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A JOYFUL LIFE
Living well with chronic cancer Metastatic Breast Cancer: A Soul Journey Skin Care After Radiation
DISCOVERING NEW CURES 5 bold ideas A Hodgkin Lymphoma Diary COVID-19 Vaccine News
Protect Your Heart
Heidi Yates
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CONTENTS
E xclusively on
Cancer Health.com Cancer Health Stories
Read the firstperson stories of people who are living with cancer, including personal diaries and honest, moving essays. cancerhealth.com/stories
Basics
Whether you’re newly diagnosed or a long-term survivor, check out our basics section on cancer treatment, managing side effects and much more. cancerhealth.com/basics
Treatment News
Learn about the latest treatment advances, cure research and conference news. cancerhealth.com/treatment
COVER AND THIS PAGE: (YATES) COURTESY OF HEIDI YATES/JOSCELYN LANGLEY; (HEART SPEECH BUBBLE, IV TREATMENT, TYPEWRITER) ISTOCK
Cancer Health Digital Scan the QR code (left) with your smartphone to check out the current issue of Cancer Health online, or go to cancerhealth.com/digital to read past issues and the entire Smart + Strong digital library.
Heidi Yates and her husband, Jake, make time for joy.
16 A CANCER YOU CAN’T CUT OUT Heidi Yates has the grit it takes to fight for a good life while living with chronic lymphocytic leukemia. BY JENNIFER ABBASI 20 THE NEXT CANCER BREAKTHROUGHS An inside look at five research developments that have the potential to transform the treatment of cancer BY LIZ HIGHLEYMAN 2 From the Editor Behind the Breakthroughs 4 Care & Treatment Fecal transplants for melanoma | tracking colon cancer recurrence | cancer mortality drops | KRAS drug for lung cancer | FDA approvals | COVID-19 vaccines | mRNA vaccines for cancer
14 Diary Erica Campbell could barely stand yet now walks the fashion runways. 26 Your Team Protecting your heart from the side effects of treatment 27 How To Care for your skin after radiation.
7 News Statins protect the heart after chemo | Keesha Sharp on her mom and pancreatic cancer | handheld fans for breathlessness | healthy survival guides | Cook for Your Life
28 Resources Colorectal cancer support
10 Voices Michael Kovarik’s soul journey living with metastatic breast cancer
32 Life With Cancer Siri Lindley’s horse seemed to know just what she needed to get strong.
13 Basics Radiation therapy
33 Reader Survey Tell us about your treatment.
30 Good Stuff A mindfulness kit, comfortable “chemowear” and a good book
cancerhealth.com
SPRING 2021
CancerHealth 1
FROM THE EDITOR
Cancer Health TM
THE THEME OF THIS ISSUE IS THE science underlying advances in cancer care and treatment. COVID-19 has given everyone a crash course in drug and vaccine development. While the new coronavirus vaccines may appear to have come out of nowhere in record time, their success is built on years of research in many fields, including oncology. In fact, the mRNA technology used in the first two vaccines authorized in the United States was originally developed for cancer treatment (page 6). For an inside look at early-stage research that could lead to the next treatment breakthroughs, we turned to the Damon Runyon Cancer Research Foundation, which funds scientists with “bold and brave” ideas (page 20). For example, researchers are developing off-the-shelf CAR-T therapies that could be faster and cheaper to produce than customized T cells for each patient. Others are working on vaccines that teach the immune system to recognize cancer and harnessing artificial intelligence to better understand how cancer spreads and develops resistance. After four decades of effort, researchers have finally cracked the code for drugs that target KRAS; the first KRAS drug could be approved this year (page 5). And there’s evidence that fecal transplants can improve response to immunotherapy (page 4). Earlier breakthroughs are helping people today. Heidi Yates is benefiting from new targeted therapies for chronic lymphocytic leukemia—and
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remains hopeful that research will lead to a cure (page 16). Michael Kovarik, a man living with metastatic breast cancer, advocates for more research (page 10). And Siri Lindley relied on her horse as she recovered from a stem cell transplant (page 32). Of course, turning basic science into treatments depends on clinical trials. COVID-19 has disrupted cancer research, but it has also spurred innovations to speed up and streamline the process, making it easier for more patients to participate. Ask your care team whether a trial might be a good option for you.
SMART + STRONG PRESIDENT AND COO Ian E. Anderson EDITORIAL DIRECTOR Oriol R. Gutierrez Jr. EXECUTIVE EDITOR Bob Barnett CHIEF TECHNOLOGY OFFICER Christian Evans VICE PRESIDENT, INTEGRATED SALES Diane Anderson INTEGRATED ADVERTISING MANAGER Jonathan Gaskell INTEGRATED ADVERTISING COORDINATOR Ivy Peterson SALES OFFICE 212-938-2051 sales@cancerhealth.com BULK SUBSCRIPTIONS order.cancerhealth.com or subs@cancerhealth.com CDM PUBLISHING, LLC CHIEF EXECUTIVE OFFICER Jeremy Grayzel CONTROLLER Joel Kaplan
LIZ HIGHLEYMAN Science Editor lizh@cancerhealth.com Twitter: @LizCancerHealth
Cancer Health (ISSN 2688-6200) Issue No. 13. Copyright © 2021 CDM Publishing, LLC. All rights reserved. No part of this publication may be reproduced, stored in any retrieval system or transmitted, in any form by any means, electronic, mechanical, photocopying, recording or otherwise without the written permission of the publisher. Smart + Strong® and Cancer Health™ are registered trademarks of CDM Publishing, LLC.
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Behind the Breakthroughs
EDITOR-IN-CHIEF Bob Barnett MANAGING EDITOR Jennifer Morton SCIENCE EDITOR Liz Highleyman SENIOR EDITOR Kate Ferguson DEPUTY EDITOR Trent Straube SCIENCE WRITERS Sukanya Charuchandra, Caroline Tien COPY CHIEF Joe Mejía ASSISTANT EDITOR Alicia Green ART DIRECTOR Doriot Kim ART PRODUCTION MANAGER Michael Halliday ADVISORY BOARD Dena Battle; Jamie Ennis Boyd; Catherine Guthrie; Timothy Henrich, MD; Carl June, MD; Gaby Kressly; Leigh Leibel, MSc; Yung Lie, PhD; Gilberto Lopes, MD; Jennifer L. McQuade, MD; Amelie Ramirez, DPH; Hope Rugo, MD; Kelly Shanahan, MD; Carla Tardif FEEDBACK Email: info@cancerhealth.com
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CARE & TREATMENT
BY LIZ HIGHLEYMAN
Fecal Transplants Boost Immunotherapy Using stool transplants to alter the gut microbiome may turn cancer patients who do not respond to checkpoint inhibitor immunotherapy into responders. A growing body of evidence shows that the gut microbiome— the ecosystem of bacteria and other microorganisms in the intestines—plays a key role in health and disease, including immune response. Researchers previously showed that melanoma patients with more diverse gut bacteria had more active T cells in their tumors and responded better to PD-1 checkpoint inhibitors, such as Keytruda (pembrolizumab) or Opdivo (nivolumab). Mice that received fecal transplants from cancer patients with good treatment response had greater T-cell activity and slower cancer growth, setting the stage for testing this approach in humans. Researchers at the University of Pittsburgh and the National Cancer Institute gave advanced mela-
noma patients who initially did not respond to Keytruda or Opdivo a single stool transplant, administered via colonoscopy, from donors who responded well to immunotherapy. Six of the 15 evaluable patients saw their tumors shrink or had stable disease after they restarted Keytruda. In these responders, gut bacteria composition rapidly shifted toward more favorable types associated with checkpoint inhibitor response, T-cell activation and reduced immune suppression. Fecal transplants “changed the gut microbiome and reprogrammed the tumor microenvironment to overcome resistance,” the researchers concluded. The team is now working to identify specific types of bacteria linked to favorable immune response. They hope to develop oral capsules containing a cocktail of beneficial microbes that can be used instead of fecal transplants.
BLOOD TEST FOR COLON CANCER A personalized liquid biopsy test that detects circulating tumor DNA (ctDNA) in the blood can help identify colorectal cancer patients who are likely to relapse after surgery, researchers reported at the ASCO Gastrointestinal Cancers Symposium. Around 25% of people with colorectal cancer will relapse, and spotting recurrence earlier can help doctors tailor treatment. In a study of more than 200 people who underwent surgery for Stage I to III colorectal cancer, the patients’ tumor DNA was sequenced to identify mutations, and a Signatera customized
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ctDNA test was designed to track tumor-specific mutations in their blood samples over time. Among 218 people who were tested before starting adjuvant, or post-surgery, chemotherapy, the ctDNA test found that 20 had molecular residual disease (MRD), or evidence of remaining cancer. Within this subgroup, 15 people (75%) relapsed. In contrast, just 14% of the 198 patients who tested MRD negative experienced recurrence. People with detectable ctDNA immediately after surgery had a particularly high risk of recurrence. What’s more,
the Signatera test was better at detecting residual disease than a commonly used tumor biomarker test. “We are able to demonstrate that serial ctDNA testing can detect molecular residual disease a median of eight months ahead of clinical relapse, with significant potential to improve patient care,” says Claus Lindbjerg Andersen, PhD, of Aarhus University in Denmark.
