Cancer Center Spotlight: The HIV-Cancer Clinic at Miami Cancer Institute

Marco A. Ruiz Andia, MD, Chief of HIV Oncology and HIV Stem Cell Transplantation at Miami Cancer Institute, part of Baptist Health South Florida, discusses the launch of the Institute’s new HIV-Cancer Clinic, including an overview of what the clinic will offer; why programs like this are needed; and details on a recent allogeneic stem-cell transplant performed on a patient with HIV and lymphoma.

Transcript

Hi, how are you? My name is Marco Ruiz. I am one of the attending physicians here at the Bone Marrow Transplant Unit at Miami Cancer Institute. I'm also the chief of HIV oncology, the associate director for the bone marrow transplant program here at Miami Cancer Institute. I’m also an associate professor at Florida International University School of Medicine.

When I came to Miami for the first time, that was about 5 years ago, I'd been following the news in terms of the prevalence of the newly HIV infected patients and new AIDS diagnosis in South Florida. Miami and Fort Lauderdale were among the top 10 cities with more cases of newly HIV diagnosed patients and also new AIDS diagnosis.

I came to New Orleans—which happened to be city number 3 or 4 over the last 10 years—and with experience from New Orleans, I wanted to apply the same sort of pattern into a Miami model.

About a couple of years ago, I came to Miami Cancer Institute. My priority was to develop this HIV oncology program, and also look for membership into the AIDS Malignancies Consortium, which is a national organization that gives you the distinction to be part of a selected group of cancer centers. They recognize cancer centers for excellence in care and HIV patients who have malignancies.

That prompted me to start looking for patterns of referrals—who sees HIV infected patients? What patients are these populations go? Where are the centers they usually go?

I presented this to the Miami Cancer Institute leadership, including Dr. (Guenther) Koehne, who is the Chief of Bone Marrow Transplant. They fully agreed about the need and the opportunity. Six months later, we gathered all the documentation, and we launched our application. I think it was January 2020.

With COVID, the pandemic, the evaluations for new applications and renewals of National Cancer Institute grants that the AIDS Malignancy Consortium has, it took longer than expected.

The good news we received finally about a year later, when I got a call from the chairman of AIDS Malignancy Consortium, Dr. Joseph Sparano of Montefiore, who basically said, "Welcome to the AIDS Malignancy Consortium. We reviewed the application. We believe that you guys have the expertise. You got all the elements to be part of our group. "

My first priority was to be part of this unique organization. There are about 37 centers in the US that belong to this organization. We're talking about major centers—Hopkins, Harvard, guys in Boston, UCLA—and here in Florida, we were sent to number 3. We have in Moffitt, where I came from, UM, University of Miami, and us, which is unique because the need is there. Of course the population is here and we tend to see more and more of these patients.

You feel a sense of accomplishment because the Miami Cancer Institute is transitioning over from a community-based center into more of an academic center. This helps, in my viewpoint, to achieve that sort of "academic center status." Hopefully in the future, a national cancer institute designated center.

What we're going to offer, is basically an HIV oncology clinic. What we're going to do is all the patients who perhaps didn't have the option to go to other centers because of demographic issues. We can offer the option of taking care of very complex HIV patients with malignancies, not only hematologic malignancies—leukemia, lymphoma, and so forth—but also solid malignancies—lung cancer, breast cancer.

At Miami Cancer Institute, we also have developed a very robust bone marrow transplant program. In the case of hematologic malignancies, when patients need an autologous transplant, we're going to offer that option. For patients with an allogeneic transplant, we can offer that option as well.

We've already done our allogeneic transplant in 1 of our HIV infected patients with a specific mutation that hopefully in the next probably year or so, we're going to know whether we cured of both the HIV and also from the lymphoma. The patient is doing great.

We also offer academic opportunities because the students who might be interested in the field of HIV malignancy may come to us, because as I said, we're transitioning to be more of an academic institution.

