Saturday, August 29, 2015

What to say and do....and NOT!!...for a cancer FRIEND (not patient)!

I have been asked about this a few times....and thought about it a LOT!!!  I don't think any one person can speak for everyone, nor be an expert on what any other person would like, feel or think....but here are my thoughts:

Do NOT ask "How are you feeling?"   Sounds benign, right?  IT ISN'T!!!!  The answer you will most likely be given is, "Fine."  And once you hear that, you haven't really learned anything, have you?  The truth is far more likely to be, "Like utter shit, left out on a hot day, to steam into a lovely confluence of horror filled with flies!!!"  OR.... "Frightened out of my mind.  I don't know what to do. I don't know what is going to happen to me, my family, or my life.  I feel literally scared to death, except cancer will probably kill me first!"  Now...if you were to get either of those HONEST answers....what are you going to do with that?  Better to be real and specific.  If you are, you will get a more meaningful answer and show you really do care.  Examples:  "Is your surgery site causing you too much pain?"  "Have you had any bad flares of your arthralgias?"  Keep it pertinent to what your cancer FRIEND (NOT cancer PATIENT) has already told you.  And, whatever they answer....  If negative, meaning they are still experiencing pain or other difficulties....say, "Oh, I am so sorry."  If they are feeling better...say, "Oh, I am glad!!"  Either way:  MEAN IT!  BEST:  If you really want to know how your friend is feeling emotionally, ask that...specifically!  "Are you feeling afraid?"  "What is worrying you the most?" Expect that they may not answer....because they may feel that to admit fear or negative thoughts would frighten you or indicate weakness.  But, they may give you an answer that will hurt your heart.  Whatever it is, you can not fix it!  You CAN hold their hand and let them say it.

Do NOT say:  "Have you tried prayer?  ...more vegetables?  ....this diet?  ...that cream?"  All of those options are highly unlikely to cure your friend's cancer and imply that they either did something wrong or inadequately to get cancer in the first place or are not doing the right things to get rid of it now!!! Better:  Ask what your friend has been advised by their doctor or where they are in their workup process.  This way, you seem interested, in tune, and can learn how to help your friend by understanding where they are in the madness that is cancer treatment.

Do NOT say:  "It could be worse." Well maybe so, but seriously???????

Do NOT say:  "I know just how you feel."   No you don't.  Even if you have had cancer yourself.  You DO NOT know how your cancer friend feels!

Do NOT say:  "Think positive..."  OR:  "Put your faith in God...."  "....and you'll be fine."  If you are saying these things to your friend...they were probably already a positive believer.  They still got cancer.  Their faith and positivity did not protect them.  Further, amazing folks with the most positive spirits and trust in God die of cancer everyday.  I know, you mean well...don't know what else to say...and your friend probably will, too....but I'm telling you what they are, just DON'T!

When you are lucky enough to coax your cancer friend to tell you their treatment plans or options.... Do NOT say:  "Oh goodness! I just don't understand that stuff!"  Never, never, say that.  EVER!  Because, about 10 minutes ago, your friend probably didn't "understand that stuff" either!!!!  If you really care, you can learn!  The Internet is an amazing tool and you CAN learn what you need to help your friend.   My sister, Ruthie, I learned sometime after the fact, sat with a medical dictionary when she first learned of my diagnosis and treatment options until the things she read, or that I sent her, made sense.  If you really don't think you can learn or understand what your friend is sharing with you....keep it to yourself!  Say instead:  "You are so amazing!  Dealing with all of this and working so hard to learn all this new information.  I am impressed." Better:  Do your homework.  If your friend can learn what they need to, so can you.  EVEN better:  Some cancer friends really do NOT understand their diagnosis and treatment options.  HELP THEM!!!!  Find resources and support groups.  Learn what you need to yourself and share with your friend.  Go to doctor appointments with them to help them listen, understand, and remember what was said. When you are the patient - emotions and pain and fear make comprehension and the ability to remember all that the doctor said very difficult.  Even with fairly good health and my background in medicine, I had trouble keeping it all straight!  Not having B or Ruthie there to help me at appointments would have left me very confused!