Sotorasib Shrinks Lung Cancer The experimental KRAS inhibitor sotorasib led to rapid, deep and durable responses in more than a third of people with nonsmall-cell lung cancer (NSCLC), according to research presented at the virtual World Conference on Lung Cancer. The KRAS gene makes proteins that regulate cell growth. Once considered “undruggable,” KRAS is the most commonly altered gene in people with cancer. Sotorasib targets a specific mutation, known as KRAS G12C, found in about 13% of people with NSCLC. In an analysis of 126 heavily treated
NSCLC patients in the Phase II CodeBreaK 100 trial, the overall response rate was 37% after a year of follow-up, including three people with complete remission. Another 44% had stable disease, yielding a disease control rate of 81%. The median progression-free survival time was 6.8 months. The Phase III CodeBreaK 200 trial is now testing sotorasib versus docetaxel chemotherapy. Amgen has submitted study data to the Food and Drug Administration, and sotorasib could become the first approved KRAS inhibitor later this year.
ALL IMAGES: ISTOCK
CANCER MORTALITY DROPS Cancer death rates in the United States have fallen continuously from 1991 through 2018, adding up to a total decrease of 31% over that period, according to a new report from the American Cancer Society. Overall mortality dropped by 2.4% between 2017 and 2018—the largest drop since rates began to fall in the early 1990s. The decline is largely attributable to a reduction in lung cancer deaths—survival has increased for people with all stages of non-smallcell lung cancer. Between 1991 and 2018, an estimated 3.2 million cancer deaths were averted thanks to smoking cessation, earlier detection and better treatment. Five-year For more care and treatment news: cancerhealth.com/treatment
survival is highest for prostate cancer (98%), melanoma of the skin (93%) and female breast cancer (90%) and lowest for cancers of the pancreas (10%), liver (20%), esophagus (20%) and lung (21%). Survival rates for most cancers are lower for Black people compared with white people, but the disparity has narrowed. However, the report authors caution that the impact of COVID-19— which has led to a decrease in cancer screening and delays in diagnosis and treatment—is not yet known and could halt the decline.
cancerhealth.com
Now Approved Here are the latest cancer drugs approved by the Food and Drug Administration: • Breyanzi (lisocabtagene maraleucel) CAR-T therapy for large B-cell lymphoma • Danyelza (naxitamab) for neuroblastoma in the bones • Margenza (margetuximab) for HER2-positive breast cancer • Orgovyx (relugolix) for prostate cancer • Tepmetko (tepotinib) for non-small-cell lung cancer • Ukoniq (umbralisib) for marginal zone and follicular lymphoma
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CancerHealth 5
CARE & TREATMENT
BY LIZ HIGHLEYMAN
COVID-19 VACCINES FOR CANCER PATIENTS People living with cancer—including those on treatment—should receive COVID-19 vaccines as soon as possible, experts say. The Centers for Disease Control and Prevention’s vaccine priority list includes people over age 65 and those with health conditions—including cancer—that put them at risk for severe COVID-19. New guidelines from the National Comprehensive Cancer Network (NCCN) recommend that all people with cancer should get a vaccine and advise caregivers and people living in the same household to get vaccinated too. People on cancer treatment were excluded from COVID-19 vaccine trials, but there’s no reason to think the vaccines won’t be safe for them. People with certain types of cancer and those receiving immune-suppressing treatment may not respond as well because they have
low levels of white blood cells that produce antibodies—key players in vaccine reponse. But the vaccines should still provide partial protection— important because some cancer patients, especially those with blood cancers or lung cancer, are at higher risk for COVID-19 complications. NCCN recommends that people on immunosuppressive treatment should delay vaccination until their white blood cell counts recover. People undergoing major surgery should wait at least a few days. But everyone else should get a vaccine as soon as they can. “I have no real concerns that there will be big surprises when it comes to safety for the cancer patient population,” says Gary Lyman, MD, MPH, of the Fred Hutchinson Cancer Research Center in Seattle. “The risk to these patients from COVID is high, and the risks from the vaccines appear very low.”
The same messenger RNA (mRNA) technology used in the Moderna and Pfizer/BioNTech COVID-19 vaccines could potentially be used to prevent or treat a wide variety of other diseases, including cancer and HIV. In fact, the technology was first developed for cancer. The mRNA vaccine approach uses lipid nanoparticles, or fat bubbles, to deliver bits of genetic material that encode instructions for making proteins. The COVID-19 vaccines, for example, deliver blueprints for making the coronavirus spike protein. Cancer vaccines contain instructions for tumor antigens; personalized vaccines incorporate selected antigens from an
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individual patient’s tumor. When an mRNA vaccine is injected, human cells produce these proteins, triggering an immune response. Moderna’s experimental cancer vaccine known as mRNA-4157 shrank tumors in people with head and neck cancer when given with the checkpoint inhibitor Keytruda (pembrolizumab), which unleashes T-cell activity. The overall response rate was 50%, including two complete responses. Another Moderna vaccine candidate targets cancers with KRAS mutations. BioNTech is also working on cancer vaccines. In a study of 25 people with advanced melanoma who received the experimental
BNT111 vaccine, one had complete remission, three had partial responses and seven had stable disease. The response rate was higher when the vaccine was combined with a checkpoint inhibitor. What’s more, among people vaccinated once monthly, memory T cells that recognize the cancer antigens in the vaccine persisted for more than a year.
BOTH IMAGES: ISTOCK
mRNA Vaccines for Cancer
BY BOB BARNETT
NEWS
ALL IMAGES: COURTESY OF COOK FOR YOUR LIFE
COOK FOR YOUR LIFE Ann Ogden Gaffney never set out to launch a cooking website for people living with cancer. In 2005, she was diagnosed with triple-negative breast cancer—she’d already recovered from kidney cancer a few years earlier—and found that the chemotherapy was messing with her stomach and taste buds. Her love for cooking—a passion strengthened during 12 years living in France—helped. “Having this ease with cooking was helping me get through my treatment,” she says. She shared tips and recipes with members of her cancer support group who were also struggling with side effects, such as nausea, gastrointestinal upsets, sore mouth, difficulty swallowing and fatigue. Before too long, she started teaching them cooking classes. Many of them could “barely boil an egg,” she says. “So when the nutritionist says, ‘You should eat more leafy greens,’ they couldn’t make it work at all. My classes helped them bridge the gap.” Gaffney started a nonprofit, working with local hospitals and cancer organizations. To reach lowincome Latinas recovering from breast cancer, she sought out Spanish-speaking chefs to run classes. In 2009, she collaborated with Columbia University epidemiologist and naturopathic doctor Heather Greenlee, ND, PhD, to develop the nine-week program ¡Cocinar Para Su Salud! A year later, women who had participated in the program were still eating more fruits and vegetables and showed biomarkers linked to reduced risk of recurrence. CookforYourLife.org launched in 2012 and later became bilingual in English and Spanish. The site features plan-ahead meals so there’s good food when you’re tired, bland but delicious foods for unsettled stomachs and smoothies to ease sore mouths. Mostly, though, it showcases mouthwatering, easy-to-follow recipes for such main dishes as whole pomegranate glazed chicken, fish in papillote with ginger and coconut, and fennel and white bean soup as well as recipes for sides and appetizers, including salsa verde, sweet potato hummus and whole wheat Irish soda Get more cancer news: cancerhealth.com/news
Heather Greenlee, ND, PhD (left); Ann Ogden Gaffney (right). Recipes: roast salmon with walnut-flaxseed pesto; avocado toast with sunflower seeds.
bread. Dessert recipes include chocolate-dipped fruit, super-simple gelato, cherry pecan dark chocolate brownies and honey cake. Says Greenlee, “We support a plant-based diet with lots of fruits and vegetables, whole grains, lean meats, fewer calories, not a lot of processed foods.” In 2016, Gaffney’s Cook for Your Life cookbook was nominated for a James Beard Award. By 2018, though, Greenlee had moved to the Fred Hutchinson Cancer Research Center in Seattle, and Gaffney was ready to retire—she felt she’d taken the site as far as she could. Greenlee convinced Fred Hutch to acquire the site in 2019; it was relaunched in December 2020. The new website features a blog, videos and information on eating well for prevention, treatment and survivorship. All content has been reviewed by an oncology-trained dietitian. You can search recipes by meal type, preparation method, health concerns (high-protein, low-fiber, easy-to-swallow, nausea, fatigue) and dietary preferences, such as Mediterranean or vegetarian. Greenlee and Gaffney, who remains involved, aim to help more people eat well, regardless of where they are on their cancer journey. Says Gaffney, “I’m thrilled about where it’s going.”
cancerhealth.com
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CancerHealth 7
NEWS
BY BOB BARNETT
New Healthy Survival Guides
STATINS PROTECT HEART AFTER BREAST CANCER Statins, the cholesterol-lowering medications, may protect women with early breast cancer from heart failure. These women are often treated with anthracyclines (chemotherapy drugs such as doxorubicin) or the monoclonal antibody trastuzumab (Herceptin), which are effective but can also damage cells of the heart muscle. Researchers at Women’s College Hospital in Toronto carried out a retrospective cohort study that included women who were at least 66 years old and received breast cancer treatment that included either anthracyclines or trastuzumab between 2007 and 2017. None had previously experienced heart failure. For women on anthracyclines, the incidence of heart failure was 1.2% in those who took statins versus 2.9% in those who didn’t. What’s more, women who took statins were 55% less likely to require hospital treatment for heart failure. For women on trastuzumab, the incidence of heart failure was 2.7% in those on statins versus 3.7% in those not taking them, although the difference was not statistically significant. They were 54% less likely to require hospital treatment for heart failure. While such observational studies cannot prove cause and effect, women being treated for breast cancer with these medications may want to consider joining a clinical trial studying statins, the researchers suggest. For more ways to protect your heart during and after cancer treatment, see Your Team, page 26. —Sukanya Charuchandra
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The National Comprehensive Cancer Network (NCCN) has two new free evidence-based guides for healthy living after cancer treatment: Survivorship Care for Healthy Living and Survivorship Care for Cancer-Related Late and LongTerm Effects. “Just because initial therapy is over, doesn’t mean that it’s done,” explains Crystal Denlinger, MD, FACP, of Fox Chase Cancer Center and chair of the NCCN Guidelines Panel for Survivorship. “Treatment may end, but fatigue, neuropathy and other effects can linger. For some, cancer survivorship means long-term management as they continue to live with and through disease. These guidelines are applicable for survivors who are disease-free as well as those living with cancer. They are far-reaching across all cancer types, genders and ages.” The books can be read online or printed by going to nccn.org/ patients. You can also download a free app that includes these and all the NCCN guides at nccn.org/apps.
