When oncologist and hematologist Brad Haverkos, MD, MPH, MS, joined the University of Colorado Department of Medicine a decade ago, he was on a mission to advance research and clinical care for patients with T-cell lymphoma, an uncommon and elusive blood cancer.
In the past 10 years, his accomplishments are extensive, from becoming a resource for patients throughout Colorado and its neighboring states, to leading cutting-edge clinical trials, to helping establish a multidisciplinary clinic with the CU Department of Dermatology — the only one of its kind in the state. Through blending his clinical expertise and innovative research, Haverkos continues to advance the field in hopes of uncovering better ways to treat this challenging disease.
“Unfortunately, many of the therapies we have for T-cell lymphoma don’t have much success in treating patients, outside of a few exceptions,” says Haverkos, an associate professor in the Division of Hematology and member of the CU Cancer Center. “We need better outcomes for this patient population. My goal is to develop a drug or therapy intervention that is safe and works quickly — and that hopefully could be curative.”
Blood cancers can either be leukemia (forms in the developing blood cells of the bone marrow) or lymphoma (forms in a type of white blood cell called lymphocytes, which are important to the immune system).
Lymphoma is divided into two types — Hodgkin (meaning a cell called Reed-Sternberg is present) and non-Hodgkin (no Reed-Sternberg cells present). Non-Hodgkin lymphoma is one of the most common cancers in the United States, and there are several different types of non-Hodgkin lymphomas. One of them is T-cell lymphoma, which makes up less than 15% of non-Hodgkin lymphomas in the nation and is considered a relatively rare cancer.
T cells are a type of lymphocyte that play a vital role in the immune system by identifying and killing infected or cancerous cells in the body. When T-cell lymphoma occurs, it means that a portion of the T cells have become cancer cells.
“Two buckets of this cancer exist. There are aggressive T-cell lymphomas that are more of a systemic disease that involve the lymph nodes and potentially other organs. It can cause symptoms like large lymph nodes, fever, chills, weight loss, and night sweats,” Haverkos says. “The other bucket is a primary cutaneous disease, or a skin disease, that generally grows more slowly.”
“Those populations get treated very differently, but still, the standard treatments are not by any stretch of the imagination home runs,” he adds.
In Colorado, Haverkos estimates there are roughly 200 new cases of T-cell lymphoma each year — but diagnosing new cases can be difficult given the complexity of the disease. A collection of laboratory tests and sometimes multiple biopsies are required.
Certain viruses can cause subtypes of T-cell lymphoma, so Haverkos will look for those viruses in patients’ blood work. He’ll also analyze what markers the tumor cells are expressing, implement techniques like flow cytometry to examine the cells, and perform procedures like molecular sequencing to analyze potential abnormalities. The clinical presentation of the disease also matters.
“It’s like a puzzle — you have to put all of the pieces together,” he says. “Then, you need to talk with the patient to determine what their goals are and the treatment options that make the most sense.”
For patients with the aggressive type of T-cell lymphoma, many find out about their diagnosis after being admitted to the hospital because of their symptoms. Unfortunately, therapies tend to not work, and the risk of relapse and mortality are high.
“Patients typically get intensive chemotherapy right away, but the cancer often comes back,” he says.
Among patients with the slow-growing type of cutaneous T-cell lymphoma, many will initially see a health care provider because they developed a rash.
“It’s a rash that can have multiple different types of presentations. It usually presents in non-sun-exposed areas, such as the bathing suit region, and many will think it is eczema or just an itchy rash,” he says. “The rash will worsen and spread, and the itching will become severe. Usually, the patients will go see a dermatologist and may eventually get referred to me.”
Although there are therapies that aim to improve the quality of life of patients with this type of T-cell lymphoma, the number of patients with positive responses to the therapies is “not nearly as good as we’d like,” he says.
“The responses in general are roughly 30% for all of our different drugs, so we’re conducting research to identify which drugs work better for certain people or potentially in combination to improve results,” he says. “All of those therapies on the cutaneous side are typically indefinite therapies.”