Do NOT say:  "You don't look sick."  While that may seem nice, it is also very strange to hear (and even see in the mirror) when you are dealing with a cancer diagnosis.  If your friend thinks you are a nice person, deep down, they will think you just aren't thinking and are trying to give them a compliment.  Else wise, they are going to think you are not appreciating their reality at all!  BETTER:  "You look pretty (handsome) today."  Because when your cancer friend really doesn't LOOK sick, they still FEEL that they are damaged goods.  Their body probably has scars that they do NOT think are lovely, even if YOU and the world in general can't see them.  They know aberrant cells may well be running rampant in their body and that is NOT the picture of health!

My best advice for you to help your cancer friend:  

Listen.  Yep.  Just be quiet, hold their hand, and LISTEN!

Give a hug.  An easy way to say a lot of nice stuff without having to speak at all!

Make plans for fun stuff THEY like.  Friend likes to garden, but is too sick and tired to do it themselves?  Pull up a chair in the shade and have them watch, supervise, and chat while YOU do the weeding.  Friend likes to read? Read to them.  Scary thoughts, pain killers, pain itself, can make focusing on the written word hard for even the most ardent reader.  Trust me, I thought after all my many surgeries..."Well...I'll just catch up on my reading."  Nope.  Not an option like I thought it would be...but almost all readers love to HEAR the words, even when we are not feeling our best.  Friend is a movie fanatic?  Rent a movie, bring popcorn, a comfy blanket and curl up on the couch with them and their favorite flic.  See????

Help!  Really, actually help.  Double a recipe when you are cooking your own dinner and bring it over ready to eat or freeze for later.  When at the grocery, call and say...."I'm already here, the strawberries look nice.  What else can I pick up for you?"  Mow their grass.  Clean their house.  If you can afford it, hire a maid service for them.  Arrange to take their kids to soccer practice, dance, or just to the park.  Parents with cancer feel like the biggest schmucks ever.  IS there a bigger burden to put on your kid?  NO!  Help them out.  Help them keep the lives of their kids as normal as possible.  THAT'S what they want....believe me!

Find the fun.  This one is not easy.  And you have to take the lead from your cancer friend.  But, when you can laugh with your friend, you have really done something.  Laughing at the crazy nuts you deal with in cancer care is essential.  The circumstances are often demeaning and ludicrous.  If you make your friend smile, you have given a gift that is unparalleled.  I still smile when I remember the pic a friend and fellow nurse of mine (Loooove you, Tammy B!!!) sent me of herself ON the potty (No!  I saw no parts, but I knew the room, the wall paper, the level of her head) while at work when I was getting injections and infusions miles away!  Not saying that would be the best thing to send to YOUR friend, but it worked for me!!!

Find a code, an inside joke or story....that builds camaraderie around what is now part of you AND your friend.  You know how close friends and family have stories about..."That time when....."  You know what I mean?  How when you have spent time and love and laughter with a dear can just say one word...with a little look...and the whole story is clear...and you will both break into laughter or tears?  Well, the cancer experience needs that, too.  It is hard to predict how it will come about...but use it once it's there!

In my life and then cancer story, the issue of "HOPE" was a big deal.  Rosie used it via the dragonfly, the last thing to escape Pandora's box...hope flies on dragonfly tell and share her side of the cancer story.  The dragonfly is now a touchstone, signifying hope and love, for many of those dear to me.

Brent found a sweet and touching way to deal with and mark off my treatments as they were completed, especially when he could not travel with me to get them.  PIE!  Frozen apple pie, that he would reheat in the oven just before I got home....carefully cutting away the appropriate amount, but leaving "1/2 DONE!" or "3/4 DONE!" as we made it though.  Ruthie and I came to depend on those to light our way to progress.

Ruthie saved up stories of her week to tell me while I was getting noxious take my mind off the pain and misery.  Sometimes she even had notes!  Her boys would even contribute..."Hey, Mom!  Tell Aunt Celeste about....."  It was wonderful.

We made up somewhat terrible names for hospital, airline, hotel, and car rental personnel.  Pilling sweater woman worked check-in.  Saggy booby lady  was weird and worked in one of the labs.  Baldy drove us nuts at car rental.  Frank (I think that may have been his real name, actually) seemed afraid of us at the airline check-in.  There were many more.  Maybe I'm just weird, but it gave me something real...a connection of a a surreal and rather horrible circumstance.

So....just be a your cancer friend.  Be the person they already made friends with.  They need that now, more than ever.  And incredible thanks, to all my friends and dear ones, who continue my journey with me.  Love, c

Thursday, August 27, 2015

Markers for response to immunotherapy: Increased eosinophils = good. Increased Myeloid Suppressor cells = not so good.

