Cancer in the Workplace

Jared Kobulnicky, MD

Hematologist-Oncologist

Virginia Oncology Associates

10/10/19

About Virginia Oncology Associates (VOA)

Physician owned Hematology/Oncology Practice

We work with all medical systems in the area: Sentara, Riverside, Bon Secours

38 physicians: medical oncology, radiation oncology, GYN oncology

538 employees

9 offices: Chesapeake, Hampton, Newport News, Norfolk, Suffolk (Obici & Harbour View),

Virginia Beach, Williamsburg, and Elizabeth City, NC

Patients seen last fiscal year: 45,060 including over 8,000 new patients

33 current clinical studies/trials: USON network, Duke, Intergroup

Phase I trial site

Stem cell transplant program

Faculty at Eastern Virginia Medical School

Tumor boards: every week, for all diseases

Hereditary cancer program: the first of its kind in the area

Cancer in the Workplace

Cancer caused by occupational exposure

Cancer occurring in the working age adult, unrelated

to their occupation (the more common scenario)

Discuss emerging treatments that will challenge your

perceptions of cancer care

New developments in Oncology

Due to significant advances in medicine, there are many new

treatments available for cancer

Whether surgery, radiation, chemotherapy, immunotherapy or

targeted therapy are recommend vary significantly based on the

cancer and stage

FDA approved 19 new medications for cancer in 2018

Patients and their employers should not make assumptions about

what treatment will entail without speaking with an oncologist

Cancer Caused by Occupational

Exposure

Asbestos and Mesothelioma

Pesticides and Leukemia / Lymphoma

Many things have been associated but not definitively

proven to cause cancer

Mesothelioma

Incidence is beginning to

decline

Traditional treatments

included surgery (for some)

and chemotherapy

Newer treatments include

immunotherapy and tumor

treatment fields (TTF)

ImmunotherapyNormally, your immune

system (T Cell) should be

able to recognize and destroy cancer cells in the

body

Cancer makes two proteins called PDL1 and PDL2 which block the ability of the immune system to recognize and eliminate cancer

Remission?

Cancers Immunotherapy is Used

For…

Lung

Melanoma

Head and Neck

Merkel Cell

Breast

Bladder

Kidney

Anal

Esophagus

Gastric

Liver

Cancers of all type (if the

patient has microsatellite

instability)

Tumor Treating Fields

Creates a small electrical field between the pads

Patient cannot fell this low level electrical field

Electrical field disrupts cancers ability to grow

Also approved from Glioblastoma Multiforme (Brain Cancer)

Round up

EPA concluded that Round up likely does not cause cancer

UN sponsored IARC concluded that it does

In making their recommendations, they used different

experiments and data bases to come to their conclusions

Recent lawsuit in California settled in favor of plaintiff in excess

of 200 million dollars

Pesticides

Many studies have shown an association with pesticide use and incident of leukemia and lymphoma

28% increase risk of lymphoma (Int J Cancer. 2008;123(7):1657)

in a retrospective study

Retrospective studies can be challenging because of recall bias – patients who develop lymphoma are more likely to remember prior exposure to pesticides

Leukemia and

Lymphoma

Cancers of the blood and lymph nodes

Traditionally treated

with chemotherapy

Many are cured with

Chemotherapy alone

CAR-T (a type of immunotherapy) is an emerging

treatment

Breast Cancer in the Workplace

Many women will experience breast cancer in their working

years

Chemotherapy can cause disabling symptoms that force

patients to stop working, sometimes permanently

Chemotherapy can last up to 1 year

Oncotype Dx changed breast cancer

treatments

Chemotherapy Symptoms

Employees and Employers

understandably concerned if the

patient can continue working now or

even in the future

Majority of women with hormone positive breast

cancer do not benefit from chemotherapy

No benefit to

chemotherapy

Lung Cancer in the Workplace

Nearly half of lung cancer is caught in the advanced stage

Traditionally, chemotherapy, radiation and surgery were mainstays of treatment

15% of patients with advanced lung cancer are candidates for targeted therapy alone

25% of patients with advanced lung cancer are candidates for immunotherapy alone

Many of these patients may be able to continue working as these treatments have

significantly less side effects on average

Targeted Therapy

40 year old female

Non smoker

Presented with stage IV lung cancer

Found to have an ALK rearrangement – 2% of lung cancer

Started on a new targeted treatment called Alectinib, still in remission several years later.

Targeted Therapy

in Melanoma

50% of melanoma has a

BRAF mutation

Dabrafenib is a small

molecular inhibitor of

BRAF

BRAF is a mutation

(change in DNA) that tells a cancer to grow

How do we know if targeted

therapy is appropriate?

Test for mutations (changes in the DNA)

This can be done on the biopsy or from a simple blood test as evidence of cancer can often be

detected there as well

Foundation 1 was the first to receive FDA approval however there are many others available that are

routinely used

Patients should talk with their doctor about whether it is appropriate to send

Cancers for which targeted therapy is

available

Breast

Lung

Melanoma

Colon

Leukemia

Lymphoma

Many others

Other occupational exposures

Bladder - Benzidine, beta-naphthylamine,4-aminobiphenyl, arsenic

– variety of solvents

Liver – vinyl chloride – variety of plastics

Lung – diesel exhaust, cadmium, many others

List not inclusive

OSHA standards designed to protect workers

THANK YOU