Category Archives: Medications

What IS Cancer, Anyway? And Why Is It So Damned Hard to Cure?!

Once a patient can stop asking why cancer happened to him/her, the next question is the fundamental version of the many questions that the researchers ask– “What is cancer really? and “Why can’t they just stop it?”.

The scary part of cancer is that it seems so insidious.  Cut it out. Burn it out. Zap or freeze it out.  Why doesn’t that work, at least for the solid tumors?  Getting rid of the blood cancers, like leukemia and lymphomas seem more difficult, less obvious, but it was really the cases of leukemia which first responded to treatments.

Without going into volumes of discussion about cell and molecular biology (you are safe from that with me), just understand that cells go wild, left to their own with the family checkbook, an endless liquor cabinet, permanent pizza delivery, car keys, disguises, blind neighbors, a fancy cloning machine, and the police on strike.  You get the picture.  Now a more formal explanation.

Cells are supposed to do their respective duties and then die.  That process is called apoptosis.  You know that your scabs don’t keeping growing, but cancer cells lose the “time to die” signal.

Foreign bodies are supposed to be cleared by the immune system, and what is more foreign that cancer?  However, cancer cells manage to evade immune destruction.   And while doing that, they can also evade the growth suppressors, the immune brakes which would otherwise slow and prevent excess growth.

While cutting the brake lines to growth, they can also change the regulating signals for growth (think scars and healing), so those signals all left in permanent “ON” position.  No brakes and an open throttle with a very full tank of fuel.  To top that, they reprogram the nutrition or energy metabolism to keep the fuel of growth alive.

Liking the growth, the cancer cells override signals that naturally limit the times a cell can divide, creating endless replication instead. With the endless replication, the chances for mistakes, or genetic mutations increase, which can mean changes from the original cancer cells.  Sheesh, not only alien cells, but aliens cells making alien-er cells!

To keep tumors growing, cancer cells send out signals to create blood vessels or angiogenesis when tumors outgrowth the local nutrient sources. Running out of room for all these many cells, billions and billions, the cells break down the lining of blood vessels and the lymphatic system to search out new locations, spreading and metastasizing away from the original cancer.  Quite naturally, they also provide support to those tumors through inflammation-related factors, mimicking the way that the immune system responds to any injury.

Since a healthy being grows, fights off infections, responds to an allergy or heals after an injury, usually with little support, those healthy responses are amazingly efficient and interactive.  Complex cellular, molecular and chemical actions are occurring all the time, and with aging, some genetic dispositions, the harmful things we ingest or do to ourselves, it is no wonder that a few things go on without our noticing it.  But when those few things are not noticed by the immune system, slipping into a growth phase, a cancer can begin.

Estimates of the numbers of cells in the human body are calculated from 10 trillion to 100 trillion, so if the occasional cell goes rogue, what’s the problem?  When all things are working well, there will be no problem. But when the tiniest cancer is visible with a CT scan, perhaps 1/8 inch, it will have millions of cells.  Not all tiny cancer tumors are dangerous. Not all become aggressive.  Digging around to cut out a tiny tumor creates plenty of opportunity for infection, for expense and emotional anguish.  But does that mean that a “Cancer!” has been prevented.  Or would the person and his natural immune system have lived in complete tranquility with his cancer until the end of his days?

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What the heck is PD-1 anyway? Immune therapy?

Probably the most talked about studies at the June 2013 ASCO in Chicago swirled around the newly released trials about PD-1 (Programmed Death-1) and similar.  “What the heck is this  all about, and why should I care?”, you may be asking.  This is important as it shifts attention back to the original immune therapies that kept me alive (and many others) when there was nothing else to offer any hope in the olden days of the 1990s.

Though a number of targeted therapies have since emerged, and  you have been hearing about them, there is new interest in the earlier and modestly successful immune therapies.  I  confess a fondness for anything described as an immune therapy, as I am alive–which I would NOT have been–without the first FDA approved agent against kidney cancer, high dose interleukin 2, brand name Proleukin.

The first new agents in the 2005+, the anti-angiogenesis drugs (not easy to pronounce,much less to understand) brought new hope to metastatic RCC patients.  With the late diagnoses of many kidney cancer patients, we desperately needed hope.  For about 14 years, HD Il2 (high dose interleukin 2) was the only game in town.  Nothing else existed,  so any patient lucky enough to hear about it, and not actively discouraged by the very “realistic” doctors, probably considered it.  This is a hospital-based agent which revs up the immune system, so the immune system would go after the metastatic disease, at least for some number of months or years.  That is why I am alive.  Nothing else was offered and nothing else was available.  Nine years!

Since that time the anti-angiogenesis drugs–translation: those that fight against (anti..) the creation (genesis) of angio (think blood vessels) drugs were approved. Think Sutent (sunitinib) and Avastin (bevacizumab) and others,. They have been the weapon of choice for oncologists and patients.  Why is that?  Though these drugs rarely offer more than some pushing back of the drug, decidedly welcome, they have rarely given more than some slowing or relief from the metastases, and always with some side effects.

For us old-timers, who faced only death, whether by efficient means or by surgical cut-and-pastes as holding actions, this was a tremendous breakthrough.  For these options, even if only holding actions versus mop-up operations, we were grateful.  We who had nothing previously were slightly scornful of those who complained about the side effects, as we were grateful to be around to have such effects.  The Stage IV sufferer  in 2004 knew too well that Stage V was a damn unpleasant journey and without a return ticket.

Now we have become greedy again, wanting more than the “stability” or “some shrinkage”, which I applaud.  We want success and life, not holding actions.  High dose interleukin 2 continues to offer that success to patients, but no one can predict which patients and  which conditions that might be likely.

Bless those researchers who continued to wonder why kidney cancer and melanoma (and maybe non-small cell lung cancer) respond to some sorts of immune therapies, and what happens to make that happen and not happen.  Those fine people have come to understand that the immune response which is revved up by HD IL2 has a complex set of “calls and responses” which either let loose the dogs of war/and immune responses, or fail to do so.

Most people understand that the body tries to protect itself from assaults, whether by poison ivy, bronchitis or cancer.  The immune system responds, gives the body aches, pains, fevers, chills, etc.  Think of flu and how rotten you can feel.  Think also of old diseases like Black Death which stimulated the immune system so violently that it was the strong and healthy with good immune systems that succumbed to the immune response, dying with lungs filled with immune reactions and fluids.  Only those with weakened systems and slower responses managed to live through the symptoms.

Obviously the body’s immune response needs a moderation, and not one that saves the village by killing it.  All of this leads to an explanation of the newest immune therapies, now in clinical trials in RCC.  You may hear about PD-1 and CTLA-1 trials, and how they may be helpful in kidney cancer, melanoma, and now in non-small cell lung cancer.

To understand all of this, it is helpful to think of a system of checks and balances, perhaps in an electrical or computer communication system.  Just as every electrical impulse might be appropriate, it could also do damage by overwhelming the system, burning it out, or failing to meet the requirements to be able to answer a “send me” signal.  So it is with the latest research on immune therapies with the PD or Programmed Death agents.