Myeloid Cells and related chronic inflammatory factors as novel predictive markers in melanoma treatment with ipilimumab.  Gebhardt, Sevko, Jiang, et al.  Clin Cancer Res. 2015 Aug 19.

Ipi improves survival of patients with metastatic melanoma.  Since only about 20% of patients experience long-term benefit, reliable markers are needed to predict response.  Analysis of blood of 59 Stage IV melanoma patients was analyzed before treatments and at different times during treatment.  An early increase in eosinophil count during treatment with ipi was associated with an improved clinical response. In contrast, elevated numbers of monocytic myeloid-derived suppressor cells (moMDSCs), neutrophils, and monocytes were found in non-responders (n=36) as compared to levels in responding patients (n=23).  Non-responders also produced more nitric oxide and granulocytic MDSCs expressed higher levels of PD-L1 ... suggesting their enhanced immunosuppressive capacity.  Upon the first ipi infusion, non-responders displayed high serum concentrations of S100A8/A9 and HMGB1 that attract and activate MDSCs.

So....folks with increased eosinophils do better.  Folks with increased numbers of myeloid-derived suppressor cells, neutrophils, and monocytes do not.  Here is more data to support the same findings:

Lab values that may predict response to Ipi

Eosinophilia and a positive response to nivo and pembro

In this link Weber talks ipi and combo's, several immunotherapy combo's are discussed...but the relevant part addresses the blood work from the folks taking nivo in my study:

Looking at pretreatment parameters in the periphery and the tumor-
Only baseline MDSC, myeloid derived suppressor cells, proved to be significant.
These are CD14, HLA-DR low, CD11 B+ cells, classic myeloid derived suppressor cells which express high levels of PDL1 and other check point proteins.
Neutrophil derived MDSC cells were not related.
The more myeloid suppressor cells you have, the worse the patient did both in response rate and survival. 
Weber hopes to soon have results of the levels of MDSC from within the tumors of these patients and see how that level related to outcomes.
You can block MDSC by incubating it with PD1 antibody as well as other check point proteins, so he is writing a grant proposal currently to test a combo of nivo with MDSC depletion.
Measurements of the T-regs in the periphery - Levels decreased in responders, in non-responders it went up. For this reason, also thinks that nivo with T-reg depletion is worth investigation.

Here, in a synopsis of articles about the positive effects of combining immunotherapy and radiation, Radiation for melanoma, better when combined with immunotheapy!, once again....patients do better when MDSCs are few and far between:  Concomitant with tumor regression from radiation, they noted that radiation and anti-PD-L1 worked together to reduce the local accumulation of tumor-inflitrating myeloid-derived suppressor cells (MDSCs)... {Note:  Remember, these are the bad guys that block your T cells.  In my study, the folks with high levels of MDSCs did least well, while those with the lowest levels did better.  That's why, some researchers, like Weber, are talking about depleting these cells in patients FIRST...then administering anti-PD1 or other immunotherapies!!}  So...the data acquired in this study demonstrated evidence of the interaction between radiation and T cells....and a basis for the rational design of combination therapy with immune modulators and radiotherapy.

Really thinking the idea about depleting MDSCs at the start may really be the way to go here!!!  Best - c 

Tuesday, August 25, 2015

It's not ALL melanoma up in here!!

Sometimes it's the cutest house for the cutest, most hard working girl!!!  Yep!  Roo, got her masters in education while completing a year with a Project Inspire Program teaching at a high need, inner city high school, and got a job teaching Algebra 2, Pre-Cal, and Calculus at a local school this year!  Meanwhile, she saved her pennies.  Got a house.  Fixed it up.  Moved in a couple of weeks ago!  WOW!

Come in and have a seat!

Plan a lesson!

Cook a meal....with curtains made from material courtesy Ruthie, that was pillow covers in various dorms and apartments and is now curtains 'a la a Parisian cafe!

Art from B, and table snagged by a girl with a discerning eye from local biz going out of business, refurbished by the amazing guys at Grain Surgeons furniture repair!

Can you say chairs for Ten Bucks each at the Zillion Mile yard sale?  A little sanding, a little spray paint.....

A cute cover for the rough spots!

Art by Roo.  Gifted quilt.  Curtains left behind by prior owners, cut to size, cute buttons applied, and old throw pillow given a new lease on life!

