How I Became Involved in CAR T-Cell Therapy Research

May 21, 2018

Javier L. Munoz, MD, MS, FACP, is an adjunct assistant professor in the Department of Lymphoma/Myeloma, caring for patients with lymphoma at Banner MD Anderson Cancer Center (MDACC) in Gilbert, AZ (in the Phoenix suburbs). Over the past 6 years, he has grown his lymphoma practice while striving to bring cutting-edge therapies to his patients in the form of clinical trials. He is the director of his institution’s Cancer Immunotherapy Program, spearheading the development of chimeric antigen receptor (CAR) T-cell trials as well as other novel therapies. Dr. Munoz is the principal investigator at his institution for multiple CAR T-cell trials, including Zuma-1 (DLBCL), Zuma-2 (MCL), Zuma-5 (indolent NHL), and Zuma-7 (DLBCL in first relapse). He is a member of the Journal of Global Oncology editorial board and the ASCO Diversity Mentoring Program.

How did you initially choose your current career path? Were there any unexpected detours along the way?

JM: My paternal grandmother, Luisa, died from metastatic cancer of unknown primary in Peru. My middle name, Luis, honors her memory. The lack of resources we faced trying to help her navigate through her challenging diagnosis was frustrating. I promised myself then that I would work hard to better understand cancer and to be at the forefront of cancer care.

My Investigational Cancer Therapeutics fellowship at MDACC in Texas, under the guidance of Dr. Razelle Kurzrock, allowed me to witness firsthand how the sickest of the sick improved after receiving experimental therapy, thus cementing my desire to be heavily involved in clinical trials. Dr. Kurzrock kindly supported me to complete a Master of Science degree in patient-oriented research from the University of Texas MDACC during my fellowship. Strong ties both with academia and pharmaceutical companies, nurtured since my training, allowed me to jumpstart my career with CAR T-cell trials straight out of the gate. I am deeply grateful to Dr. Arie Belldegrun, Dr. William Go, and the Kite pharma team who trusted me to run their trials as a young investigator.

The next step was to bring to the table multiple team members including hospitalists, cryotherapy, apheresis, intensivists, administration, pharmacists, outpatient infusion therapy, nursing, advanced practice providers, and stem cell transplant coordinators to communicate a simple message that would resonate: the importance of CAR T-cell therapies for our patients and our cancer center.

I have had my share of unexpected setbacks, yet I prefer to see each situation as an opportunity for personal growth, thus I focus my energy to overcome negativity and learn from each experience. Acknowledging my passion for immunotherapy early in my career has allowed me to remain diligent towards my goals. I am grateful to be practicing oncology at my institution, where we have the unique opportunity to bring large academic cancer center care, afforded by the partnership with MDACC, to a smaller but rapidly growing community cancer center in Gilbert, AZ.

I am most interested in developing techniques to harness the immune system and unleash its strength to launch a decisive attack against cancer. We are re-educating our immune system with CAR T cells to unveil the fingerprints of cancer. This is an exciting time to be an oncologist.

Describe your typical work day.

JM: The work day begins by communicating with the clinic team and research companies to coordinate care for our patients, mostly via email, before I see my first patient of the day. I prefer to see my follow-up patients or those on active therapy in the morning and reserve new consultations for the end of the day. I see only hematologic malignancies in my practice, particularly lymphomas and chronic lymphocytic leukemia, hence some of my patients need to be seen in the morning to receive same-day extended intravenous therapies. The last patient appointment is planned at 4 or 4:30 PM, thus ending the clinic day around 6 PM.

Our workroom houses our team, which includes my nurse, an advanced practice provider, a scheduler, a clinical pharmacist, and research coordinators. It takes a strong team to have a successful practice, as trust and delegation are critical to share the workload and decrease burnout. Having close physical proximity in the same workroom promotes a dynamic relationship, improves communication, and makes the day go by faster and in a more enjoyable manner. As a team, we address patient concerns from the day prior to leaving the clinic. I strive to complete all orders and documentation for the patients seen before going home, although I admit it is a very challenging task. Administrative days provide the time needed to complete pending notes, hold research meetings, attend our weekly hematology tumor board, and dedicate time to complete research-related duties.