Fans Fight Breathlessness People with advanced cancer who experience breathlessness may benefit more from nonpharmacological interventions, such as handheld fan use, than from medications, researchers at Johns Hopkins University in Baltimore report in the journal JAMA Oncology. Breathlessness is a common symptom of advanced metastatic cancer. As the body weakens, respiration becomes progressively more difficult, causing considerable anxiety and negatively affecting quality of life. Oncologists have historically
prescribed medications such as opioids and benzodiazepines, but their ability to provide relief is not strongly supported by available evidence. The researchers reviewed 29 studies of non-pharmacological interventions in 2,423 adults with advanced cancer. The strongest evidence, supported by nine studies, was for respiratory interventions such as fan therapy and bilevel ventilation. Fan therapy entails a fan, often handheld, blowing air (roomtemperature or cold) toward the mouth and nose of the person
experiencing breathlessness. Bilevel ventilation refers to breathing on one’s own while simultaneously being supported by a ventilator. Other studies found benefits from acupressure and reflexology in an outpatient setting. “Guidelines and clinical practice should evolve to incorporate non-pharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness,” the authors write. —Caroline Tien
(HEART AND FAN) ISTOCK; (SHARP) COURTESY OF KEESHA SHARP/BRETT ERICKSON
KEESHA SHARP HONORS HER MOM Actress, writer and director Keesha Sharp, known for her roles on the TV show Empire and the feature film Marshall, has a positive message for people living with pancreatic cancer. She has teamed up with the Pancreatic Cancer Collective on a public service announcement to raise awareness of pancreatic cancer research. The reason was her mom. “Mary was one of those people who was always doing everything for everybody, the one people called on to help them feel better,” Sharp says. Four years ago, her mom was diagnosed with early-stage pancreatic cancer, which was treated with surgery but returned as metastatic disease a year later. By the time she got into a clinical trial for a promising new treatment, it was too late—she died after just two sessions. “Those last two years were incredibly tough,” says Sharp. “It was horrible, but there is also beauty in it. My mom and I believe in God, so I knew Get more cancer news: cancerhealth.com/news
she was going to a better place. That’s my spiritual side, and I was grateful. But my human side—the child in me—was ailing.” Now, Sharp wants to teach others about the robust research on pancreatic cancer treatment. “It’s too late for my mom, but if I can help another sister, another mom, another son, that’s what I want,” says Sharp. Her voice can be heard in an animated public service ad featuring the Pancreatic Cancer Collective, a joint initiative with Stand Up 2 Cancer and the Lustgarten Foundation that has funded more than 400 investigators from nearly 70 leading research centers in the United States and the United Kingdom. Sharp is particularly passionate about getting the word out to the Black community, which has a 20% higher incidence of pancreatic cancer than any other racial or ethnic group. She wants people to appreciate that there is hope when itcomes to treating pancreatic cancer. Visit PancreaticCancerCollective.org for more info.
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CancerHealth 9
VOICES
BY MICHAEL KOVARIK
Soul Awareness IT BEGAN WITH A LUMP NEAR my left nipple. I was sure it was only a cyst, so I wasn’t concerned. But when I heard my doctor’s voice, his words stopped me cold. I was now one of the rare cases of male breast cancer. Stunned, my inner voice screamed out, “Wait, men don’t get breast cancer!” But we do— about 1 in 100 cases are in men. I was diagnosed with Stage I in 2007; other detections soon followed: a chest wall recurrence in 2010 and Stage IV metastatic breast cancer in 2015. My advocacy was born with my initial diagnosis. I found a place within the Male Breast
Cancer Coalition where I could share my story as a man, a gay man, living with breast cancer. It expanded with the recurrence and fully blossomed with my metastatic diagnosis as I connected with the community within METAvivor. I embarked on a more intense schedule of speaking, traveling, mentoring and lobbying Congress. As I immersed myself, I pushed aside the raw emotions that accompanied each diagnosis. I was determined that people know that men get breast cancer, that men get metastatic breast cancer. I desperately wanted people to be aware that Stage IV needed more in general— more funding for research, more acknowledgement, more support, more inclusion within the breast cancer community. I connected Michael Kovarik with many on his farm amazing in upstate individuals: New York patients like me and their families, friends and caregivers, doctors, researchers, those within the pharmaceutical industry wanting to help. Each became family. Yet as I was working to build awareness, I was unaware myself that I had buried unresolved emotions, cleverly hiding them within my passion for advocacy. Seeing many of my new friends
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die of this disease fueled my passion to advocate harder. But beginning in late 2019, I began to notice that each loss, every passing, stole a piece of my heart and soul, creating a void deep inside. I cried, exploded in anger and fear, pleading with the universe to stop this pain, stop taking these gentle souls! I was losing me. I needed to make some drastic changes. I stepped away from advocacy and sought to relearn the joys of silently gazing up at the stars, embracing the peace of being in nature, truly taking in the beauty that surrounds me here on our old farm in upstate New York. Here, where I can lose myself in weeding the vegetable garden, whose bounty will nourish us. I embraced the centeredness that fills me as I create new gardens and enhance those already established. I felt healing as my hands worked in Earth’s soil, felt the gifts of stillness and meditation. I began to notice the beauty in each action, to rediscover the balance my spirit is yearning for, one steeped in honoring those who are gone, holding for now a space that advocacy may once again occupy, cherishing the beautiful souls in my life now and gifting myself the time to heal my spirit and soul. ■ For more first-person essays: cancerhealth.com/stories
COURTESY OF MICHAEL KOVARIK
Retired schoolteacher Michael Kovarik, 64, lives with his partner on their farm in Greenwich, New York. He has metastatic breast cancer.
BY CAROLINE TIEN
BASICS
Radiation Therapy
ISTOCK
Innovative approaches can kill tumor cells more effectively and with fewer side effects. RADIATION THERAPY REFERS to the use of targeted radiation to damage the DNA of rapidly dividing cancer cells, preventing them from growing and causing them to die. Radiation can shrink tumors and halt the spread of cancer. Normal cells that are damaged are typically better able to recover and survive. Roughly half of people treated for cancer will receive radiation therapy. It is most often delivered by an X-ray or other machine (external beam radiation) but can also be delivered via implants or pellets inserted near the cancer site (internal) or taken orally or injected intravenously (systemic). Radiation therapy can also relieve pain in people with advanced cancer by shrinking tumors.
field. Proton therapy, a relatively new approach, employs proton beams rather than X-rays, largely sparing surrounding tissue; it is especially beneficial in treating cancers near vital organs. People who receive externalbeam radiation therapy are not radioactive and can safely interact with friends and family.
EXTERNAL BEAM Several kinds of machines deliver this form of radiation. Threedimensional conformal radiation relies on detailed pictures taken by computed tomography (CT) or magnetic resonance imaging (MRI) technology. Intensitymodulated radiation tailors dose amounts within the treatment area to increase effectiveness and reduce exposure of healthy tissue. Image-guided therapy involves the comparison of images to direct the radiation precisely. Stereotactic therapy administers a single dose of radiation to a tiny treatment
INTERNAL AND SYSTEMIC Internal therapy (brachytherapy) delivers radiation by means of a temporary or permanent implant surgically placed within or near cancerous tissue. Systemic therapy delivers radioactive drugs, orally or via injection, that are engineered to target cancer cells. This approach may reduce the likelihood of side effects. In contrast to external-beam radiation, people who receive internal or systemic radiation should limit physical contact with children and pregnant women for a period of time.
To read more Basics: cancerhealth/basics
GOALS AND USES Radiation therapy can be employed on its own or in combination with other treatments, such as surgery, chemotherapy and immunotherapy. It may be administered before surgery to shrink the tumor (neoadjuvant, or preoperative, therapy) or afterward to prevent recurrence (adjuvant therapy). For those with advanced cancer, such as bone metastasis, it may be used to alleviate physical discomfort (palliative therapy); this constitutes more than half of all radiation therapy administered. SIDE EFFECTS Because radiation damages the DNA of normal cells, it may increase your risk of developing cancer again. The treatment benefits usually outweigh potential harms, so this possibility should not stop you from beginning radiation therapy if your doctor recommends it. Radiation can also cause a wide range of side effects, including skin changes, such as dryness, itching, blistering, burning and peeling, as well as fatigue (see How To, page 27). Other side effects depend on the site at which the radiation is directed. Newer therapies may have fewer side effects. Be sure to report distressing symptoms to your care team so that they can be addressed. ■
cancerhealth.com
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CancerHealth 13
DIARY
AS TOLD TO KATE FERGUSON
A Hodgkin Lymphoma Diary When Erica Campbell, age 35, was diagnosed with Stage IV Hodgkin lymphoma, she could barely stand. Now, the Washington, DC–area beauty walks runways as a plus-size fashion model.