Keep in mind that the immune response is typically used against infections, and not generally against cancer.  I assume that we cavemen needed more protection evolution-wise against infections and less so against the ravages of cancer, which seems to result from getting older and getting overwhelmed by changes/mutations in the body.  (Not always, I know, but that is a discussion for later.)

T cells are supposed to react to a number of infections and such, and trigger an immune response to fight back against the “aliens”, such as cancer and ragweed. Just right amount of fight, and the body recovers.  Too little, and you have the devastation of the Black Death, an over-the-top immune response.

The  immune system is supposed to respond to handle the natural threats to the body, but not over react and set the system on fire metaphorically.   It had built in checks in balances, as do normal cells.  We see this everyday when our normal growing hair cells decide to stop growing and the hair fall out.  Chemo patients struggle with the balance of killing all cells, with the faster-growing cancer cells being killed off first.

New agents have been developed that interfere with a signaling system that puts the T cells, the protective/fighter cells into action against cancer cell.  This naturally happens, but the nasty cancer cells try to evade that process by interfering with that process.  Not letting the body protect itself, by disguising itself as the evil twin, equally eager to live, as the good twin, the healthy cell, cancer interferes with Programmed Death.  More next time…

And as Mae West said, “I like a man who takes his time.”…

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Filed under Biological Systemic, Immune Therapies Old & New

PD-1 Programmed Death for Cancer Cells “More, Please!” Dr. Wolchok

If anyone can find a cancer event exciting, it is the ASCO annual meeting, at which thousands of oncologists present their studies and learn from one another.  In the kidney cancer world, the “buzz” has been about “programmed death”–for the cancer cells, which we all prefer over that of our healthy cells.

 

This is a transcribed lecture, fairly short, to explain the immune therapies that may add to those weapons against RCC.  Dr. Wolchok clarifies how this happens, with the agents interfering with the “Shields Up!” commands that protect the cell from what should be their programmed deaths.  With appreciation to all researchers.

Peggy–Nine years of life free of cancer, thanks to the original immune therapy, HD IL2

 

 

ASCO Daily News June 6, 2013

Dr. Jedd D. Wolchok, MD PhD of Sloan Kettering Memorial Cancer Center

PD1 Pathway and Activity of Nivolumab

 http://chicago2013.asco.org/dr-jedd-d-wolchok-pd1-pathway-activity-novel-agent-nivolumab-potential-predicative-target  (Transibed interview with above link.  Easier to read and review, fans say!)

 We now recognize that there are several pathways that constrain T Cells and the immune system from achieving a state of full and persistent activation.

One of those pathways is called the CTLA4 pathway and there was a medicine approved call Ipilumimab last year, that blocks CTLA4 for treatment of melanoma. There is another pathway, the PD 1 pathway which usually constrains the immune system in a different way.  And PD 1 is also present on T cells in the immune system and it binds to a family of ligands, one of which is known as PD-L1 or PDL ligand 1.

In the ever-expanding a list of ways in which cancers try to evade the immune system, cancers have learned to express this PDL-1 ligand on their surface.  By doing so, they actually cause the death of T cells that come close enough to them or PDL-1 to bind to PD-1 on the T cell surface. This ability of cancer cells to express PD L1 on their surface allows them to defend themselves against T cells that the body is trying to educate to see the cancer and to defend itself.

So the PD-1 pathway is active across multiple disease sites. Some of the earliest work done with anti-bodies that block the PD -1 pathway used an anti-body called Nivolumab. Nivolumab was used in a phase 1 clinical trial that was presented at ASCO last year, and additional data will be presented this year.

The data last year showed that the antibody Nivolumab blocks PD -1, and that it can cause regressions in melanoma, in kidney cancer and importantly, really, non-small cell lung cancer. It is not traditionally recognized that as a cancer amenable to immune intervention. But when you people talk about cancers that responsive to immunotherapy, melanoma and renal cell carcinoma come to mind.

Now I think with the data generated first with Nivolumab and now with another PD-1 blocking antibody called Lambrolizumab(MK-3475), these anti-bodies which block the PD -1 pathway are demonstrating activity outside the “usual suspects”, melanoma and kidney cancer.

This ability to affect multiple different cancer types is important, as it shows that immunotherapy is not a treatment for one particular kind of cancer,.  It is a treatment that primarily targets the patient, Then it is the patient’s immune system that goes out and treats the cancer.

One of the most important characteristics of immunotherapy is its ability to induce durable and certainly there are many different types of anticancer medications which can cause a tumor to reduce in size, but the challenge has been and continues to be, how to get disease to regress and stay regressed.  Tumors, because of their genetic instability, can find pathways to become resistant to these interventions such as chemotherapy or targeted pathway inhibitions.

Immunotherapy really falls into a different category. Again, it is not targeting the tumor itself. It is targeting the patient’s immune system. It is causing the patient’s immune system to respond to certain parts of the tumor cells that the immune system finds interesting and then to control.

We know that the immune system has the ability to remember, through to a population of cells called memory cells.  Because the immune system is really a dynamic organ that cannot only sculpt itself around changes in the cancer, but also can remember what it has been exposed to in the past, we believe that durability is in fact a hallmark of response to immunotherapy. The first medicine to show us this in a meaningful way was a drug called interleukin two which was really actually developed now over 25 years ago and has led to the cure of some patients with melanoma and kidney cancer. That medicine is a hormone that causes the growth and differentiation of T-cells and patients who have a complete response to IL-2 and remain in complete response for at least two years don’t ever seem to recur with 10 or more years of follow-up.

We definitely need to learn more about the PD-1 pathway we specifically need to know whether it’s absolutely required for a tumor cell to express PDL-1 that on that surface to benefit from PD-1 or PD L-1blockade. It would be ideal, in fact, if a predictive biomarker that could identify the precise patient population who would benefit from that intervention. However, I think that is not going to be a simple as predictive biomarkers been for some of the targeted therapies, where it is mutation-present or –absent.  Here PDL-1 is not just important when it was expressed on the tumors, but PDL-1 plays a role by its presence on antigen-presenting cells. So, in its normal physiologic role, the PD -1 pathway actually involves interactions between T cells and antigen presenting cells and by blocking cells–even if the cells doesn’t express PDL-1–one could imagine that a patient could benefit, perhaps not as likely as if the tumor expressed PD L1.

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It’s Spread! Is It Too Late to Do Anything?

http://www.urotoday.com/Renal-Cancer/tumour-burden-is-an-independent-prognostic-factor-in-metastatic-renal-cell-carcinoma-abstract.html

I love this study, as it really symbolizes the tremendous change that has occurred in kidney cancer treatment these last 6 years. It is remarkable that the 124 patients are described as having already received first- line treatment, and were now in their second-line. These same metastatic patients might have received neither just six years ago.

The study was really not to compare the response to the treatments received, whether Sutent (sunitinib),  Nexavar (sorafanib), or placebo.  (Why any party chose or was chosen to receive a placebo is another, darker question.)  That the median follow-up was 80 months is a triumph by itself.  This is in contrast to the clinical trials that often show just a few months extra time which we and politicians can focus on, when the reality of much longer responses is clearly shown here.  Of course, these longer survival times came from those trials which showed those few months–and this shows the reality of many more months and years of life!