Bath room tub and tile re-glazed to beauty!  Shower curtain and valance made by me...yes indeed!
Wide Open Spaces
Sorry, Roo.  But, you knew it was coming!!! So very proud of my girl.  So very lucky to get to share this special time with you.  Much love, my dear.  - mommy

Thursday, August 20, 2015

Jimmy Carter, Melanoma, and me...

Given that those of you who have followed this blog for more than ten minutes would certainly agree that I am a weird adult, you will not be surprised to learn that I was a strange child.  Born in 1964, I talked early and a lot (so I'm told).  I had a simultaneous aversion and attraction to things that were "suzzy"! (No one says I spoke with good pronunciation!) So much so, that my dear Granny made me a decoupage picture of kittens that I still have.  I could memorize poems and songs easily.  I wanted to please.  And I remember perfectly clearly three events that touched my heart and made me see just how big the world really was from a very small town in south Alabama.

I have to believe that my desire to help the children pictured in a National Geographic magazine showing the devastating effects of famine in Africa led me to the career path of pediatric nursing of which I have been a part since 1984.  I spent so much time looking sadly at the pictures that my family finally hid the magazine.

In 1972, when I was in the 5th grade, I remember explaining to my classmates the story of Watergate.  It was my first glimpse into the pompous hubris of the powerful and the absolute stupidity of being taped or filmed, knowing that there is a record that can eventually be replayed - clearly showing the truth - yet denying that very truth publicly.  I still cannot believe the great numbers of folks who have not learned this lesson as we watch such ridiculousness play out daily.

But, in 1978, through the efforts of the Israeli prime minister Menachem Begin, Egyptian president Anwar Sadat, and American President Jimmy Carter, a peace agreement between Egypt and Israel was achieved.  I watched the talks and interviews with rapt attention on the evening news shows.  THIS was what men could do when their hearts were in the right place, political opinion was deemed less important than what was best for real people, and power was used constructively!  I have adored Jimmy Carter ever since.  His lack of willingness to "play" the system may have made him something less than an impressive president.  But his intelligence, his work ethic, his sense of right and justice and willingness to speak out....have made him an amazing human who has made an incredible difference in this world.  Post presidency he has continued to be a leader in pushing for world peace with diplomatic work in Korea, Israel and Palestine with the achievement of the Geneva Accord, Africa, and Vietnam.  The Carter Center, a non-profit he founded in 1982 with his wife and Emory University, has made an incredible difference in the lives of people across the globe.  His reputation allowed him to develop and institute the process of election observation to help ensure free and fair elections in countries world wide.  The Center supports those working to safeguard human rights.  The positive steps Carter's Center has made in the health of millions is unbelievable.  The near eradication of the Guinea Worm, through simple education and water filtration, is nothing less than heroic. (Here's a link to show just how yucky Guinea Worm infestation can be:  Dracunculiasis - Guinea Worm Infestation ) In 1986 there were more than 3.5 million cases annually across 20 countries in Asia and Africa.  In 2013, there were only 148 cases in 4 countries. Here is a clip of Carter being interviewed by John Stewart about that very thing, noting that by 2015 Guinea worm cases were down to 126:  Jimmy Carter on The Daily Show in 2015   I love that some of his greatest successes were born out of the simplest, common sense techniques:  Jimmy Carter talks Guinea Worm filters and latrine building to stop trachoma

What a man.  So incredibly brilliant, funny, determined, and humble.  And now....he has Stage IV melanoma.  Apparently since his melanoma diagnosis in early August with a liver biopsy and an MRI showing additional brain mets, he has started anti-PD1 (Keytruda) and is to have SRS to brain mets very soon at Emory in Atlanta.  Good moves, sir!  If fighting melanoma is something you must do, after all the other things you have done...this is exactly how I would go about it.  Anti-PD1 has some of the best results going (topped only by the ipi/nivo combo...but that brings increased side effects as well) and when dealing with brain mets, combining immunotherapy WITH radiation gives better results than either therapy alone.  In fact, in the case of ipi, "Patients treated with SRS during or before ipi had better overall survival and less regional recurrence." Here's a link to data regarding the combo:  Radiation for melanoma: better when combined with immunotherapy

You are in my heart, President Carter.  You have led the way for so many.  Perhaps, some of us melanoma ratties have led the way for you.  I wish you well. - c

Immune related side effects from immunotherapy can and SHOULD be treated!!!!