December 2012 The biopsy result was “non-diagnosis,” meaning it hadn’t been successful. I’d been experiencing night sweats, fatigue and weight loss. I had looked up lymphoma symptoms and was experiencing some of them, so I was drastically worried. The specialist wanted to send me to another specialist for another biopsy. But I had health insurance issues and put it off for a few months. My health worsened. I couldn’t even stand in the shower longer than a few minutes because I’d feel dizzy and light-headed. March 2013 As they prepped me for the second biopsy, the doctor told me that my red blood cells were very low, so I had to get a transfusion. When I came out of recovery, they took me to my room, where my family was waiting. An hour later, the surgeon came in and said I had Hodgkin lymphoma, which had spread throughout my entire upper body and bone marrow. I was devastated. Before I was released, my oncologist assured me that lymphoma
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was highly curable, but I was too overwhelmed to be reassured.
Erica Campbell’s memoir details the ups and downs of her cancer journey.
April 2013 Before I started chemotherapy, they gave me transfusions of platelets. I spent a lot of time in the hospital because of medical problems. I asked God why He chose me for this journey. But with a lot of spiritual support from my pastor and friends I thought to myself, Why not me? June 2013 A PET scan showed no evidence of cancer. But to prevent recurrence, I still had to continue treatment. My social worker connected me with someone I could speak to about what I was going through. She also put me in contact with the Lymphoma Research Foundation (LRF) and the Leukemia and Lymphoma Society (LLS). September 2013 I officially finished chemotherapy. It was a bittersweet day. I was happy to leave, even though I had become used to being in this environment. After that, I saw my doctor probably twice a month, just getting checkups. I also had to do CT scans every couple of months. Then I would get a scan and see my doctor every three months. May 2014 I shared my story on LRF’s Stories of Hope website. I did their 5K lymphoma walk, attended their annual forums and participated in their campaign “Erase Lymphoma.” I was invited to do a cancer awareness fashion event where I walked the runway for the first time. This started my modeling career,
COURTESY OF ERICA CAMPBELL/DWAYNE HAZELWOOD, @DWAYNE_HAZELWOOD
November 2012 I had this persistent cough, so my primary doctor prescribed antibiotics and cough meds. Nothing helped, so my doctor referred me to a radiology clinic for a CT scan. He said it looked like pneumonia and ordered another CT scan with a contrast. He called 45 minutes after that scan and said the lymph nodes near my lungs were swollen, causing the coughing. He suggested that it could be sarcoidosis or lymphoma and that I needed to see a specialist. That’s when he scheduled a biopsy for that area.
which flourished during the next few years.
because of a job-related incident. I kept pushing and did my best to stay positive.
January 2019 My doctor stated that I didn’t have to come back and see her for a year or do any more scans. There were no signs of recurrence in my blood work or scans. I had become a survivor, a cancer-free inspirational speaker, able to give hope and encouragement to others.
June 2020 My mom and her best girlfriend were hospitalized after being in a car accident. My family was distraught, and I was scared. Because of COVID-19, we could only see her via video chat. I continued to share my cancer survival story and appeared in a video by GCI Health, a communications agency.
June 2019 I shared my life-changing story through different magazines. I used modeling as a platform to let other women and young girls know to live your best life even when life throws you a curveball.
COURTESY OF ERICA CAMPBELL/JERMAINE GIBBS, @J_UNIQUEEYE
September 2019 I was one of 10 women selected out of thousands, from all different walks of life, to participate in the DSW [Designer Shoe Warehouse] Create and Cultivate fashion event. The whole journey was amazing. As a cancer survivor, I was very grateful.
August 2020 LRF asked me to participate in a virtual fireside chat with other cancer survivors, patient caregivers and doctors. The event was sponsored by BeiGene, a biotech company. Also, happy news: I am now dating someone very special! September 2020 It’s National Blood Cancer Awareness Month, and I got to celebrate the seventh anniversary of my last day of chemo. I am going back to work. Look at God. This was a true definition of having faith, because I honestly did not know when I would get that call to return to work. My story was also featured on Get Up DC, a program on the local news station WUSA 9. January 2021 The New Year is here! Despite COVID-19 and everything else going on, I managed to finish my memoir, I Survived: From Cancer to the Runway. It will be available March 26. Despite the rollercoaster ride cancer took me on, I’ve triumphed and beat the odds in all facets of my life.
January 2020 Since October, I’ve been a young adult ambassador with LRF and shared my story at their annual educational forum. At LLS, I am a peer-to-peer First Connection ambassador. I speak with patients newly diagnosed with Hodgkin lymphoma and answer any questions they have about HODGKIN LYMPHOMA 101 starting their treatment and survival jourOne of the most curable forms of cancer, neys. My story was featured in Plus Model Hodgkin lymphoma usually develops in a type magazine, on HelloBeautiful.com and on of white blood cell called B cells, which prothe cover of Luxe Curves magazine. duce antibodies. Treatment may include chemotherapy, radiation therapy, stem cell May 2020 transplantation or immunotherapy. Doctors I celebrated my 35th birthday with a few may also enroll patients in clinical trials girlfriends and my sisters. But just a that offer access to new therapies. couple of days before my special day, I was sent home from work without pay For more first-person stories: cancerhealth.com/stories
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Fitness entrepreneur Heidi Yates uses her drive and work ethic to advocate for herself and get the best care.
A Cancer Cut Out YOU CAN’T
Heidi Yates, who has chronic lymphocytic leukemia, has the grit it takes to fight for a good life with chronic blood cancer. BY JENNIFER ABBASI
COURTESY OF HEIDI YATES/JOSCELYN LANGLEY
THE PAST YEAR HAS NOT BEEN AN EASY ONE for anyone, least of all Heidi Yates. COVID-19 flattened the energetic fitness studio owner for two weeks in June. Two months later, her son, Jackson, then 12, was diagnosed with type 1 diabetes—a notoriously stressful disease for families. Meanwhile, Yates has been struggling with awful side effects likely caused by the daily pills she takes for chronic lymphocytic leukemia, or CLL, the most common form of leukemia among adults. Yates, 41, learned she had the blood cancer in 2016. But she believes it was brewing in her bone marrow and lymph nodes for much longer, leaving her immune system vulnerable to the nasty sinus infections she endured for years. CLL is a typically slow-progressing disease of B lymphocytes, white blood cells that normally build antibodies to fight infections. Over time, leukemia-affected lymphocytes can crowd out healthy immune cells in the bone marrow and spread to the blood, lymph nodes and spleen.
To manage a chronic cancer well, you need to educate yourself, seek the best specialists and find ways to stay strong emotionally. In many ways, Yates is a role model, according to her specialist, Jan Burger, MD, PhD, a CLL expert at the MD Anderson Cancer Center in Houston. “She’s not just relying on her doctors—she is proactive,” Burger says. “She’s doing all the right things.” Yet even for Yates—with her strong marriage and family, can-do attitude, restless intelligence and extraordinary support network—the road can be rocky. She has had to adjust to living with a cancer that isn’t rapidly fatal but can’t be cured. Says Yates, “I just wish I had a cancer I could cut out.” A LYMPH NODE LIKE A CLEMENTINE CLL is usually discovered in routine blood tests when patients are still asymptomatic. In Yates’s case, however,
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an ear, nose and throat doctor found the malignancy when he biopsied a clementine-sized lymph node on her neck. Imaging revealed numerous swollen nodes throughout her neck, chest and abdomen; a biopsy showed 30% of her bone marrow was affected. Her age and sex also make her unusual—CLL most often affects elderly men. Although treatment is advancing rapidly, CLL currently has no cure. Yates’s cancer is wellcontrolled with drugs but poses unique challenges. Most CLL patients can take a monthlong break from their medication to manage side effects. The two times Yates tried to do so (once so she could undergo Lasik eye surgery and a second time to relieve the drug’s side effects), her lymph nodes swelled within days, some growing to the size of golf balls—painful golf balls. So drug holidays are off the table. But the side effects, including chronic and intractable yeast infections that have stumped her physicians, have become unbearable. Yates describes being in an impossible position: Medication keeps her in remission but comes at the cost of her quality of life. “There’s a part of me that’s like, My cancer’s controlled, just deal with the side effects,” she says. “But it’s gotten to where I just can’t anymore.” After more than a year of misery, during which she tried every yeast infection treatment, switched to a different targeted therapy and reduced her dosage, all to no avail, in January, she started a newer drug in a different medication class. She and Burger hope the side effects will subside. It’s a proactive approach she learned to apply early.