Metastatic tumor burden(TB) was measured, based on the size of the sum of the longest unidimensional diameter of each targeted lesion.  The additional increase of 1 cm (about 3/8”) was significant in predicting response to the medications. Siimply, adding the one-direction measure of the lesions and comparing them showed that more tumor was a bigger problem.

One can also assume that to remove as much tumor as possible may be helpful in maximizing the benefit of the meds given, although this study does not address the actual types and locations of the mets, nor indicate why no other therapies, surgery or ablation, were used.  With 124 patients this would represent a mix of individual experiences, more like the typical patient group.

What does “median follow up of 80 months” really mean?  A median is not an average, but a measure of the time point at which ½ of the population studied had follow up less than 80 months and ½ had follow up for more than 80 months.  Since this is considered a long time in clinical trials and becomes more of a longitudinal study, we may never know the average length of time that these patients had either PFS (Progression Free Survival—time until the mets began to grow again) or OS (Overall Survival).  In any case, we are aware that following this second-line of treatment, there are still more therapies and interventions which may be available.  And even more options are up for FDA approval as I write.

All these options and the greater success of each muddies the study waters, but clarifies the hopes of those with metastatic RCC, or are at risk. This study proves that tumor burden (TB) is a disadvantage. Most patients have naturally assume that more cancer is worse for you than less cancer—who knew? But this gives weight to the notion that the removal of some tumors, if not all, can be beneficial used with targeted therapies. In the past, some oncologists have discouraged additional surgery in the light of metastases, with the implicit message, “It’s too late, and won’t help you anyway.”  Not the doctor for me.

The story is quite different right now, but patients may need to tell this to their doctors–in the language that the doctor speaks. Certainly, there was a time at which doing more surgery for mRCC patients added little, if anything, to survival and probably even less to the quality of life. That no longer is the case, and those older studies no longer have meaning.  While each patient must be treated as an individual, in light of all the variables that impact his health, there is increased optimism for the metastatic patient. Aggressive and early treatment can no doubt extend life and make it worth living.  

 

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Filed under Ablation & Radiation, About Peggy, Biological Systemic, Clinical Trials, Immune Therapies Old & New, Medications, RCC Basics, Surgery, Targeted Therapies, Your Role

Immunotherapy Part 3: Am I Cured? And How Big is 9mm?

Halfway through my high dose interleukin 2 (Proleukin) treatments, having completed weeks 1 and 2 and into the second rest period, I got the second most important scan of my life.  The most important CT scan changed my life, with its image of a tumor larger than a baseball, and countless tiny specs of white death in my lungs.
This new scan in August of 2004 would let me return to the hospital for more of the immune stimulant, Proleukin, which revved up my internal immune system to the max. My system was then to recognize and fight off the residual kidney cancer that had settled visibly in my lungs and any other new sites, as yet unseen.  The new vocabulary of cancer forces me to say that while hundreds of tiny lung mets/lesions/nodules–no wonder we patients get confused–were not just there, but ” visible”.  Implicit was the message that many hundreds more were  invisible, certainly  alive and thriving, just not yet “imaged”.
The tools of imaging cancer are varied and unequal, some more effective for some cancers, and yet inadequate for others.  First of all, the tumors are measured in centimeters and millimeters, and that language shift alone makes them even more inaccessible to Americans.  Just how big is 9 millimeters anyway?  And a centimeter seems a pretty vague measurement after years of holding thumb and forefinger together to how 1/2 inch with decent precision. Is a change from7mm to 9mm cause for alarm?
Plus the panic of hearing “cancer” drives any math computation out of one’s head.  The only math question that can be asked and then not understood is, “How long have I got, doctor?”.  And then there is the matter of what can be seen with which instrument.  When doctors tell smokers that their  x rays are clear,  naive civilians translate that to mean their lungs are free of cancer. A rough interpretation might be more like, “Your tumors–if you have them–aren’t big enough to be captured by this 100 year old device.  Come back when we can see something/you are pretty much past help.”  Notice that I provide the translation here.
The x ray is more like using a child’s microscope to look at something; great for noticing crud on your pet’s hair, but not quite like those grownup electron microscopes which can see cells.  Note to kidney cancer patients–don’t even bother.
Another imaging device is a PET scan, which measures the activity of cells, and which I understand a quick snap shot of liveliness of the cell, and it manifestation, the tumor.  Is it chowing down on the body’s nutrients faster than the orderly cells?  That activity will “light up” in a PET scan, so the lazier cancer cells might be overlooked.  Not to effective in kidney cancer, whose tumors are often slow-growing.  That is also possibly why kidney cancer can establish itself so thoroughly in so many patients, not noticed until a broken rib or vague back ache or a non-existent ulcer finally results in a CT scan. Note to lots of kidney cancer patients–don’t even bother with a PET scan.
So a CT scan, with contrast to enhance the vague and ghosty images is the way to go for most RCC patients.  A blood test to see if the single kidney can handle the assault of the imaging fluid precedes the test, and then the patient settles onto a big padded tray which is drawn slowly into a large doughnut-shape machine that somehow can see into the patients insides.  I’m not even trying to explain that.
That exam is not painful, not pleasant, and not anything you can study for; you simply submit, as patients are supposed to do, and then the impatience begins.  Most patients must wait to get their results from the doctor, and this is the longest wait of one’s life.  Am I dying more efficiently than before?  Are the cells multiplying more quickly?  How long have I got, doctor?
But I had learned the secret, which I now announce to all.  You are ENTITLED to your own reports, and with a bit of research as to when they get read, you can go get them.  Apparently for many imaging centers, this comes as a surprise, but we are all grownups and can explain that.  Sometimes your doctor will need to hear that too.  I have always just called ahead to the “Medical Records” department and asked for the report to be ready, as I have no patience…again.
But in August 2004, I had to be outside before I could read it.  To read a report of impending death inside a hospital with its metal window frames and linoleum floors and sad, bent people waiting their turns is too harsh a setting.  Immediately stepping outside, I could rip open the envelope, and read that my lung tumors were shrinking, even those big ones.  The 13mm lesion was now 8x9mm, the 8x7mm lesion was just 4x4mm.  And the countless other unmeasured one?  They were likely shrinking, too.  And 9mm is .354 inches, which I still can’t measure between my thumb and forefinger, but the CT scan could, and that was good enough for me.
Back to the hospital, a much easier trip than before, to get two more week-long sessions of HD IL2. The mets were shrinking and I was getting more ammo against them.  The cloak of invisibility was pierced and my immune system was working again.

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Immunotherapy Part 2: Is There Any Hope?

My first week at home following the CT scan was to be a recovery week, following five days in the hospital. When I had anticipated that first weekend, post Proleukin/High Dose InterLeukin 2 treatment, my plan was to go to a local kidney cancer meeting.  I would be a bit soggy, post “flu”, but not contagious, just recovering from the immune stimulant.  I planned to sit around, smile bravely, and look like those heroines in the old days of consumption.