Immune-Related Adverse Events, Need for Systemic Immunosuppression, and Effects on Survival and Time to Treatment Failure in Patients With Melanoma Treated With Ipilimumab at Memorial Sloan Kettering Cancer Center.  Horvat, Adel, Dang, et al.  J Clin Oncol.  2015 Aug 17.

Ipilimumab is a standard treatment for metastatic melanoma, but immune-related adverse events (irAEs) are common and can be severe. We reviewed our large, contemporary experience with ipilimumab treatment outside of clinical trials to determine the frequency of use of systemic corticosteroid or anti-tumor necrosis factor α (anti-TNFα) therapy and the effect of these therapies on overall survival (OS) and time to treatment failure (TTF).

We reviewed retrospectively the medical records of patients with melanoma who had received treatment between April 2011 and July 2013 with ipilimumab at the standard dose of 3 mg/kg. We collected data on patient demographics, previous and subsequent treatments, number of ipilimumab doses, irAEs and how they were treated, and overall survival.

Of the 298 patients, 254 (85%) experienced an irAE of any grade. Fifty-six patients (19%) discontinued therapy because of an irAE, most commonly diarrhea. Overall, 103 patients (35%) required systemic corticosteroid treatment for an irAE; 29 (10%) also required anti-TNFα therapy. Defining TTF as either starting a new treatment or death, estimated median TTF was 5.7 months. Twelve percent of patients experienced long-term disease control without receiving additional antimelanoma therapy. OS and TTF were not affected by the occurrence of irAEs or the need for systemic corticosteroids.

IrAEs are common in patients treated with ipilimumab. In our experience, approximately one-third of ipilimumab-treated patients required systemic corticosteroids, and almost one-third of those required further immune suppression with anti-TNFα therapy. Practitioners and patients should be prepared to treat irAEs and should understand that such treatment does not affect OS or TTF.

Pancreatitis Secondary to Anti-Programmed Death Receptor 1 Immunotherapy Diagnosed by FDG PET/CT.  Alabed, Aghayev, Van den Abbeele.  Clin Nucl Med. 2015 Aug 18. 

A 57-year-old man with metastatic melanoma developed colitis secondary to ipilimumab, a known immune-related adverse event (irAE). The patient then received pembrolizumab immunotherapy, an anti-programmed-death-receptor-1 (PD-1) antibody. Restaging FDG PET/CT study following 3 cycles of therapy demonstrated diffuse increased FDG uptake throughout the body of the pancreas associated with fat stranding in the peripancreatic region, suggestive of pembrolizumab-induced pancreatitis. Although the patient was clinically asymptomatic, diagnosis was biochemically confirmed with elevated amylase and lipase levels. In the era of immunotherapy, it will be critical to recognize irAEs early to allow prompt initiation of appropriate therapy and reduce the risk of long-term sequelae.

It is becoming more and more clear that the old "bug-a-boo" of, "Oh, you're on anti-PD1 (or ipi)!  You can't treat side effects with prednisone or any other immune suppressing medication!!!  If you do, the therapy won't work on your melanoma!" IS WRONG!!!!!!!!!  Rather, if immune side effects are noted as soon as possible and TREATED, it is much more likely that the melanoma patient can continue their needed treatment (perhaps with a drug holiday for a brief time), still receive benefit from that treatment, and diminish the likelihood of long-term problems from those side effects!

Be vigilant my friends.  And, be sure that you are going to a doc who knows how to recognize and TREAT any side effects that may develop.  Yours - c

Monday, August 17, 2015

This one's for you, Artie! Electro/chemo to zap tumors!


Electrochemotherapy is a new antitumor treatment that combines systemic bleomycin with electric pulses delivered locally at the tumor site. These electric pulses permeabilize cell membranes in the tissue, allow bleomycin delivery diffusion inside the cells, and increase bleomycin cytotoxicity. Previous clinical studies have demonstrated the effectiveness of Electrochemotherapy in the treatment of several primary and metastatic solid tumors.

Treatment planning for electrode positioning and electrical pulse parameters was prepared for four needle electrodes. Mini-open surgery with a left L5 laminectomy was performed to introduce the eletrodes.

The assessed follow-up period was 48 months after the Electrochemotherapy procedure. Neither serious Electrochemotherapy-related adverse events, nor bleomycin toxicity were reported. Overall improvement in pain, ODI [level of disability] and KPS [performance] outcomes was better.

