Wednesday, June 27, 2012

Caffeine remains my first-line therapy

Melanoma is notorious for its unusual natural history. It takes unexpected twists and turns, it can spread and then stabilize, metastasize and then grow quiescent. For all its unpredictability, melanoma is also among the most responsive of malignancies to immunological treatment, which makes news about emerging drug therapies of keen interest to me.

One of these experimental agents, called anti-PD1, achieved celebrity status at the annual meeting of the American Society of Clinical Oncology earlier this month. According to clinical trial results reported at ASCO, it shrank or eliminated tumors in 18% of patients with advanced melanoma. And significantly, the cancer stayed in check for at least a year in some patients. A related treatment, called anti-PD-L1, provided similar results.

Both agents will be tested further in coming months and, with luck, be submitted to the FDA for approval late next year. It’s hoped they will then become available for routine clinical use. Neither is likely to be a home run, but in melanoma therapy it’s good just to have some runners on base.
Both agents are engineered antibodies, given as a series of injections that unleash the body’s natural immune defenses. Tumors often evade immune attack by sending signals that ward off killer T cells—the assassins of our immune system. Anti-PD-1 and anti-PD-L1 target key checkpoints in the signaling chain, allowing T cells to continue their assault on cancer tissue. Once an immune response is activated, studies suggest that long-term suppression of cancer without additional treatment may be possible.

Bristol-Myers Squibb makes the two new agents and a previously approved drug called Yervoy, the first immune-enhancing treatment shown to improve overall survival in metastatic melanoma. Among the facilities collaborating with BMS in its research is Providence Cancer Center in Portland, where I was yesterday to see my oncologist and make sure I wasn't misinterpreting what I've been reading. I hadn’t seen him in a year and I don't want him to totally forget about me. I may need his help as an inpatient some day.
Dr. Curti didn’t express a strong opinion about which drug might be my first-line defense, if needed, but like most “melanomologists” he’s pretty excited about the sudden turn in melanoma research toward a whole lineup of potential immunotherapeutic options. In 2010, when I first had this conversation with him, the only strategy to which hopes for treating stage 4 melanoma could be pinned was interleukin-2. Yervoy is now cutting into its turf, with anti-PD1 coming up fast. There is also a form of targeted therapy for advanced disease, but because I don’t have the BRAF mutation in my melanoma genome, I’m not a candidate for Zelboraf. That’s just as well, as I’m betting immunotherapy is more likely to provide long-lasting remissions. There’s also something very appealing--intellectually and emotionally--about harnessing the natural defenses of the body to fight cancer. It just feels like the right way to go.

Our discussion yesterday about systemic therapy was secondary to my need for another simple surgery. Dr. Curti agreed that I can continue to “berry pick” mets as they appear in the absence of symptoms that suggest advancement of the melanoma into internal organs. He took a cursory look at the nodules near my navel that have sat there quietly for months and, figuratively speaking, brushed them off.  So I’ve made an appointment in mid-July with my surgeon to have them removed. While Dr. Curti didn’t quite endorse my tactic of stalling on another PET-CT scan, he agreed there wasn’t any urgency to getting one given my overall health status.
Caffeinated coffee: the anti-cancer
wonder drug?
 “You look like a guy I might see down at Starbucks,” he said. I presume that to mean that if you must make an appearance in an oncologist’s office, it’s better to look like an overcaffeinated yuppie than someone in need of strong cancer drugs.

Based on what I’ve read, the conventional thinking is that Yervoy may be the best first-line treatment for metastatic melanoma when disease is less advanced. The response rate isn’t exactly confidence-building, but it at least matches IL-2 and its side-effects are less severe.  For now, that’s about all I need to know. I’m hoping that my daily self-administered caffeine therapy is enough to keep me out of Dr. Curti’s office for at least another year.

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