Heidi Yates with husband Jake, their son, Jackson, and one of their dogs, Tico
She found an oncologist in her hometown, Memphis, where she lives with Jackson and her husband, Jack. But he didn’t initially offer prognostic testing to help guide her therapy—a recommended approach. He suggested a six-month course of chemotherapy and told her she didn’t need a second opinion. He didn’t mention targeted therapy, which works against cancers with specific characteristics, even though it was available. Fortunately, a physician friend nudged her to get a second opinion. Over the past five years, several large clinical trials, some led by Burger, have demonstrated that targeted therapy drugs extend CLL remission and help patients live longer than they do with chemoimmunotherapy, a combination of chemotherapy and antibodies that was the previous standard of care. These drugs are less toxic than chemotherapy. What’s more, according to Burger, a small proportion of CLL patients who receive chemoimmunotherapy go on to develop additional untreatable blood cancers—myelodysplastic syndrome and acute myeloid leukemia. Burger started Yates on a BTK inhibitor—now the preferred first-line treatment for CLL in the United States—and later switched her to a different targeted therapy, a BCL-2 inhibitor. Back in 2016, some physicians may have prescribed chemotherapy for otherwise healthy young CLL patients like Yates because they can often tolerate its side effects. But specialists at the time already considered that thinking outdated. “It isn’t that it’s a wrong treatment—it certainly will treat the disease appropriately—but it isn’t the most current treatment,” says Gwen Nichols, MD, chief medical officer of the Leukemia & Lymphoma Society. When Yates flew to Houston to meet with Burger for a second opinion, she found out that it had been years since
TAKING TIME When Yates was diagnosed in 2016, she acted fast. “All I could think was, Cancer. I have an 8-year-old. Get it out of my body. Give me whatever.” Now she regrets her haste. “That is not the way to go into it. Just take your time,” she says. “I wish I’d taken a breath.”
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COURTESY OF HEIDI YATES/JOSCELYN LANGLEY
ALL I COULD THINK WAS, GET IT OUT. I WISH I’D TAKEN A BREATH.
he’d used chemotherapy as a first-line CLL treatment. Yates and Burger eventually made the decision to begin BTK inhibitor therapy; within three days, she lost five pounds of fluid as the lymph node swelling disappeared. Nichols estimates that about 80 new blood cancer therapies have been approved over the past five years. The incredible pace can make it hard for nonspecialists to keep up. That’s why, she says, “when you have a cancer that is going to require long-term treatment, unless you are deathly ill, it is worthwhile to get another opinion.” Patients should be given the time to learn about their disease, ask informed questions and get prognostic tests before starting on a course of therapy. About a third of CLL patients have such slow-growing disease that they may never even require treatment.
Facebook support page with Sabrina, a Canadian woman who underwent a stem cell transplant for CLL, and recently connected with an Australian woman with CLL who received experimental CAR-T therapy. She exchanges daily Facebook Messenger texts with Sabrina and a young Israeli woman with CLL. “That’s been life-changing because we all kind of have similar disease,” she says. Her network of friends is another positive force in her life. They have flown to Houston for her appointments— and to help her cut loose after. “I drink wine,” she says. “Don’t put me on a medicine where I can’t because that’s not going to work.” She and her husband are foodies who love to travel. These family trips and girlfriend getaways help sustain her zest for life. “I’m very driven,” she says. “I always have a good work ethic, and I just kind of work it like a job,” Yates says of her cancer. She takes the same approach to managing her son’s diabetes. Yates looks at the CLL treatments as buying time until a cure is found. For now, researchers are focused on testing combination therapies that can extend medication-free remission. But with the current pace of discoveries, Burger is optimistic that a cure for CLL is an eventual possibility for some patients. Despite her own positive mindset, Yates is candid about what it feels like to live with chronic cancer. “There are times it will just hit me like a punch in the gut,” she says. “I’ll kind of lose my breath, and I’m like, Wow, why do I have to deal with this? And I’ve had a lot of those moments.” When those thoughts strike, she remembers that it could be worse. Memphis is the home of St. Jude Children’s Research Hospital, a world-renowned pediatric cancer clinic. She knows it’s fortunate that she’s the one with leukemia, not her son. These moments of perspective ground her and give her the strength to continue to enjoy the decades of life she is confident she has ahead of her. “CLL is not going to kill you,” she tells herself. “You are going to become an old lady.” ■
LIFE GOES ON After meeting with Burger, Yates found a new oncologist in Memphis. She periodically flies to Houston to see Burger, who works with the local doctor to implement her care plan. Unlike with most cancers, these doctor-patient relationships are potentially lifelong. Many people with CLL will have a normal life span and die of other causes, but Yates is three decades younger than average. At certain times, like when she’s facing the unknown of a new treatment, it can feel like a dark cloud is following her. Soon after her diagnosis, she began taking antianxiety/antidepressant medication to help cope with the stresses—emotional, physical and financial. Yates is by nature optimistic, resilient and tenacious, important qualities for anyone living with any chronic disease and navigating the health care system. Her husband calls her a bulldog. In 2014, before her diagnosis, she opened a Pure Barre fitness studio in St. Louis, 300 miles from home; a second studio followed the next year. She regularly made the four-hour drive from Memphis, where she taught the workout inspired by a ballet barre. Under Burger’s order to reduce stress, she cut back on the St. Louis trips, shifting her GETTING HELP own role to marketing. She hasn’t made the For people with blood cancers and their families and trek during the pandemic but plans to soon. “I caregivers, the Leukemia & Lymphoma Society provides love my team,” she says. “I’ll teach as many free, personalized support. The group’s information classes as I can, see as many clients as I can. specialists are master’s level oncology social workers, When I do get up there, I don’t have to worry nurses and health educators. Go to https://lls.org/ about kid, dogs, anything. I can just work.” support/information-specialists or call 800-955-4572. Yates finds daily support in the online CLL community. She runs an under-50 CLL Read Heidi Yates’s CLL Diary: cancerhealth.com/Yates
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THE NEXT CANCER BREAKTHROUGHS An inside look at five research developments that have the potential to transform the treatment of cancer BY LIZ HIGHLEYMAN
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ANCER TREATMENT IS EVOLVING RAPIDLY. NEW techniques can identify and target tumor vulnerabilities while leaving healthy cells alone. Immunotherapy can harness the body’s immune system to fight cancer. But new treatments still don’t work for everyone. We need more breakthroughs. To find out what’s in the pipeline, we turned to the Damon Runyon Cancer Research Foundation. Th is organization provides multiyear funding for scientists, often at the beginning of their careers, who have “bold and brave” ideas and connects them with a worldwide network of mentors. The result is a long string of cancer fi rsts—and 12 Nobel prizes. So we asked Damon Runyon to help us identify five researchers they have supported who are doing transformative work. Welcome to the future of cancer care.
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JEREMY COPPERMAN, PhD: Harnessing Big Data
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The machine can take all these different measurements and learn patterns that a human doctor can’t see.
HEN JEREMY COPPERMAN, PHD, DEFENDED HIS thesis in statistical physics, he was finishing treatment for Hodgkin lymphoma. After his recovery, his priorities changed, and he decided he wanted to focus on fighting cancer. “My motivations are personal,” he says. “As a survivor, I wanted to see whether the things I’ve worked on in my research career could teach us anything about cancer. I’m a physicist by training trying to learn cancer biology now.” Working with mentors Daniel Zuckerman, PhD, and Joe Gray, PhD, at Oregon Health and Science University (OHSU), Copperman is studying how machine learning and artificial intelligence can help researchers understand how cancer cells continually adapt to gain the ability to metastasize or develop resistance to treatment—and how to adapt treatment in response. “There are a lot of new targeted cancer medicines plus a lot of proven existing medicines, but how do you know when to use what and what will be effective at what stage in a cancer that is rapidly changing? Here at the OHSU Knight Cancer Institute, researchers with the SMMART (Serial Measurements of Molecular and Architectural Responses to Therapy) program are almost characterizing the cancer cell population in real time. It’s really changing and adapting treatment on the fly,” Copperman says. Using repeated tumor biopsies from patients with advanced cancer, a multidisciplinary team analyzes tumor proteins, gene mutations, immune system interactions and cell structure and behavior. Copperman believes the data-driven cell modeling he’s developing can contribute to the personalized management of metastatic disease. “I’m looking at living cells through a microscope—basically movies of cells—and building models of how they behave,” he explains. “How would that cell migrate through tissue, for instance? If you have a model, you can predict that. And once you can predict it, perhaps you can control it.” All that analysis yields a massive amount of data, which is where artificial intelligence comes in. “The beauty of machine learning is that data can have a lot of dimensions, more than a human brain can take in. But the machine can take all these different measurements and learn patterns that a human doctor can’t see,” Copperman says. “It’s a way to pull out predictions and inferences from large amounts of information. You don’t have to know what is important ahead of time—the machine will learn that.” Now in remission for four and a half years, Copperman is grateful to have the support to move into a new field of research. “I don’t know if you know many physicists, but the work can be very abstract,” he says. “I want to be able to connect all those dots where I can get from an almost atomic level understanding of what’s happening with the interactions of specific molecules all the way to stopping a cancer cell from becoming metastatic. I want to know that the work I’m doing is going to do some good for a cancer patient.”