Our case represents, to our knowledge, the first one to test the potential role of Electrochemotherapy as treatment of spinal metastasis. Electrochemotherapy allowed a successful treatment of metastatic spinal melanoma. However, we believe that there is a strong scientific rationale to support the potential utility of Electrochemotherapy as a novel treatment of spinal metastasis, regardless of the histological types.

Super new.  No impact on or survival data included.  Don't know where it is offered in the US. Melanoma doesn't usually respond to "normal" chemo.  But in this treatment methodology...zapping the tumor with electrodes first seems to make them more responsive to the chemotherapy....that was then administered systemically. (Wonder why they didn't try a local injection???) Reminds me a bit of the ADC therapy J tried where nasty ass chemo was linked to a monoclonal antibody that (in theory) would be drawn into the tumor cells only.  Once there, the chemo would be unleashed. Here's a post on that one:  ADC's - Antibody Drug Conjugate
Unfortunately, while ADC therapy held tumors in check for some...there was pretty substantial chemo leakage that led to typical chemo side effects:  hair loss, fatigue, loss of appetite, neuropathy, etc. 

So...don't know if you could even access this treatment, Artie....but it is one of the ways folks are trying to make old time chemo work for melanoma patients.  Warm wishes to you all - C 

Sunday, August 16, 2015

Positive response to Helper Peptide Vaccines for melanoma

Long-term Outcomes of Helper Peptide Vaccination for Metastatic Melanoma.  Hu, Kim, Blackwell, Slingluff.  Ann Surg. Sep 2015

The objective of this study was to compare the long-term outcome of patients with metastatic melanoma vaccinated with 6MHP to that of a group of unvaccinated historical controls.

A multipeptide vaccine (6MHP), designed to induce helper T cells against melanocytic and cancer-testis antigens, has been shown to induce specific Th1-dominant CD4+ T cell responses.

The 6MHP vaccine was administered to patients with metastatic melanoma. Circulating CD4+ T cell responses were measured by proliferation or direct IFN-gamma ELIspot assay. Overall survival of vaccinated patients was compared to a group of clinically comparable historical controls using multivariable Cox regression analysis and Kaplan-Meier survival analysis, taking into account age, metastatic site, and resection status.

Across 40 vaccinated patients and 87 controls, resection status and vaccination were associated with improved overall survival. Forty pairs of vaccinated patients and controls were matched by metastatic site, resection status, and age within 10 years. Median survival was significantly longer for vaccinated patients (5.4 vs 1.3 years). Among the vaccinated patients, the development of a specific immune response after vaccination was associated with improved survival.

Helper peptide vaccination is associated with improved overall survival among patients with metastatic melanoma. These data support a randomized prospective trial of the 6MHP vaccine.

I was given 6 peptide vaccines IM every two weeks with every infusion of nivo I received for the first 6 months of my trial.  It was determined that they did no good and administration of them was ceased in patients who followed my cohort.  Link to the explanation of their use:  My anti-pd1/vaccine trial results 2012 
However, in 2013, there was this out of MD Anderson:  Peptide Vaccines do not trigger effective immune response 

BUT!  My vaccine was quite different from this one!!!  I still hold out hope that vaccines will be the answer to at least some, if not all, of the curing melanoma equation!!!

Best to you all - c


Thursday, August 13, 2015

Being female with low LDH, no ulceration in primary, and BRAF V600E positive = increased rates of survival with BRAFi for melanoma patients?!!!

Clinicicopathologic features associated with efficacy and long-term survival in metastatic melanoma patients treated with BRAF or combined BRAF and MEK inhibitors.  Menzies, Wilmott, Drummond, et al.  Cancer.  Jul 28, 2015.

For 142 consecutive immunotherapy - and MAPK inhibitor-naive patients with BRAF-mutant metastatic melanoma who were treated during clinical trials with BRAFi (n=111) or the combo of dabrafenib and trametinib (n=31), clinicopathologic factors were correlated with the response to MAPK inhibitors and survival.