After joining CU in 2015, Haverkos prioritized building a strong clinical practice at the CU Anschutz Medical Campus for patients with T-cell lymphoma. He introduced himself to other physicians in the community and quickly became a resource for oncologists throughout Colorado and in neighboring states.
“I came to CU because there really was no one else in Colorado or in any direction near us who focused on T-cell lymphoma,” he says. “That’s why I wanted to build a clinic and research program centered on it.”
In 2017, Haverkos and Theresa Pacheco, MD, a CU professor of dermatology, launched the Multidisciplinary Cutaneous Lymphoma Clinic — the only clinic of its kind in Colorado. Each week, the pair visit patients, who are typically referred by other dermatologists, and determine if they have cutaneous T-cell lymphoma and the best treatment approach. Haverkos estimates the clinic sees roughly 50 or more new patients a year, in addition to the other patients the pair continues to provide care for.
“This multidisciplinary approach is the best way to treat these patients,” he says, emphasizing the value of having a dermatology expert with him to examine a patient’s rash. “With our combined expertise, we usually can immediately come up with the right diagnosis and work together to help the patient. Treatment often requires a multi-pronged attack, with many patients needing skin-directed therapy and other types of systemic therapy.”
Working in close collaboration with his colleague Eduardo Davila, PhD, a professor in the Division of Medical Oncology, Haverkos is working to translate laboratory findings into clinical trials in hopes of bettering patient care.
“When our patients relapse, we try to have some clinical trial options, and we’ve had some reasonable success,” he says. “We’ve also had trials for newly diagnosed patients. For example, we developed a clinical trial that was a standard-of-care chemotherapy intervention with an immunotherapy partner drug that was pretty successful.”
Haverkos is currently involved in several clinical trials he is excited about. The first trial involves reformulating an old drug that is often used for treating cutaneous T-cell lymphoma.
“We’ve essentially made the drug more potent, and it doesn’t have the side effects that the old drug had, so it’s been well tolerated so far and has good patient responses,” he says. “We think it’s a really encouraging approach and hopefully can move the needle forward.”
The other trial focuses on the aggressive and more systemic type of T-cell lymphoma. It involves giving newly diagnosed patients the drugs that have been shown to be effective among patients who have had a relapse of the cancer.
“Because of the nature of this aggressive disease, patients usually only get one or two chances at treatment options before their organs become too weak,” he says. “So, we’re bringing some of these drugs used in relapse and incorporating them into newly diagnosed therapy interventions. We’re excited and think it might change the standard of care for some of these patients.”
Haverkos is also collaborating with other organizations, including researchers at Colorado State University and CU Innovations, to conduct research that aims to improve the understanding of T-cell lymphoma and identify novel drugs that may improve health outcomes.
Being an innovative researcher has not only advanced scientists’ understanding of T-cell lymphoma — it’s also helped directly change the lives of Haverkos’ patients.
One woman, for instance, had seen numerous dermatologists in both New York, where she is from, and in Colorado, looking for answers on what was causing a rash she had. It wasn’t until she was referred to the Multidisciplinary Cutaneous Lymphoma Clinic and saw Haverkos and Pacheco that she was finally diagnosed with cutaneous T-cell lymphoma.
After a therapy intervention did not work, Haverkos helped her enroll into a clinical trial at CU for roughly a year.
“She benefited from a clinical trial for a year or so, and then she went on this drug that had just been approved at the time, mogamulizumab, and she was able to get into a complete remission,” he says.
After she was on the drug for some time, she eventually weaned off it. Luckily, the cancer has not returned, and it has been roughly two years since she stopped treatment. Now, she’s a champion for Haverkos and his colleagues, promoting their innovation and determination.
“I really enjoy being a clinician and a researcher, because you can learn a lot on both sides,” Haverkos says. “The clinic can guide the research, and the research can guide the clinical care so that, overall, we continue to move the field forward.”