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GEOFFREY OXNARD, MD: A New Kind of Blood Test
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monitoring would require multiple invasive biopsies. Drawing blood is much less invasive, and blood is rich in DNA—some of which comes from cancer cells. “If you can just find that needle in the haystack, you actually can get an actionable result from a blood test,” Oxnard says. “That’s the promise of the liquid biopsy: to characterize a tumor and figure out its biology—what makes it tick. You send off the blood, and within a week or two, you get back information about the cancer that tells you what to do next.” More aggressive and metastatic cancers shed more DNA, and changes in the amount of DNA detected over time can be used to gauge disease progression and response to treatment. “After surgery, you can see if the cancer goes away. The blood test is negative. But if the DNA comes back positive, it tells you the cancer is reemerging,” Oxnard explains. “We can give a treatment and the DNA shedding goes down. If the patient develops resistance, the shedding goes back up. So this dynamic phenomenon creates an opportunity for monitoring. It makes us more nimble in how we care for cancer patients.” Oxnard’s team is working to develop new uses for liquid biopsies. For example, KRAS mutations are common to many tumors. If they’re detected in the blood, can epigenetics and methylation patterns—chemical tags that turn DNA on or off—reveal whether they came from a pancreatic, colon or lung tumor? While these possibilities are being explored, liquid biopsies have already “democratized access to tumor profiling,” Oxnard says. “You can get next-generation sequencing of any advanced cancer anywhere in the United States and maybe anywhere in the world. That creates access to this new horizon, tapping into the promise of precision cancer therapy.”
How do you move away from the historical precedent of chemotherapy for all? That’s precision cancer medicine.
PREVIOUS PAGES: (BACKGROUND) ISTOCK; (COPPERMAN) COURTESY OF JEREMY COPPERMAN/WHITNEY BRADSHAW THIS PAGE: (OXNARD) COURTESY OF GEOFFREY OXNARD, MD
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HILE WORKING at Dana-Farber Cancer Institute in Boston, Geoffrey Oxnard, MD, helped develop a blood test that can detect more than 50 types of cancer, often at an early, more treatable stage. But blood tests known as “liquid biopsies” can do much more, revealing whether cancer is progressing and whether a tumor has mutations or other features that make it susceptible to specific targeted therapies or immunotherapies. “I was a physician and academic researcher focused on lung cancer for almost 10 years, but I found myself thinking about liquid biopsies more and more,” Oxnard says. So last June, he joined Foundation Medicine, which is developing the technology for clinical use. Liquid biopsies are used for next-generation sequencing (NGS), a process that can characterize hundreds of genes at once instead of laboriously analyzing them one at a time in a tumor tissue sample. NGS is now covered by Medicare and many commercial insurers. Last fall, the Food and Drug Administration (FDA) approved Foundation Medicine’s FoundationOne Liquid CDx test, which analyzes more than 300 genes, as a companion diagnostic test for eight targeted therapies for breast, ovarian, prostate and lung cancers. Another approved test from Guardant Health, Guardant360 CDx, analyzes 55 genes. “The dilemma that got us here is a world where cancer patients have a growing number of therapies available and doctors are trying to figure out how to get them the right ones,” Oxnard says. “How do you move away from the historical precedent of chemotherapy for all? That’s precision cancer medicine.” Testing tumors directly is not always feasible—for example, because enough tumor tissue may not be available. Moreover, ongoing
MARCELA MAUS, MD, PhD: Taking a BiTE Out of Tumors
COURTESY OF MASSACHUSETTS GENERAL HOSPITAL
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NEW TYPE OF IMMUNOTHER apy, CAR-T, or chimeric antigen receptor T-cell therapy, involves collecting T cells from a patient, adding receptors so the cells can recognize and attack that person’s cancer and reinfusing them back into the body. While CAR-T offers a new option for treating blood cancers, so far it has not proved very effective against solid tumors. But Marcela Maus, MD, PhD, of Harvard Medical School and the Massachusetts General Hospital Cancer Center, hopes to change that. “I come from an immunology background,” she says. “The human immune system is so incredibly powerful that we think it can be leveraged against multiple solid tumors.” Maus and her collaborators are now designing nextgeneration CAR-T therapies, aiming to create modified T cells that can locate and kill tumor cells while sparing healthy tissue. “Engineering the T cell itself, which is the kind of cell that actually kills cancer, is a powerful strategy because you can add in new genes to redirect it or force it to penetrate cold tumors,” she explains, referring to tumors that are not usually susceptible to immunotherapy. Maus’s team is working on so-called armored CARs that attack glioblastoma, the deadly brain cancer that killed President Joe Biden’s son Beau. These modified T cells are designed to target a specific mutation that is found only on glioblastoma cells. But the CAR-T cells alone failed to do the trick. “We gave it to patients with glioblastoma in a trial back in 2015, and we saw that the CAR-T cells were actually able to get into the brain tumor. But because not every single tumor cell has the mutation, the tumors ended up growing back lacking that mutation. We also learned that the body’s immune system would block the CAR-Ts.” So Maus and her colleagues gave the engineered T cells an extra gene that produces a T-cell engaging antibody-like molecule—more commonly known as a bispecific T-cell engager (BiTE)—that links T cells and their cancer targets. “A bispecific engager is a synthetic antibody-like molecule that has two business ends,” she explains. “One end targets a tumor molecule, and the other binds to a T cell
and activates it. So by forming a little Our goal is bridge between the T cell and the always to tumor cell, you can get a T cell to make our kill it, even though the T cell itself is work not specific for the tumor—it will relevant to just kill it because it’s so close.” patients. These molecules are normally too I’m a large to enter the brain if injected human into the bloodstream, but T cells can doctor, not cross the blood-brain barrier and a mouse deliver them to the tumor. doctor. Maus and her team found that CAR-T cells with bispecific engagers led to complete remission in mice, and they’re now planning to start the first Phase I clinical trial for glioblastoma patients within the next six months. She thinks it should be possible to use this approach for other brain tumors and perhaps other types of cancer as well. The researchers are also starting to look at ways tumors can evade an attack by T cells, with the aim of developing strategies to get around them. “Our goal is always to make our work relevant to patients,” she says. “I’m a human doctor, not a mouse doctor. We use mice to get a sense of whether something is going to be effective and safe and to try to pick the strategy that’s most likely to be the winner. But our goal is to make patients’ lives better.”
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MAJOR CHALLENGE OF CART therapy is that it must be custom-made for each patient—a costly and timeconsuming process. But what if these cells could be mass-produced and given to multiple people? “Cell therapy could be a real game changer, and we’re particularly focused on off-the-shelf approaches that can help treat large numbers of patients in a more practical manner,” says Jakob Dupont, MD, the global head of research and development at Atara Biotherapeutics in South San Francisco. While working with his mentor, Richard O’Reilly, MD, at Memorial Sloan Kettering Cancer Center, Dupont was part of a team that developed a CAR-T therapy that targets Epstein-Barr virus (EBV), which can cause certain types of lymphoma and nasopharyngeal cancer. “What we use are essentially T cells from healthy donors that we educate against Epstein-Barr virus These offproteins and then generate a population of T cells that are EBV-specific,” the-shelf he says. T cells are This research started in the late a great 1990s, before the first commercial foundation, custom-made CAR-T therapies were and we can approved. Now Atara is working to make many bring off-the-shelf T-cell products different to market. Not only is the process flavors. faster and cheaper than engineering cells for each individual patient, it can also benefit people whose own T cells are damaged. “You’re not necessarily working with the best T cells, because the patients have received chemotherapy, radiation therapy, and they also have an underlying cancer, so their immune cells are not functioning terribly well,” Dupont explains. “Instead, we’re using normal, healthy T cells that should be more active.”
These EBV-specific T cells can be given to patients who develop lymphoma after an organ transplant because the immunosuppressive drugs they take allow the virus—which most healthy people carry—to multiply and cause disease. The product, dubbed tab-cel, is in Phase III trials, the final step before FDA approval. “If you give these T cells to these patients, it actually treats—and in many cases cures—this aggressive lymphoma,” Dupont says. “We can also use these off-the-shelf EBV T cells to treat multiple sclerosis, which is thought to be driven by EBV as well.” What’s more, the EBV-specific T cells can be used as a base to insert genes for additional receptors that recognize tumor antigens, such as CD19, which is found on B cells that grow out of control in people with leukemia or lymphoma. “We can also make other CAR-T cells that work against solid tumor antigens, like mesothelin, which we can use to target tumors, including mesothelioma, nonsmall-cell lung cancer, ovarian cancer or pancreatic cancer,” he says. “So the bottom line is, these off-the-shelf T cells are a great foundation, and we can make many different flavors.” Atara also has a tool kit of accessory molecules that can be inserted into the CAR-T cells to make them work better and last longer as well as a molecule that stops PD-1, an immune system checkpoint, from turning off T-cell activity. “This is sort of a way to rev up the cancerfighting potential of those CAR-T cells—we refer to them as armored CARs,” Dupont says. “So you don’t have to give a checkpoint inhibitor drug because it’s essentially already built into the T cells.” With 20 years of experience as a tumor immunologist, Dupont shifted to industry to help bring therapies to the clinic to improve care for people with cancer. “I believe a patient’s own immune system holds great promise to treat cancer, and it’s a matter of finding out how to augment the immune system to be as effective as possible,” he says. “But when you can’t necessarily wake up a patient’s own immune system, you can provide a strong immune response from outside. I think that could have a great impact, especially for patients whose immune system is simply not sufficient to fight their cancer on its own.”