Median f/u = 15.7 months.  The 2, 3, and 4 year overall survival (OS) rates were 43%, 24% and 24% respectively.  Statistical analysis demonstrated that the only clinicopathologic factors associated with longer Progression Free Survival (PFS) and OS were being female and a normal pretreatment serum lactate dehydrogenase (LDH) level.  BRAF V600E genotype and an absence of primary melanoma ulceration were also independently associated with longer PFS but not with OS.  The median OS was 23.5 months for patients with normal LDH levels and 7.3 months for those with elevated LDH levels.  Complete responders had the best survival, but disease progression still occurred in 2 of 7 patients.

We certainly need to figure out what treatment works for whom.  I think it is important to note that these patients were all treatment naive...apparently.  For whatever that is worth.  This provides the first real confirmation of the importance of a low LDH to outcome that I have seen.  It also provides one more bad mark for ulceration of primary lesion, as that has long been noted to be related to a poorer prognosis.  

Hang in there, peeps! - c

Friday, August 7, 2015

Leptomeningeal disease - a case study

Intrathecal administration of tumor-infiltrating lymphocytes is well tolerated in a patients with leptomeningeal disease from metastatic melanoma:  A case report.  Glitza, Haymaker, Bernatchez, et al.  Cancer Immunol Res. 2015 Jul 27.

Patients with leptomeningeal disease from melanoma have very poor outcomes and few treatment options.  This is a case of intrathecal administration  [an injection directly into the spinal fluid] of autologous tumor infiltrating lymphocytes (TIL) in a patient with leptomeningeal disease (LMD) which developed after prior treatment with surgery, high-dose bolus IL-2, and systemic TIL infusion and experienced radiographic progression after intrathecal (IT) IL2 therapy.  Pt was given weekly treatment with increasing numbers of IT TIL followed by twice weekly IT IL2.  Analysis of CSF demonstrated increased inflammatory cytokines following the treatments.  Subsequent imaging demonstrated stable disease and neurological deficits also remained stable.  The patient expired 5 months after the initiation of IT TIL therapy with disease progression in the brain, liver, lung and abdominal lymph nodes but, WITHOUT LMD progression.  These results demonstrate safety of IT TIL and support a prospective clinical trial to determine clinical benefit in these patients.

Very sad overall.  Though hopeful in the sense that while IL2 intrathecally didn't help...when combined with TIL it did.  This is a very difficult situation that some melanoma patients and their families face, so any treatment improvements will certainly be a boon.  Why this patient wasn't simultaneously or previously administered an immunotherapy is not mentioned.  But, it seems to me that might have been helpful as well.

Wishing you all my best.  - c

Wednesday, August 5, 2015

51 years, 51 years...and believe it or not...I'm still here!!!

What a beautiful surprise!  51 years! I am thankful for every one.  Not every  moment was perfect or pain free, but they all combined to build the person I am today.  I like that.  I tried to teach my children and students that while one could learn from perfect examples and textbook cases, there was much to be said for learning from those you didn't wish to emulate, experiences that were less than fun.  I hope I have lived up to my own advice. I am not certain what my future holds.  Is anyone?  I find myself still a bit desperate to "get things done".  There are those who would argue that that was the case for me since birth.  However, I know the change in how I  feel.  Since melanoma.  There is an urgency I can't shake.  And I don't think that's bad.  At first...I wanted to see my children through middle school.  With that accomplished, please....could I just help mentor them through high school?  Set them off to college or the next step they chose?  Once there...might I just help them settle into the lives they have built for themselves?  Not a bit greedy am I?  But, I am.  Greedy for these things and more....  Time with B.  Laughter with friends.  That special light at dusk. A walk in the woods.  The sound of rain.  A beautiful song.  A perfect verse.  A parent helped. The smile of a child.  A diagnostic puzzle solved.  Melanoma thwarted.

And there was my MONTH of BIRTHDAY.  Because I am spoiled ROTTEN!!  A beautiful table built by B.  A picture like a window...into sweet memories and a beautiful river.  A perfectly designed blouse.  Beautifully wrapped and explained sewing toys.  A trip to a cup.  Visits and art from those dear.  And then there was this...from a dear one...who knows me well....

An amazing classical Happy Birthday to YOU!!!

Thanks to all of you.  Celebrate YOUR best you can.  Much love - c

Monday, August 3, 2015

Keeping you informed about the a$$hole: Dr. Dana Hansen from Kent State University

You may remember this post:  Lame lazy phd student 
It was in response to an A$$ HOLE who wanted to interview my peeps about reading the blog of a DYING cancer patient....replete with typo's and crass ass shenanigan's....who was stupid enough to post her shit on MY blog.  I sent her the letter published in the link. Surprisingly (not)...there was no reply.  Funny, Dana.  You liked posting on my blog before! know I love my research!!!  Turns out....she's not a student!  She's a chubby weirdo who is actually PAID as an assistant PROFESSOR at Kent State!!!!!!!  Check her out:   (Dana, honey!!!  Did you not take diet, nutrition, and exercise classes in your nursing curriculum????)