As a measure of my mental competence, it was several weeks later before I realized I had missed the meeting, and in fact, had missed most of the week, and a good portion of the recovery week as well.  My response to the Proleukin was such that I did not receive but 9 of maximum 14 doses and had to spend an extra day in the hospital to recover.  The last thing I do remember of that week at UCLA was a doctor walking me down the hall, and seeing a sign overhead.  At least I could read, and knew I was in the hospital, and then somehow I was home.

Flashes of memory come to me of those first few days, retching in the toilet, and then being sat in the shower on a tiny plastic stool, and being scrubbed by my daughter, a miracle of an experience. And more odd oblivion.  At this time, my mother-in-law was headed deeper into an oblivion of Alzheimer’s, and I joined her.  One WEDNESDAY morning, I was reading the paper  v e r y s l o w l y…not my usual style, and I noted that the LA Times used Tuesday’s date.  Obviously this was major mistake, which rather incensed me, and tried to interest my husband in this crisis.  “What day is it?”  He also thought it was Tuesday!  For that matter so did the local paper, and the Wall Street Journal!

Naturally, I had misread or misheard this, so checked again, and asked again, and asked again, and read again.  Even the damn computer was in on this mistake, but I waited patiently for corrections to occur, and still they–now the entire world–claimed it was Tuesday.  And the family was getting a little odd in their responses to me. “Still Tuesday, Mom…”.

Not once all that Wednesday nor the Wednesday that followed it did I ever think for a second that I might have been mistaken.  My testing, my logic, my checking and rechecking all these reliable resources did not change my mind, but it did cause me to wonder why everyone else was wrong.  I figured the nice thing to do was to wait until they got it right.

It took me several months and a number of similar events to realize that this was a tiny gift from HD IL2–and insight into craziness, or whatever word describes the inability to accept fact in the face of facts from trusted and even beloved sources.  No wonder poor Nana could get so angry at all of us, and no wonder that telling her something in a logical manner was futile.  Her brain had been compromised by Alzheimer’s and mine by the medication that was trying to save the rest of me.

So was it working?  Brain issues aside, I felt fine, or so I told my oddly polite and amused family.  Taking a plate to the sink proved to me that I was doing all my household duties.  Writing a 25 word email in 30 minutes proved my computer skills were intact.  But what about those precious lungs and the icy white granules of tumor dividing relentlessly?

Without proof that the IL2 treatment was slowing down the growth, I would not have been permitted back into UCLA.  To push the immune system into the kind of response that causes it to seek and destroy the cancer cells so well-settled into my lung, not only the visible ones, but their countless and invisible spores, is dangerous.  No doctor wants to make a patient sick without hope that this synthetically induced sickness would drive out the virulent and relentless cancer cells, so it had to be shown to be worth the risk.

As I really became aware that I had missed one week and more in my life due to the treatment, and that I had no control of memory over what had happened in the hospital, I realized how hard it would be to readmit myself to the hospital.  Excuse after excuse–all good ones, of course–delayed my walk into the lobby, accompanied for the first time by fear.

Years earlier, as my father lay dying in our family room, he told me that he was afraid to go to sleep, for feared he would wake up dead.  We grinned wryly, and promised not to let that happen, though it did–everything but the waking up.  I was raising my hand and volunteering to do  just that, walking back in through the gray and damp parking entrance to UCLA.

Coming out the second week with equal blank spaces and some low blood pressure “events”, I was still alive, and could plan for my CT scan.  Back to the same place where they had first found and failed to tell me of the lung mets, and let them try again to “image” them.  (Is image now officially a verb?) One thing remained in my brain, and that was the knowledge of how to get the report from the CT scan done two weeks plus into my rest period after week two.

My son drove me to the scan center, as I was oddly not thought to be capable of going there myself, such a smart family, and parked as I rushed to collect the report.  It was at the desk, as promised, and I tore open the envelope, and pulled up the last few sentences of the report into view.  “Significant decrease in size of multiple pulmonary nodules!”

And back for more Proleukin.  And a cake that I ordered for myself, which read (Charlotte’s Web alert) “Zuckerman’s Famous Peg…Amazing.”

 

 

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Drug Interactions; Don’t Be Surprised!

At a City of Hope Medical Center, teaching hospital/research center, a pharmacist spoke to our patient group about drug interaction.  She reminded us that we are responsible to follow the dosages, to alert our doctors to ALL the medications we take–prescribed and over the counter, herbals and supplements. “Remember that diet and its fat content affect our drug’s efficacy”, she added.

 Pharmacists consider three types of interactions, which can happen between drug and another, with drugs and food or beverages, and drugs and conditions under which a drug is taken.  They are described as follows:

 1)     Pharmokinectic issues of absorption, distribution, metabolic and excretion—how does the body bring it in, how long is it in the system, and where does it get absorbed?  Does one drug slow down the effect, or prevent its use?

2)     Pharmocodynamic effects occur when drugs with similar properties to one another are used together.  They may interact with one another; such interactions might cause one or more to be ineffective, or too effective, or with side effects that are unexpected.

3)     Toxicity may happen if the combinations of drugs have a toxic effect on an organ that would not occur with just one of the drugs. 

For example, soranfenib (Nexavar) should be taken without food, while Sutent is recommended to be taken with food—but never with grapefruit juice. 

 Some drugs cannot be taken with NSAIDS; some are platelet inhibitors, for example.  Sutent’s efficacy may be impaired by taking St. John’s wort, or when taken with barbiturates.

 How do you keep track of all of this?  Speak with the pharmacist whenever you have a change in medication—or right now, since you probably have not done that! Make an appointment to have the time cover all the questions. Bring in ALL the medications you use, even those you feel are “probably” safe or those you are embarrassed to admit you take!  Pharmacists have access to extensive data bases, not only of the prescribed drugs, but also many of the supplements and herbals on the market.

 As to herbals and supplements, she reminded the group that there are no controls as to the quality and quantity of active ingredients in the non-FDA approved supplements, and they can vary dramatically. Meningitis caused by a fungus in steroids produced by a US-company has caused the death of 44 and sickened at least 600 just last year.   

It was fascinating to hear that, “Pharmacists don’t take medications”, but she emphasized that she rarely uses anything. It’s harder to convince her mother! Anticipating problems in the future with family-related conditions, she eats properly and exercises, for example. 

Trust your gut about your body’s reactions.  If something seems amiss, talk to your pharmacist or doctor to be sure you are not having a drug interaction.

Read the labels and follow the instructions.  Not sure when and how much to take? Go back to the pharmacist or doctor for clear instructions.

 Bring a “brown bag” of meds and such to your pharmacist to get a review of your meds. You know you should have already done this, so get going!

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Immune therapy in a Clinical Trial of Anti-PD-1 It Can be Good to be Anti

Dr. Suzanne Topalian, professor of surgery and oncology at Johns Hopkins Sydney Kimmel Cancer Center presented a paper at a recent ASCO meeting which caused quite a stir in the kidney cancer community.  Her short talk is in the link below, with the transcription to follow.Topalian and Title

What’s the good news about being anti?  The complex interplay of our immune system and the manner by which cancer escapes its notice is a challenge to the researchers, but this trial shows that there are many ways to interrupt the growth of cancer cells.  This trial and another mentioned offer new hope to patients who have already exhausted earlier options.