COURTESY OF JAKOB DUPONT, MD
JAKOB DUPONT, MD: Off-the-Shelf CAR-T
JOSHUA BRODY, MD: Vaccines That Fight Cancer
COURTESY OF JOSHUA BRODY, MD
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E’RE ALL FAMILIAR WITH vaccines that prevent disease, but similar approaches that train the immune system can also be used to treat cancer. Joshua Brody, MD, director of the lymphoma immunotherapy program at the Icahn School of Medicine at Mount Sinai in New York City, is working on a promising new “in situ” cancer vaccine that, when injected into a single tumor, activates the immune system to fight cancer throughout the body. “Therapeutic vaccines—as opposed to prevention vaccines—teach your immune system to fight a problem you already have. In situ means that instead of developing the vaccine in a lab or a factory, we are actually inventing the vaccine at the site of our patient’s tumor—a vaccine made at the site,” Brody explains. “Every vaccine you’ve ever heard of takes some feature of the thing you want the immune system to recognize and attack, known as an antigen, and puts it alongside something that turns on the immune system,” he continues. “But that’s tough to do with cancer because, while COVID-19 or the flu are the same for everyone, everybody’s cancer is different, so it’s harder to make one standard vaccine.” Brody’s approach combines a growth factor that stim-
If a person has cancer throughout their body, you only have to teach the immune system to recognize it at one site.
ulates the production of immune dendritic cells, a low dose of radiation and a second drug that triggers an immune response. “The dendritic cells are the generals of the immune army, which tell all the soldiers—the T cells—what to do. We inject a protein called Flt3L into a tumor, which steps up production of dendritic cells,” Brody explains. “Then we load those dendritic cells with tumor antigens using a mini-dose of radiation. The radiation kills some of the tumor cells, and as they’re dying, their antigens spill out and can be eaten up by the dendritic cells. Then, number three, we activate those dendritic cells with a little stretch of RNA that looks like a virus, even though it’s not a virus. We’re basically putting something into the tumor to teach the immune system to think of it like an infection.” Preliminary results from a clinical trial that tested the triplet vaccine approach in people with low-grade lymphoma showed that some patients experienced partial or complete remission that sometimes lasted for months or years. A follow-up trial is testing the vaccine plus a checkpoint inhibitor drug in people with lymphoma, breast cancer or head and neck cancer. “We start with tumors that are superficially accessible, meaning you can poke a needle right into them. You could do it for deeper tumors, like pancreatic cancer or lung cancer, but it’s trickier,” Brody says. “If a person has cancer throughout their body, you only have to teach the immune system to recognize it at one site, and then the immune cells can travel around the whole body to get rid of cancer everywhere.” ■
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YOUR TEAM
BY BOB BARNETT
Care of the Heart
Cardiologist Michael Fradley, MD, is the medical director of the Penn Medicine Cardio Oncology Program at the University of Pennsylvania in Philadelphia. What is cardio-oncology? It’s a multidisciplinary field aimed at managing cardiovascular risk and disease in cancer patients and survivors. A key goal is to ensure that patients can receive optimal cancer treatment without cardiovascular problems becoming a barrier.
at higher risk of developing cardiovascular disease than the general public. I talk about the ABCDE of risk reduction: A is for awareness of cardiovascular symptoms, B is blood pressure, C is cholesterol (and cigarette avoidance), D is diabetes control (and diet) and E is exercise.
How can treatment raise cardiovascular risk? Chemotherapy and radiation can damage normal cells, including those of the cardiovascular system, which can lead to complications, such as decreased ability of the heart to pump blood or abnormal heart rhythms. Targeted therapies can impact pathways that affect the cardiovascular system, leading to, for example, blood pressure elevation. Checkpoint inhibitor immunotherapy can in rare cases lead to an inflammatory condition that affects the heart.
What cardiovascular symptoms should people look out for? Shortness of breath, especially with activities that don’t normally cause you problems; chest pain; a heart rate that is fast for no particular reason. You know your body better than anyone, so if you feel that something is not right, ask for an evaluation.
Does a consultation ever change treatment plans? It can inform decision-making, but I don’t dictate oncology care. For example, if you have a history of heart failure, your oncologist may choose a different therapy. When should someone seek a referral to a cardio-oncologist? If you are facing a treatment that puts you at risk for cardiovascular problems, be proactive. I want to see you before a problem occurs. You won’t get a million tests, but you’ll have an opportunity to find out how to be as healthy as possible. Do you help cancer survivors? Absolutely! Cancer survivors are
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Is cardio-oncology widely available? Most major cancer centers and larger academic centers have cardio-oncologists, but it can be more challenging to find one in the community setting. Telehealth has opened some opportunities to connect patients. What inspires you? Definitely my patients. It is a true privilege to be able to help a person get through their cancer journey and prevent cardiovascular issues from happening, to move into survivorship and live their life in a healthy way. It inspires me every day to see what my patients can accomplish. ■ Who’s on your team? cancerhealth.com/team
COURTESY OF PENN MEDICINE
How do you counsel patients? I view myself as the first mate. The oncologist is the captain. I am there to support the oncologist so that he or she can give the best treatment. I focus on risk factor modification, such as optimizing cholesterol or blood pressure. For example, statin medications may be protective even for people who don’t have high cholesterol. I also talk to my patients about diet and exercise.
A cardio-oncology consultation can help protect your heart from cancer treatment side effects.
BY KATE FERGUSON
HOW TO
Relieve the harsh effects of radiation on treated skin with gentle care.
Caring for Your Skin
6 WAYS TO SOOTHE SKIN
ISTOCK (MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY)
Minimize side effects, soothe skin and speed recovery from radiation therapy.
RADIATION IS A STANDARD TREATMENT FOR MANY CANCERS AND IS used both for curative purposes and to minimize cancer-related pain by shrinking tumors (see Basics, page 13). But it can cause skin to burn, peel, itch and dry out and can lead to sores and rashes. Ask your care team to recommend specific skin care products, and follow these tips to help minimize unpleasant side effects. Wash treated skin softly. Using only your hands, gently apply a fragrance-free, low-pH cleanser or mild soap on treated skin, and splash with tepid water. (Do not disturb any markings placed on the body for proper positioning of treatment machines.) Moisturize daily. Dry, itchy skin can easily become irritated and infected. Specially formulated topical products help skin recover more quickly, but don’t use them on wounds. Avoid hand razors. Treated skin can develop painful rashes when scraped with razors. Instead, when shaving, use an electric razor, or skip shaving temporarily, especially if your skin is sore or tender. Men who get radiation in the head or neck area should avoid aftershave, as alcohol and scents can irritate treated skin. Steer clear of potential irritants. Avoid powders, antiperspirants, deodorants, perfumes, cosmetics, creams or lotions, adhesive-backed medical supplies and heat and ice packs. Protect sensitive skin. Irradiated skin is more sensitive to heat, cold and sun exposure. Before going outside, apply a sunscreen with an SPF of at least 30, and cover your head to shield it from sunlight, heat and cold. Wear loose-fitting clothing to avoid chafing. Monitor symptoms. Follow directions for home care of wounds, sores, scabs or rashes. If you experience distressing symptoms, call your oncologist or dermatologist. ■
cancerhealth.com
1
Cleanse gently with warm water and low-pH soap, using hands only.
2
Apply moisturizer frequently.
3
Avoid shaving with a hand razor.
4
Choose personal hygiene products that are free of possible irritants.
5
Dress warmly in loose-fitting clothing; protect exposed skin with sunscreen (SPF 30 or above).
6
If you have distressing symptoms, call your doctor.
SPRING 2021
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RESOURCES
BY ALICIA GREEN
Colorectal Cancer COLORECTAL CANCER AFFECTS THE COLON OR RECTUM. Whether you are newly diagnosed, are on treatment or are a survivor, family member or caregiver, these resources can help.
cancer.org
This organization provides patients and caregivers with detailed information about colorectal cancer diagnosis, staging and treatment. Survivors can learn about posttreatment steps, such as developing a survivorship care plan with their doctor and managing long-term side effects. The Cancer Survivors Network helps people living with cancer connect with one another and share stories. CancerCare cancercare.org
Whether you need emotional, financial or educational support, CancerCare is here for you. Speak to an oncology social worker, find a case manager and connect with others through free online or in-person support groups. In addition, you can learn more about your disease from leading oncology experts and get help with treatmentrelated costs, including transportation, home care or childcare. Cancer.net cancer.net
Run by the world’s largest association of oncologists, this patient information website provides extensive information on how to cope with colorectal
cancer treatment and how to find a cancer specialist, clinical trials and follow-up care as well as what questions to ask your health care team. Colon Cancer Foundation coloncancerfoundation.org
The foundation’s health management tool helps people living with colorectal cancer manage, organize and securely share their health information. CRC Connect, a new digital community, allows people to share information and best practices in real time. Early-onset (before age 50) colorectal cancer is a focus of the nonprofit’s annual summit.
family members and caregivers. Dana-Farber Cancer Institute dana-farber.org
The institute’s Young-Onset Colorectal Cancer Center is one of the first centers in the United States to focus primarily on patients under age 50. Via the center, they receive comprehensive care, including support services and resources specific to young adults and access to a multidisciplinary team that will help create a personalized treatment plan based on their cancer’s genetic profile. Fight Colorectal Cancer fightcolorectalcancer.org
Colontown colontown.org
A community of private Facebook groups, Colontown has over 100 hosted “neighborhoods” organized according to disease stage, treatment, age, and more. Colorectal Cancer Alliance ccalliance.org
This nonprofit provides guidance for patients, including what to do depending on the stage of your cancer and how to find financial assistance and support through its helpline (877-4222030) and buddy program. It also offers tips for survivors,
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This organization equips patients and survivors with the tools to advocate on their own behalf. Learn about prevention and treatment options as well as how to help fight colorectal cancer in your own community. The Colon Club colonclub.com
The Colon Club’s mission is to help adults under age 45 who have been diagnosed with colorectal cancer. Through The Colon Connection, patients, survivors and caregivers are matched with someone who has had a similar diagnosis or experience for emotional support. Discover more resources: cancerhealth.com/resources
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American Cancer Society
Triage Cancer is a national, nonprofit organization that provides education on the practical and legal issues that may impact individuals diagnosed with cancer and their caregivers, through free events, materials, and resources. As long as there are questions, we’ll have answers. TriageCancer.com
WEBINARS Free educational webinars on practical and legal cancer-related issues that impact people beyond diagnosis. Open to everyone!
