large B cell lymphoma, we didn't even know there was such a thing as diffuse large B cell lymphoma. We called it something different back then, and it wasn't one thing, it was a mixture of things. If you had that disease -- the most common form of lymphoma -- you had some chance to be cured. It was just becoming clear that some patients could be cured. And today, well over half those people will be cured with the available treatment. We've been reducing the side effects of the drugs we use to treat lymphoma over time. More and more, our treatments might be given by mouth rather than by vein. We're also better at managing the side effects of transplants and treatments.
The survival rate for some lymphomas has improved dramatically -- some better than others. Hodgkin lymphoma, Burkitt lymphoma, diffuse large B cell lymphoma have probably doubled in survival rate. But for T cell lymphomas, we've not made so much improvement.
How does research play a role?
Research is the only way to advance treatment. You have an idea.that might come because somebody's made an observation in the laboratory, or it might be because someone sees something interesting thing in the clinic by seeing patients. Then you try out that idea to see if it makes things better, and it either does or doesn't. If it does, that's a new standard; if it doesn't, you try something else. As we understand more about the genes in cancers that are being expressed and the proteins made by those genes, we're trying to be more intelligent about planning treatments. That is, if a particular gene metabolic pathway seems to be important, if you have drugs that you know can attack that particular pathway, then maybe they'd be particularly helpful in that disease. And more and more, that's the away treatment regimens are being devised. But we have a way to go to make it work.
How have new discoveries in treatments for lymphoma and transplants made a difference?
Hodgkin lymphoma today can be cured in more than 80 percent and some patients more than 90 percent. It depends on what their characteristics are. Transplants have made it possible to cure patients who used to die. Once you had recurrent lymphoma, it was very unusual to be cured. but since we can do transplants, we can take a significant number of those patients that would have died before and cure them. It's exciting stuff, and it has been fun to be part of it. It makes a big difference to some people. The second patient we transplanted was a young Nebraska woman who had recurrent lymphoma who was ill and dying. Today she has raised her family, retired from her career and has grandkids. This really matters.
Does where someone is treated make a difference?
Patients can seek treatment anywhere - protocols are the same or similar if you get cared for by a physician specializing in lymphoma. Most people aren't cared for by fulltime lymphoma doctors. You do want to have somebody who does it well. These are curable diseases. You want to have someone who knows how to do it and does it carefully and precisely.
What's on the horizon for transplants and lymphoma treatment?
For allogeneic transplants, in fact we're in a movement back to bone marrow cells to suggest that certain patients might do better with bone marrow cells than blood derived cells.
We are beginning to try to learn how to treat patients with T cell lymphoma. The focus is still to cure them, but also to do less harm with the treatments because these treatments are not that simple.
What do you think about when you think about your job and how you make a difference in a patient's life?
One of the really special things about what I do is, I get to know these really interesting people from all over the world and get to see how brave people are and help them deal with these problems. It's a very rewarding thing to do. They can go on and live their life and have kids or see their grandkids. I've treated probably thousands of people. I have patients who I'm friends with and I know their family. After being faced with cancer, I've seen patients live more than they ever had before - doing stuff they really care about. I've learned you should not put off the things you've always wanted to do.
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