Not only did this trial show that this drug could provide relief to some patients with kidney cancer, lung cancer and melanoma, the presence of this anti-body may serve as a biomarker, and may predict which patients might respond to the drug treatment.  Another step forward and more hope for all of us.

Anti PD-1 (BMS-936558, MDX-1106)

http://www.youtube.com/watch?v=Ij_hq_52K7M

Today I would like to describe do the clinical activity the safety and potential biomarker of clinical response to the drug PD-1, which is an anti-body therapy. PD-1 or Programmed Death-1 is a molecule that is expressed on the surface of activated immune cells it plays a very important role in suppressing the tumor by suppressing antitumor immunity.

1 role of PD-1 in suppressing antitumor immunity

In order to understand how anti-PD one works you need to understand a little bit how the immune system works, and how it can fight cancer. T-cells are a central cell type in the immune system that fight cancer. T cell function is regulated by two different signals. Signal one is a specificity signal, whereby the T cell recognizes its target and here we are talking about the targets being components of tumor Cell., but then you need a second signal to tell, the T Cells what to do, a regulatory signals.  That signal can be either positive or negative.

If the signal is positive or stimulatory,  t he T-cells become activated. They secrete cytokines. They can kill tumor cells. They proliferate; they percolate throughout the body, seeking out and destroying tumor cells.  All of that is what we want to see.

But after activation, T-cells naturally begin to express the molecule PD-1 on their surface. This is will turn the T-cells off.  If they encounter the partner molecule PD-L1 or PD ligand 1, tumors cells can express PD-L1. So the interaction between these two molecules becomes a protective shield, that shields the molecule from immune attack. Even if the T-cell can recognize the tumor and they can get to the tumor, once they get there and they are expressing PD-1, if the tumor is expressing PD-L 1, the T-cells will be turned off. The anti-PD-1 antibody is a blocking antibody to PD-1. It interrupts this interaction and functions to rescue exhausted T-cells and to enhance anti- tumor immunity.

The phase 1 trial of anti-PD-1 that I’m describing today is a multi-dose regimen in which something is given the outpatient in the outpatient clinic once every two weeks. Patients were treated for a cycle of four treatments over eight weeks. At the end of which, they were restaged. Patients were eligible for these trials if they had advanced metastatic melanoma, kidney cancer, lung cancer, prostate cancer, colorectal cancer with progressive disease after having had at least one prior systemic therapy.

But they were allowed to have up to five of the therapies. Generally these patients who came on this trial had good performance tab status. But they were heavily pre-treated. Approximately half of them had at least three prior therapies be before they came onto the trial.

After the first cycle of treatment if patients had rapid continuation of disease or clinical deterioration, they went off study. If they had unacceptable side effects, the patient remained on study. They did not receive any more drug, but they continued under observation. If the patient demonstrated tumor regression or stable disease or even if they  had some progressive disease, but were clinically stable, we continued to treat those patients until we saw confirmed Complete response, worsening or progressive disease or unacceptable toxicity.  We could treat patients on this trial continuously for two years. After, they went into a follow up phase.

3 BMS-936558 related Adverse Events Here I’m showing you the drug-related adverse events are side effects that occurred in at least 5% of 296 patients which was the total patient population on this trial You can see that serious side effects were encountered in 14% of the patients. The most common side effects are listed here (fatigue, rash diarrhea, pruritis, etc.) There other side effects that are not listed here because they occurred less frequently. Many of the side effects were consisted with the side effects with over immune related causality as you might expected if you release the brakes on immune responses. As we are seeing anti tumor responses, you might also see immune-related sided effects.

We did see three treatment related deaths on this study. This was in 1% of the patient population due to pneumonitis, or lung inflammation which we’ve believe has an immune-related etiology. Over the course of time we developed better ways to identify people who are at risk for the side effect and also better ways to detect it early on and to treat it aggressively.

Also note that only 5% of all patients treated on this trial had to discontinue treatment, due to related side effects so in general the treatment was well tolerated in an outpatient setting, and in general the side effects were manageable.

4 Clinical Activity of BMS-9356558

This is showing the clinical activity of anti-PD-1 antibody in three different types of cancer across a wide range of doses. (Showing doses (mg/kg) of 0.1-10 for melanoma, 1-10 for lung cancer, and 1 or 10 in RCC). The largest number of patients in this treatment population of 236 patients who had at least six months of follow-up were 94 with melanoma.  We had 26 patients (28%) who had objective responses. An objective response means either a complete response or a significant partial regression of cancer.

We also saw stable disease that lasted at least six months in another 6% of patients. Among lung cancer patients we saw patients with squamous as well as non-squamous subtypes we saw a CR plus PR of 18%, and with a patient population of 76 and again 6% with stable disease, with another group of patients with stable disease (referencing 7% of lung cancer patients.)

Finally in kidney cancer (33 patients), 27% had a response rate and 27% who had prolonged stable disease.  There were 31 patients on this trial who had a response that occurred at least one year ago and among those 31 patients, two thirds of them had a response that persisted for more than one year. One of the remarkable features about this therapy is that it can induce very durable responses in otherwise treatment-refractory patients with advanced disease.  We did not reserve any objective responses in 19 colon cancer patients or 13 prostate cancer patients.

Finally I’d like to draw your attention to a possible molecular marker that would allow us to predict which patients are most likely to respond to therapy.

In a subset of 42 patients on this trial, we examined pre-treatment tumor biopsies for presence of PD-L1—and again this is the partner molecule to the PD-1 that is expressed on tumor cells. What we found was a correlation between the expression of PDL-1 on tumor cells and here I am showing you the pre-treatment staining biopsies.

I am showing you with its ringed expression an example of melanoma, kidney and cancer in a sample of lung cancer. When we saw this kind of expression in that group of patients we had a 36% objective response rate.  If we did not see that expression on the surface of tumor cells we did not had no responders. I would stress that these are very preliminary data but give us an important lead for further investigations and potential biomarker development.

In conclusion anti-PD-1 antibody–BMS 936558– can be administered safely in an outpatient setting for heavily pretreated patients with durable clinical benefit for patients with lung cancer, melanoma and kidney cancer.

6 Conclusions

These results will be released tomorrow, as you know in the New England Journal of Medicine, which is under embargo until early tomorrow morning. At the same time in the New England Journal, there’s a companion paper with the blocking antibody against PDL-1. The lead author of that paper here is Dr. Julie Braemar of Johns Hopkins and shall be available to answer questions at the end of session.

We found responses also in melanoma and lung cancer and kidney cancer with a blocking antibody against PD-L1, so we feel these two studies are in a sense bookends to point up the point the importance of the PD-1 pathway in cancer therapy across multiple histologies.

The preliminary data correlating PDL-1 expression in pretreatment tumor biopsies with outcomes needs to be further explored and that’s an area of active investigation.  Finally controlled clinical registration trials of this drug with patients with the three types of cancer that seem to respond are planned. Thank you for your attention.