CONFERENCES Triage Cancer Conferences are for individuals diagnosed with cancer, caregivers, advocates, & health care professionals! Learn how to navigate insurance, work, finances, & more. Free registration, gif bags, & prizes! *Free contact hours/CE for nurses & social workers.
REGISTER HERE TriageCancer.org/conferences
*Free contact hour/CE for nurses & social workers.
REGISTER HERE TriageCancer.org/webinars
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GOOD STUFF
BY KATE FERGUSON
GETTING HEALTHY
Just in time for spring: gadgets, gear, products and stories to help heal your mind, body and spirit
Each product in the introductory MyndSet Debut Collection is intended to help those with chronic illnesses practice mindfulness and reduce anxiety and stress. Pictured here: a 90-day journal with pencil, a lavender face mask spray, mindful moments exercise cards, an air plant in a handmade clay pot, a natural soy candle and an inspirational word stone ($59.99; contents may vary). This is a great gift for anyone undergoing a personal health journey. One of the business’s founders, Kristin Westbrook, is a breast cancer survivor.
Staying active is key to recovery. Make doing so easier with the Motast P22D Fitness Smart Watch (1.4-inch touch screen, compatible with Bluetooth 4.0, iOS 9.0 or above and Android 5.0 or higher; $39.99). This ergonomically designed, multifunction, waterproof watch tracks a variety of exercises, including walking, running, cycling, hiking and climbing. It also monitors heart rate, hours slept and calories expended by activity and features a soft silicone strap for comfort and a matte watch face that’s easy on the eyes.
Many cancer patients require regular infusions as part of chemo treatments. To make chest port implants more accessible, oncology nurses designed ComfyChemo Chemowear, a line of shirts for men and women (long- sleeved, $34.99; short-sleeved, $34.95; available in sizes S, M, L, XL, 2XL and 3XL in various colors). Made from a comfortable blend of cotton and polyester, these stylish, functional T-shirts sport nifty left and right zippers on the front.
At 17, Eddie Olcyzk was a member of the 1984 U.S. Olympic ice hockey team. Later, he played with some of the country’s most outstanding ice hockey teams. He eventually became a U.S. Hockey Hall of Famer and a popular hockey analyst on network TV. An absorbing and entertaining tale for hockey fans, his book, Beating the Odds: In Hockey and in Life (Kindle, $15.99; hardcover, $19.59; paperback, $16.95), is also an inspiring account of his battle with Stage III colon cancer that helps to raise awareness and offer support to people fighting this illness.
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Dehydration is a common side effect of cancer treatment. The solution? Carry your beverages on the go in the Hydro Flask Insulated Water Bottle (various colors, styles and sizes; from $22.46 to $64.95). This quality portable container keeps liquids cold or hot for extended periods and is perfect for staying hydrated during therapy—and when you resume your busy life.
Find more products to make life easier: cancerhealth.com/good-stuff
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LIFE WITH CANCER
BY SIRI LINDLEY
My Healing Angel Siri Lindley, 51, a former world-class triathlete, lives with her wife in Longmont, Colorado. She was treated for acute myeloid leukemia.
literally and figuratively. Their hearts beat very slowly. When you stand next to one, your own heart rhythm gets slower too, calming you and giving you this beautiful sense of peace. While in the hospital recovering from my stem cell transplant, the dream of riding my beautiful Savannah again kept me going. But when I was able to return home to the ranch, I was 20 pounds lighter, weak and feeling sick. Now, keep in mind, Savannah is a young, strong, feisty and fast Arabian thoroughbred. When I told my wife I was going to ride Savannah, she seemed very concerned. I saddled up my beautiful girl and carefully got on. She could sense my lightness and weakness but also my pure joy. She took tiny, little baby steps. She sensed what I needed to feel safe and supported. Usually, Savannah pulls hard on the reins so she can reach down and eat the fresh grass. I have to pull with all my might to keep her from doing that. But this time, although there was fresh springtime grass all around, she didn’t even try to graze. As the days and weeks went by, Savannah challenged me a bit
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more. I was in awe Savannah always of her intuitiveseemed to ness, the level of know just care she showed what Siri Lindley me, her underneeded. standing not just of where I was in my recovery but what I needed to move forward, to believe in myself and not be so afraid. I had trained her to trust me as her guide. Now she was my guide, a beautiful, understanding spirit who built up my confidence on the path to becoming cancer-free. ■ Editor’s note: Life coach and author Siri Lindley is cofounder of Believe Ranch and Rescue, a nonprofit dedicated to rescuing thoroughbred horses. Her website is SiriLindley.com. For more first-person essays, go to: cancerhealth.com/stories
COURTESY OF SIRI LINDLEY
WHEN I RESCUED MY HORSE, Savannah, in 2016, I didn’t realize the profound impact she would have on my life. Not just on my identity but in giving me the strength and confidence to triumph over acute myeloid leukemia. I rescued Savannah from slaughter—the brutal, painful practice of butchering horses for human consumption. In return, she changed my life. My first task was to convince this 1,500-pound animal to trust me, to let me be a leader she could count on to protect and guide her. Horses can read humans; you cannot fool a horse. Don’t try to pretend you are happy when you are not or not scared when you are. To become her leader, I had to gather all my courage, overcome my fears. The more I did, the more she became my trusted partner and soul mate. Little did I know that she came into my life for an even greater purpose. My initial treatment, a clinical trial that combined intensive targeted therapy with chemotherapy, got me to remission so I could qualify for a stem cell transplant. I was afraid and anxious, but Savannah would sense my fear and pain, nuzzle my nose and just sit calmly with me. Horses have enormous hearts,
SURVEY
Before you started treatment, were you given information about all the possible side effects? ❑ Yes ❑ No Do you feel you were provided with enough support to deal with the side effects of your cancer treatment? ❑ Yes ❑ No
TREATMENT CHOICES In recent years, treatment options to fight cancer have rapidly expanded. The type of treatment you choose will depend on the type of cancer you have and whether it has spread. Take our survey to let Cancer Health know about your experience with cancer treatment.
Have you ever participated in a clinical trial for cancer treatment? ❑ Yes ❑ No
What type(s) of cancer do you have? (Check all that apply.) ❑ Bladder ❑ Kidney ❑ Lymphoma Breast Leukemia ❑ ❑ ❑ Melanoma ❑ Colorectal ❑ Lung ❑ Prostate ❑ Other (Please specify.): __________________
Have you used complementary and alternative medicine (e.g., meditation, massage, herbal supplements) in your cancer care? ❑ Yes ❑ No
Are you currently receiving cancer treatment? ❑ Yes (Skip next question.) ❑ No
What is your gender? ❑ Male ❑ Transgender ❑ Female ❑ Other
How long ago did you have cancer treatment? ❑ Less than 6 months ago ❑ 1–2 years ago ❑ 6 months–1 year ago ❑ More than 2 years ago Which of the following types of cancer treatment have you had? (Check all that apply.) ❑ CAR-T therapy ❑ Radiation therapy ❑ Chemotherapy ❑ Surgery ❑ Hormone or ❑ Targeted therapy endocrine therapy ❑ None of the above ❑ Immunotherapy Do/did you feel comfortable talking with your doctor about all your treatment options? ❑ Yes ❑ No
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How far do/did you travel to receive your cancer treatment? ❑ Less than 25 miles ❑ 50–100 miles ❑ 25–50 miles ❑ More than 100 miles
Do/did you feel you were provided with enough information about all your treatment options? ❑ Yes ❑ No
What year were you born? _ _ _ _
What is your current level of education? ❑ Some high school ❑ Bachelor’s degree ❑ High school graduate ❑ Graduate or professional degree ❑ Some college What is your annual income? ❑ Less than $15,000 ❑ $50,000–$74,999 ❑ $15,000–$34,999 ❑ $75,000–$99,999 ❑ $35,000–$49,999 ❑ $100,000 or more What is your ethnicity? (Check all that apply.) ❑ American Indian/Alaska Native ❑ Arab/Middle Eastern ❑ Asian ❑ Black/African American ❑ Hispanic/Latino ❑ Native Hawaiian/Pacific Islander ❑ White ❑ Other _________________________ What is your ZIP code? _ _ _ _ _
Please fill out this confidential survey at cancerhealth.com/survey. Or scan or take a photo of the completed survey and email it to website@cancerhealth.com.
THE PROBLEM WITH CANCER RESEARCH THAT FOLLOWS CONVENTIONAL WISDOM IS THAT THERE’S NOTHING CONVENTIONAL ABOUT CANCER. At the Damon Runyon Cancer Research Foundation, our research focus is singular: High-risk, high-reward. We believe that only by pursuing and investing in the most audacious and ambitious ideas, and the young scientists who have those ideas, will we achieve real and lasting victory over humankind’s deadliest enemy. To learn more, visit damonrunyon.org
Sakiko Suzuki, MD Physician-Scientist Inflammation and Cell Death
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