Anyhow...Miss Dana...DID get my email.  How do I know?  Well, she deleted some of her bullshit...though it is preserved on my original post.  Some of her links in my message have been take down and typo' least some of them....have been corrected.  However, this is what I have also learned.....

She posted her crap here:  Blog: My Journey with Inflammatory Breast Cancer

And here:  I have cancer, but it won't have me...  I'm sorry, but does this sound like a dying person to you?

And she went my tears and threw on my big girl pants  I mean really!!!  Read this post.  Would you post here that you wanted to interview the peep of the "dying" person????  But, a "NURSE" did!!!!!!!!

And this...on a post from 2014:  COPD thread

And here:  carcinoid syndrome flushing You thought THIS chick was dying?????!!!!

And she put this:  on someone's 2014 post!!!

This poor person is freaking out because she SURVIVED!!!!!  Yet Miss Compassionate Nurse Dana posted here too:  Sometimes i feel like i am falling apart

With a sense of humor like this....this lady is NOT on death's door....Don't worry, it's not ebola
Of course PhD Dana couldn't be bothered with figuring that out!!!

And this blogger, while going through some hard times, is training for a triathlon!!!!!  cancer cures life

Sadly...there are more.  However, I feel I have proven my point and wasted enough time.  You are one sick cookie, Miss Dana PhD Hansen.  And to all of us proud to be in the nursing extreme embarrassment.  Kent pay this person????  Seriously?????  WOW!

(Oh, peeps.  I'll be forwarding this post to Kent State...and Ms Dana.  Don't you worry!!!)  As if having cancer wasn't enough!!!  - c

Saturday, August 1, 2015

Itching and vitiligo associated with progression free survival after Pembro/Keytruda???!

Pembrolizumab cutaneous adverse events and their association with disease progression.  Sanlorenzo, Vujic, Daud, Algazi, et al.  JAMA Dermatol.  2015 Jul 29.

While immunomodulatory anticancer drugs, like anti-PD1 are promising....little is known about cutaneous adverse events caused..and their possible correlation with treatment response.  Single institution, retrospective medical record review, March 1, 2011 - May 28, 2014.  83 patients from 2 clinical trials...who had at least 1 dose of pembro and at least 1 f/u visit.  43 patients had 10mg/kg q 3 wks, 24 had 10mg/kg q 2 wks, and 16 had 2mg/kg q 3 weeks.  66 were melanoma pts, 15 were lung, 1 prostate cancer and another was treated for Merkel cell carcinoma.  

35 patients (42%) developed cutaneous AE's.  Most common = papular eruption (24[29%]), itching (10[12%]), hypopigmentation {vitiligo} (7[8%]).  All 7 pts who developed hypopigmentation were being treated for melanoma.  Survival analyses showed that patients who developed cutaneous AE's had significantly longer progression-free intervals in all 3 treatment dosage groups, compared to patients who did not develop cutaneous AE's.

CONCLUSION:  Pembro was associated with side effects related to the skin in 42% of patients.  The development of these cutaneous AE's, especially hypopigmentation in patients with melanoma, could point toward better treatment response.

Link to post describing general side effects from anti-PD-1 and why we get them:  Side effects of anti-PD1 (Nivo in this case, though data is very similar for Pembro)

Link to post from ASCO 2015:  How Nivo side effects are associated with survival

Link with info from 2015 with article demonstrating positive link between vitiligo and remission of melanoma, back ground info, and white patches:  Vitiligo a good prognostic indicator for melanoma

Pretty much what we've been hearing (and seeing!!) already.  There has got to be something going on between the CD8 T cells, dendritic cells and melanoma, especially since only the melanoma patients in the study developed vitiligo.  B's been screaming about this for years!!!  It is clear that a link between these things exists...but we don't yet know how to ELICIT the vitiligo response so that more melanoma patients GET a response!  Come on researchers!!!  We've got a vaccine for ebola, a reliable treatment for Hep C...let's do this!!!!! - c