 

 

 

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Filed under Biological Systemic, Clinical Trials, Immune Therapies Old & New

Immunotherapy: A Trial by “Flu-Like Symptoms” and a Lot More

When I was diagnosed with Stage IV kidney cancer, I just assumed that the doctor would take some sort of medically-approved SMALL melon baller, scoop out the bad stuff, and send me on my way, never to sin/cancer again.  That was my first plan, and one which couldn’t be.

First of all, there is no medical melon baller, and certainly not for a tumor the size of a big orange.  No tiny key hole scar for me, but a large incision, and the removal of my tumor, my kidney, an adrenal gland, and  a few local lymph nodes for good measure. Though the scan seemed to indicate that the tumor was scrambling up my vena cava, a big vein heading toward the heart, the scan was more ambitious than the tumor.  The pathology confirmed that my cancer was “clear cell”, which was good, as it is the most common subtype of kidney cancer.

Bad news.  There were hundreds of tiny mets all over my lungs,  the CT scan showing tiny evil snowflakes throughout my lungs. “Too numerous to count”. Impossible to remove by surgery or radiation. Systemic metastatic disease–very bad stuff– and the reality that  visible mets were outnumbered by the tinier ones still unseen in a CT scan.  Only one medication was approved for advanced kidney cancer in 2004. It didn’t really work for many people, maybe just 7%, according to the clinical trials that had led to its approval 12 years earlier.

This treatment was High Dose InterLeukin 2, brand name Proleukin.  No one else seemed to have ever heard of it> When I asked if they had heard of  “interferon”, most people nodded politely.  That’s how much general awareness there is of the life-saving regimen recommended to me.  Most doctors and few oncologist have never seen a patient in treatment with it.  Not the popular choice–but none other treatments existed!

Statistically, the odds for a good response were pitiful, but so were the odds for my getting kidney cancer in the first place.  The “Why me?”s became “Why not me?  Someone has to be in the 7%!”.   I talked to a patient who had gone through the treatment. She described it as “Hell”. I winced visibly, and she nodded in sympathy.  Still she was alive and at a meeting. Given the chance, she said she would do it again!   Thank you, Paula, for your courage.

Proleukin is essentially a synthetic version of your body’s immune system reaction protein. Thus, the patient reacts with a wide range of immune responses–all in hopes of revving up the immune system so that it recognizes and fight off the cancer cells. Those cells have escaped detection by the immune system, disguised as “evil twins” of the healthy cells.  If the Proleukin could empower the immune system to be super sensitive and aggressive in finding the tumor cells, maybe the cancer would be destroyed.

This is not traditional chemotherapy, in which all the cells are targeted for destruction, with the fastest-growing ones–the cancer cells–being the most vulnerable.  Chemo patients are bombarded again and again, in a delicate balance between killing the cancer cells and keeping the others and the patient intact.  Many people stay on chemo for months and months. But no chemo ever worked for my cancer.

My treatment was to happen in five-day spurts, offset by days and home to recover and then to return.  Roughly, I was to be in the hospital one week, out a week, back in for a week, and then rest and await the verdict delivered by a CT scan.  Good news meant I could be permitted to return for another set of treatments.  Bad news–go home and look for another clinical trial and…no one wanted to speak of it.

My mets were shown to be fast-growing after a series of CTs , so even  stabilization of  growth would be considered ample reason to return to the hospital. ” Just slow them down”, I prayed, “Let me back in the hospital.” Determined that even if the doctor could not whole-heartedly recommend it, I would go back for more.  Of course, that was before I had the Proleukin and understood what would happen.

Had Proleukin not been effective for me, I would not be writing this. Still I have little independent knowledge of all that I endured during the treatment.  My family usually says that I am happier not knowing, that it was brutal, that it took me to the edge of life.  No wonder they don’t want to talk about it.  But I was in a excellent hospital, with experienced staff, having been considered to be healthy enough to get through the treatments, and determined to live, what ever it took.

This medication is delivered by IV, through a port which led a tube straight into my heart, a channel to get that and all other meds to me as quickly as necessary.  Doses are given every eight hours, unless the patient is unable to tolerate the next dose, needing to recover from the reactions to the previous.  Over the five day period, a patient might get 14 doses, though few ever do.  In my case, I received an average of nine doses per week, and my length of day was twice extendedby a day, so that I could recover before I was sent home to recover some more.

I remember arriving home, rather suddenly, it seemed. No memory of the drive, just a vague recollection of  walking down the hospital corridor with a doctor and trying to read a sign.  Apparently that was a bit of a test, which I passed, because I was home.  Home–to recover and praying do it all over again.

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Filed under About Peggy, Biological Systemic, Immune Therapies Old & New

Systemic Targeted Therapy for metastatic RCC in 2012

Dr. Eric Jonasch of MD Anderson Cancer Center gave the following talk at a KCA patient conference in April 2012.  “Systemic Targeted Therapies” include a group of drugs, all approved by the FDA in .  the last six years.  These drugs mark a critical breakthrough in providing more options for kidney cancer patients, and their use and complete integration into treatment is still ongoing.

(Where good slides were available, they were used; those which were hard to read have been recreated.)

I am going to talk as systemic targeted therapy for Metastatic Renal Cell Cancer, how we are using it, and the science about it, and how that leads us to new ideas, moving forward.  When we talk about kidney cancer, we cannot talk about just one disease type.  What I am going to talk about mainly is clear cell, and Dr. Tannir, my friend and colleague, is going to talk about the non-clear cell subtypes.

So what is ccRCC?  It is essentially a cancer that looks like this under a microscope, and it was called this, back in the day.  We more recently found that it has a mutation in the VHL gene (Von Hippel Lindau) in the vast majority of individuals with and I also run a clinic where I try to marry the information we have about hereditary kidney cancer with non-hereditary kidney cancer to improved therapies.

This is not to scale; it is 213 amino acids long and for the scientists in the audience, that is mercifully short, and it also has three exons in or three parts, or easier to study than most, but obviously still hard to study.

It essentially regulates how the cell reacts to oxygen.  Obviously, oxygen is our life’s blood, we need oxygen, we need water, we need glucose.  And our cells, if they feel like they need oxygen, they basically sit back and VHL will then take the transcription factor, which tells the cell which protein to generate, and then it breaks it down.  If you have low oxygen state, then the cell will say, “Help, I need oxygen” and the VHL will step back,  the transcription factors, HIF alpha and HIF beta are going to come together and you will get production of proteins, like VEGF which is a growth factor for blood vessels and some other things.  If you have a mutation or something how an inactivation of the VHL gene, you have essentially an ongoing process of these cells, now cancerous, saying—somewhat untruthfully—we need more oxygen, we need more blood, build me an infrastructure.

That infrastructure is as follows:  When we think of cancer we can’t think of cancer cells. The cancer cells are in black on slide and in blue are the stromal cells–the “glue” cells, and above those the endothelial cells or blood vessel cells.  This triumvirate plus other cells generate an organ—and it really is an organ—that we call cancer.  And when we use therapies, we are blocking specific areas there.

I’ll tell you a bit about the therapies we use now and that some of you are on, and what they are actually blocking.

Here is some terminology you are about to hear, some jargon, as we talk about trials.

Progression free survival (PFS)—time it takes for cancer to start growing again

Overall Survival (OS)—time it takes from start of treatment to passing of patients

So the “blood vessel starving” are the antiangiogentic therapies we currently have are listed here, and I am going to go through each of these in details.