We offer the option that in the future, we're going to have training programs and hematology, oncology fellowship programs hopefully over the next 3 or 4 years.

In partnership with FIU, Florida International University, we are offering this research opportunity. As you can see there's a blanket of opportunities, not only from the clinical care center, but also research and community-based participation in this endeavor.

I think we are 2 years old in terms of our bone marrow transplant unit. It's not a long time, but we already performed over 100 transplants. One of the complexities is, as you see more and more of these populations, they’re going to tend to have very complex cases. We have a case of a patient who had a very chemotherapy refractory disease, plasmablastic lymphoma, which is very unique and more common in HIV-infected population.

He did not respond initially to first- or second-line of therapy. We put him in our third line of therapy. When we were able to finally get him into the allogeneic transplant opportunity or platform. We were able to identify allogeneic bone marrow transplant donor who had a specific mutation that doesn't allow the entry of HIV cells into the T cells.

We we're able to find a donor compatible with the patient who also happened to have his mutation. It was basically a 2-in-1 sort of view. We of course perform the transplant. The patient responded initially well. It's a very unique case because the patient had an Epstein-Barr infection. He has since relapsed in the first 30 to 35 days of transplant. That is not very encouraging.

With control of the immunosuppression, control of the other factors, and control of the Epstein-Barr, basically creating a new "maintenance therapy" for this patient, we were able to successfully control the disease.

The patient now is in complete remission. He is only number 180 after transplant, so 6 months after transplant. He is very happy. We actually saw him a couple of weeks ago at the clinic. He is not having any issues. The HIV viral load remains undetectable. The disease is in complete remission.

It's a very interesting success story, because they didn't look very successful at the beginning, especially because of the re-emergence of Epstein-Barr, but finally we were able to control it. In a way we're already close to day 180, which is something very important for the patient.

I think there are so many different studies now, not only in the US, but in the world. For one, I think there was a major impact for 3 different reasons.

Reason number 1, many of the patients experience over the last year or so delayed diagnosis in terms of cancers. The reasons were many—there were no services available, there was only telehealth—proving that fact that we have more delayed diagnoses in cancer.

The second point is that the patients who were getting the therapy also experienced some of the complications associated with COVID. Which is in fact sometimes delaying therapy, meaning that these patients couldn't get any treatment for whatever reason.

Third point is that for instance, in the born marrow transplant world, there were some specific times in which you have to decide which transplants you could delay, of course not causing harm to the patient, and which transplants were deemed to be completely necessary.

Here at Miami Cancer Institute, believe it or not, we were lucky enough to continue with our operations. Of course, not in 100%, but close to 80%, which is very significant. Basically, we continued with some of the urgent transplant, especially for leukemic patients, some of the lymphoma patients and so forth.

We we're able to bridge some of these patients during the pandemic to perform the transplants later for some patients who were truly not in harm of having any consequences with a delayed transplant.

Second point, we were blessed with the fact that we continued with operations and we didn't have too much of an impact. And we continue with the clinical operation, initially more telehealth than face-to-face, and then with a gradual transition over to a more face-to-face these days.

Once again, I want to thank you for the opportunity. This is a very interesting and exciting new field. It's not necessarily a new field. I think it's always been there, but I think sometimes you truly want to do things, but you need to recognize number 1, you need commitment from leadership and we are lucky enough to have commitment from the MCI, Miami Cancer Institute here, who basically provided us with all the logistic tools. That is really important, believe it or not, because your institution backup is very important.

Then of course, the expertise, because I was able to partner with other providers, partner with some of the nurse practitioners here as a team has been developed. In our team there is a nurse practitioner, a pharmacist, a social worker for medical assistance. In other words, you truly need a dedicated team to deal with these cases. Unfortunately, still HIV is at a peak in our society, and many people see this as still a big problem, especially for many cultures.

We understand. I’ve been working with these populations for almost 20 years, so I understand the limitations and some of the problems that they experience.

We shall continue advancing therapeutic strategies for these patients.