We also have a Stem Cell Transplantation and Cellular Therapy (SCTCT) planning meeting which is fundamental for our CAR T-cell trials. Dr. Matt Ulrickson, Dr. Raj Nath, and Dr. Jonathan Abbas from our SCTCT department have been doing the heavy lifting admitting patients receiving CAR T-cell therapies under their service. The SCTCT team goes out of their way to provide excellent care as CAR T-cell toxicity can occur 24/7 and this herculean task is performed in addition to running an already busy stem cell program.

Finally, we also have frequent teleconferences with MDACC in Houston. I am profoundly grateful to the CAR team at MDACC in Texas (led by Dr. Elizabeth Shpall, Dr. Sattva Neelapu, and Dr. Michael Wang) as they continue to guide us through this exciting novel process. It would be impossible for us to run such complex trials in Arizona without the full support from the main campus in Texas.

If you have to pick one aspect, what part of your job is your favorite?

JM: The ability to give myself to others in caring for my patients by helping them to understand their disease and treatment options as I accompany them on their cancer journey. In collaborating, supporting, and educating our patients as a strong team, we can provide the best care with confidence and pride. Few other jobs will provide you with the opportunity to participate in cutting-edge clinical trials, develop caring relationships, and continue to grow as a clinician. Overall, I am humbled to be able to provide a service to my patients.

What do you wish you had known before you chose your career path?

JM: The practice environment you choose will impact your resources, salary, promotional opportunities, and academic potential. There is significant importance in knowing contract limitations, how your goals and the goals of the organization align, and how the practice dynamics will affect your ability to succeed. The importance of finding a good fit between you and your institution is not emphasized enough during our education. For example, a smaller institution may have faster career advancement opportunities available.

Identify your motivation, the “why” that makes you get out of bed in the morning and do your absolute best. For me, the ability to participate in clinical research is both challenging and rewarding. Community hospitals that are affiliated with academic institutions provide strong support and supervision to run complex clinical trials. No matter where you choose to start, the sooner you know what you want, the faster you can get there. Make sure to choose an institution supportive of your personal and academic goals. Leadership is contagious and trickles down from the top; Dr. Peter Fine, Dr. Matthew Callister, and Dr. Tom Dragovich have been fundamentally supportive of my career within the Banner system.

Why would you recommend this career to someone starting out in oncology?

JM: Patients will gracefully teach you courage and resilience. Medicine is a career that offers a continued spectrum of learning both academically and on a personal level. Practicing oncology will prove to be ever challenging and rewarding to those who are curious and driven. I am grateful for what I learn from my team, colleagues, and patients every day.

What kind of person thrives in this professional environment?

JM: During my training, Dr. Jorge Casas in Peru and Dr. Philip Kuriakose in Michigan impressed me as role models who embodied masterful characteristics both as diagnosticians and teachers. I would describe my mentors as humble, compassionate, driven, and grateful. These are the characteristics that I cherish the most when interacting with my colleagues. You need to remain optimistic and resilient despite adversity. Many of my mentors have made a lifelong impression on my career and there are too many to mention. It is important for me to emphasize the team effort, not only locally at our institution, but also as a cancer care network and beyond. The toxicity from CAR T cells is not for the faint of heart and it takes a village to manage cytokine release syndrome and neurotoxicity. Practicing oncology is about working together and learning from each other. When it comes to novel therapies and CAR T cells, it is fascinating to see team members from multiple hospitals, administration, and pharmaceutical companies collaborate with a common goal.

“How I Became” is a series about the numerous and varied career paths in oncology. In each issue, a member will discuss their career journey and give an insider’s view of their profession. Email to tell us what career paths you’d like to see covered, or to contribute to this series.

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