Antiagiogentic Agents FDA Approved

1. Sunitinib  (Sutent)

2. Pazopanib (Votrient)

3.  Bevacizumab- IFN (Avastin + Interferon)

4.  Sorafenib (Nexavar)

5.  Axitinib (Inlyta)

mTOR Inhibitors   Mammalian Target of Rapamyin Inhibitors

6.  Temsirolimus (Torisel)

7.  Everolimus (Afinitor)

We also have some up and coming drugs.  And the way these drugs work with graphic shown again—is they block the blood vessels. They try to kill the blood vessels that feed the cancer.  They don’t seem to have much effect on the cancer itself.  That is why you have encountered resistance. That we can shrink this down, this cancer, but we can’t make it go away.  And what we need, and on our wish list, are kidney cancer cell-killing therapies for the future.

mTOR Inhibitors

The mTOR inhibitors, of which there are two, Torisel and Afinitor ( Temsirolimus and Everolimus).  What they do; they are actually working inside the cell perhaps both in the cancer cell and the  blood vessel cell.  And they are blocking particular proteins that seem to be up regulated, overexcited, that give them a selective growth advantage.

There we have on the bottom, kind of a brown color, mTOR, which if up regulated, results in production of and more survival advantage… for the cancer cells—which is shouldn’t have.  What Torisel and Afinitor is block that signal.

So let’s talk about the drugs that in 2012 were currently using.  The one that is probably most commonly used is Sutent or Sunitinib.  It this is a pill and what is does the block those blood vessel cells.  It doesn’t seem to block the cancer cells that much.  It’s given officially 4 weeks on, 2 weeks off, although I don’t remember the last time I prescribed that way for anyone.  I tend to start 2 weeks on, 1 week off as I find people tolerate it better that way, and its FDA-approved now since January of 2006, amazingly, a long time ago.  But it is pretty amazing that we have some people who are still on it, starting in January of 2006. 

The reason this drug was approved, it was compared to the old standard of Interferon. What we found saw was a prolongation of Progression Free survival, the time it took for the cancer to progress.  And this was doubled to 11 months from five months, with Interferon, which some of you might remember as shot you give under the skin, three times a week.  And the top line is where the individual were progressing, where they were on Sutent, and the lower line is where people were progressing on Interferon.

This is what is now call the Overall Survival curves, so essentially what we have here on the bottom is TIME, and the top lines the individuals that are still alive, and what we see on the top line are those on Sutent, and the lower line those on Interferon.  It may not look like a huge gap, but what has happened on these research studies, when we do them, is what we call “cross-over”.  When you progress on one of the drugs, you get to another and another and another.  And the good news about this, it that it raises up the survival expectations to some degree, but it makes it hard to say, “That one drug is the one that is really making the difference.”  Until we actually get therapies that consistently and reliably cure kidney cancer, we will still  have this dilemma of having incremental benefits, but, “Hey, we’ll take them!”

Another drug which has come out and has been used since 2009 is Pazopanib or Votrient.  It’s an oral drug, given daily, once a day.  Same sort of thing, a blood vessel blocking agent.

This was tested in a slightly interesting as you have study where you had no therapy before, or you had immune therapy, and they were randomized, randomly allocated between the Votrient (Pazopanib) or placebo.  I have to say that most of the people were enrolled in non-US sites because it is a little bit of a hard-sell for people, if you have not had any therapy before to be told we’re going to put you on placebo, maybe.

Nevertheless, the trial was accrued to and it demonstrated a very significant progression free survival, the time to progression of the disease for the individuals on the Votrient compared to those on the placebo.  And what we see on the left hand side here, we see one of these showing the charts, with the orange line on top is the group (with Votrient, )people who remained free of progression over time, and the lower line, the people on placebo. And the progression free survival data for the people who had not been on prior therapy was as good as we had seen with Sutent.

We had a trial that is currently completed and is being analyzed to see if Sutent is better than Votrient, and we still don’t know which is “better”, but Votrient is certainly gaining traction because of the fact that it looks kind of promising.

Now its interesting when they did Overall Survival analysis, they did not succeed in showing a big difference, because as lot of people had gotten onto Votrient when they were on placebo at the beginning, and they got onto all sorts of other drugs.

So the next drug we are going to talk about is a little different (Avastin).  What Avastin is –it’s an injectible antibody against the thing the cancer produces, the VEGF circulating in the circulation.  It tries to take it out of circulation, so the blood vessel cells can’t see  it.  It’s given every two weeks, by injection, and officially given with interferon three times a week, so a little less attractive for some people.

This is a bit messy to read; the progression free survival in combination with interferon is substantially better than interferon alone, and this was done to two different studies and the data were true in both these big studies.

Thus we’re pretty confident, that along with Sutent, and Votrient, this prolongs progression free survival.

In terms of overall survival, 21 month for the interferon group, and next to it the interferon and Bevacizumab, 23 months.  Again, in the same ball park as we were seeing with Votrient and Sutent, and not a statistically different figure.  That statisticians take these numbers and crunch them and take p values and such, but still there was a lot of cross over data, and clearly, we are moving up the bar here.

One of my favorite data pieces is from the Sutent study. The patients on that Sutent study who had received Sutent or interferon were treated in countries where there was no opportunity for second line therapies or 3rd.  All they got was Sutent or interferon.  And the people who were on the sutent arm only, and nothing else, had a 28 month survival, and the people who received interferon only, had a 14 month survival.  So that’s an untarnished bit of data, showing the magnitude of benefit that they were receiving.  That is more reflective of what we are seeing in our clinics today.

I wont’ go into this in detail, but bottom line is that. There’s a lot of number and you are probably getting numbered out.  Bottom line we look at historical data compared to these people who are on these drugs and then get subsequent drugs, and we are seeing survival in the two to three to four years.Also known as Nexavar

The next drug we are going to discuss is Nexavar, which was approved in 2005, the first of these drugs to be approved.  Same deal, the blood vessel starving drug, given twice a day, orally.

It was given initially to people who had not been given any targeted therapies before, but had progressed on immunotherapy  and it demonstrated that there was an improvement in progression free survival again. 

If you looked at Overall Survival there was improvement if you took out those people who crossed over.  So again, modest improvements and definitely doing something for patients.

Now when this drug was compared directly to the untreated patient group to interferon, what was happening, was that it did not look like it was better than interferon alone. I just finished telling you that Sutent, Avastin, Votrient all beat interferon, and here we have a drug, that seemingly, didn’t.  Subsequent studies were done which shows that PFS is somewhat better than this trial, but in reality in 2012, this drug is not much used in front-line therapy, for better or worse.  It’s not that commonly used, and personally don’t use it much, based on these data.

What I have been talking about now, has been about individuals who have clear cell RCC, good risk features, and these are features looking at “are you anemic?, is your calcium elevated?, are you feeling and so on.”  These are risk features to decide if a patient is in a good or intermediate risk category versus a not so good category.

 

And Torisel, an mTor inhibitor, which I talked about before, and was tested in this poorer risk population of patients, and was approved in 2007.  Essentially, they took patients who had not had any prior therapies, and they checked off boxes. Do you have a low performance status?, your “good feelingness”, have you had your kidney removed before or not?, have you had anemia?, have you had high calcium?, have you had high LDH?, six categories in all.  If you had at least three of those negative categories, they said, “OK, we’re going to put you on Torisel, and compare you with interferon and with Torisel and interferon in combinations.” And because they know this group of individuals tends to have a lower overall survival, they did an overall survival study.

 

It is a bit difficult to see in the background, but bottom line, that this was the first drug that showed in poor risk patients, that it improved overall survival, compared to interferon.  Does that mean Torisel is good for people who  have good risk features? Those who don’t have overall poor risk factors?  Unfortunately, we don’t have an answer to that since that study has not been done.  But this drug was approved, and we know that Torisel seems to provide benefit for patients with the poorest features.

SLIDE MAY BE MISSING

Does that mean that Torisel shouldn’t be used in a second line treatment where people have clear cell?  No, it doesn’t.  It simply means that those are the data that we have, and in the second, and third and fourth line setting—except for the data I am now going to present—we just have to figure out. “You’ve been on this, we’ve tried that, now let’s try this.”  There’s a certain amount of art to it, as well as science.Also known as Afinitor

Afinitor was approved in 2009 for individual who had received either sutent, sorafenbit or both.  This was a study that asked, “Have you progressed on Sutent or Nexavar?”

If yes, you were entered into the trial, randomized,ie the computer flipped a coin so that you went into the Afinitor or placebo, and we asked, “What was the progression free survival?”

This was clearly better in terms of progression free survival. And that’s why the drug was approved, and it is one of the most commonly used drugs in the second or third line for patients with metastatic kidney cancer.

The new kid on the block is Axitinib or Inlyta, in the second line setting.  Dr. Brian Rini presented these data last year, looking at this, another blood-vessel starving drug.  It’s the next generation, it’s more highly engineered to block more of the VEGF pathways, and it does less of the other stuff, which in some ways might be better, but you might want to have some “playing the field” in terms of stopping things in comparison of blocking one thing.  So what did this data show?

This is the study.  People had previously received one of these prior drugs, Sunitinib, Bevacizumab, interferon, Temsirolimus or Cytokine, and then they looked at the progression free survival.

The progression free survival was longer in the Inlyta(Axitinib) group compared to the Nexavar (Sorafenib), about 6.7 months versus 4.7 months. 

What was interesting, was this was a group of individual who had receive either these targeted drugs before or immune therapy, and it shows it nicely in table form, but what it shows is that if you had received prior immune therapy, the Axitinib or Inlyta was way better than the Nexavar.  If you had received prior targeted therapy, in the same class as Inlyta, then the differences were not that great.  Then it’s better, the Nexavar is better in people previously treated with Sutent, for example, but its not incredibly better, but it’s a clean drug, and it’s very welcome addition to the drugs we have available.  So we are using it and getting good results.

Up and comers.  For the last few minutes we will show Tivozanib, another one of these blood vessel starving drugs.  So we have 1,2,3,4,5, and now six of the same class, and like other classes of drugs, it is always good to have gradual improvement.  It is in a pill form, same sort of thing, blocking VEGF pathways.  There were some combinations, a phase III trial, showing that it does actually do better than Nexavar it was compared to, and is coming down the pipeline, probably an approved drug in the next year.

It is interesting that with all of these drugs, that the newer the drug, the lower the side effect profile as they are getting better and better at engineering these drugs, so at least we are getting a better drug in this class arena.  But it is not dramatically better, and we need something better.

Combinations and Sequences

 So what about combinations?  In oncology, we like to do this, combine drugs.  If you have drug A and that works and you have drug B and that works, then let’s combine it and hope we get a duplicative effect, and additive effect.  Hasn’t really happened unfortunately.

Bottom line.  Combinations at that time have not really consistently been shown to be superior to single agents. You get more side effects and you don’t get more bang for the buck in terms of survival or progression.  Sequencing is really what we do, meaning you start with drug A and move to drug B, you move on to drug C.  That’s what we do in the clinic.  One of the trials that Dr. Tannir has championed is the START trial and we have 80-90 patients on this.

We re looking at, if you start with Nexavar or Votrient or Avastin,  and you get randomized to one of the remaining drugs, does that provide you better benefit?

And there are other trials ongoing like that, the SWITCH trial, for example, going on in Europe, starting with Nexavar, then going to Sutent, or starting with Sutent and going on to Nexavar.

Or the RECORD 3 trial, with Afinitor followed by Sutent, or Sutent followed by Afinitor. We’re trying to figure out whether that works better for some patients than others.

This is a big table put up my former mentor Dr. Michael Atkins, a form thereof in 2006, and its been a gradually refined over the years.  Bottom line is we have favorite drugs for untreated patients in the first line setting.  We talked about immunotherapy before lunch, with Dr. McDermott talked about interleukin 2 and others, we have our blood vessel-starving drugs for that category as well.  People with poor risk features, we have Torisel.

In the second line setting we now have good data from these trials that show that Afinitor and Axitinib probably provide benefit after failing these other drugs, and we have ongoing studies to try to determine whether or not one sequence is better than another. All this is nice, and we’re making real strides, but what do we really need to do?

Coming back to the picture of the cancer, we are good at hitting the red part, (the blood vessel structure), but why, when they get used, are we getting resistance after 10-12 months or so.  Why can’t we kill the cancer cells?

We need new drugs that can block other receptors in those blood vessels cells.  We need agents that can actually fix, look under the hood of the cancer cell, see what is misbehaving there, fiddle with it, and make it act more like a normal cell.  If we can’t do that, kill the cancer cell.  Agents that can actually block novel targets in the blood vessels, so we are looking at new receptors on there, and seeing if those drugs, in combinations with other drugs, can starve the blood vessels, are useful.

I am part of a nano-medicine grant, where the hypothesis is that, the big idea, is that a lot of the VHL proteins are mutated, are kind of wounded, but not dead.  If we can revive them, maybe they can make the cancer cell behave more normally.  One of the ways to do that, to raise the level of VHL, is with a drug called Carfilzomib to validate that.

MET Inhibitors

The last thing is those agents that can actually kill the cancer.  This is amazingly, in 2012, still in the experimental stages. We have a colleague in Stanford, Imato Jatia(?) who has done some of these screens, some people at Harvard, all around the country, and we as well, looking at this strategy, where the cell kills itself.  We have go to perhaps stop focusing as much as getting as yet another blood vessel-starving pill.  An example of one of these drugs that might do this, is a MET inhibitor.  So, a MET is another protein that is found on the surface of the Cancer cell.  There were some reports at ASCO that this might a promising avenue.

So in summary, we are getting really good at blocking VEGF pathway, we’ve made real inroad in Overall Survival.  MTOR inhibitors are doing a good job; we kind of know where to use these, but we are getting better at it.  We have got to figure out why resistance occurs, and do something about it.  Participation in clinical trials is key.  We need to find drugs that kill the cancer cell directly.

QED

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Filed under RCC Basics, Targeted Therapies, Your Role