Immunotherapy and Jesus Christ Superstar

Life has many of those incidents that change your life.  In University I stumbled upon auditions for Jesus Christ Superstar and Chicago.  I got parts (chorus type), due to the fact that not many guys auditioned.  Afterwards, I tried writing and directing.  I wrote a play (musical) thereafter, which was really, really, bad.  (At least, so I was told by one person I showed it to, the other person I showed it to liked it, but I think she was just being nice.)

The play was a musical, where the main character had HIV.  It was part comedy, part drama, and  part informative science.  There were two separate stories intertwined- one was the main story ‘real life’, and the other was a story of cops, army, intelligence, foreign armies, and home-grown terrorists (which were supposed to represent CD8+ T cells, B cells, CD4+ T cells, bacteria and malignant cells respectively.)  HIV (which kills or inactivates CD4+ cells, essentially inactivating the bodies ability to respond appropriately) was like massive budget cuts…..  Anyway, it’s clear I made a good choice NOT trying to make it in theatre :).

Immunotherapy or vaccines or other modalities to turn the immune system on has been one of the most promising avenues for cancer treatment over the past couple of years, and with drugs being approved in lung cancer treatment – such as Opdivo (nivolumab), and Keytruda (pembrolizumab), there is hope that we are just beginning to unlock the potential of these drugs and this avenue of treatment.

Basically, some cancers appear to be able to grow – i.e. the ‘home grown terrorists’ that are cancer cells are allowed to expand – because they have found a way to turn off the immune response in the tumour -i.e. they’ve paid off the local cops.  If we give a drug that turns off this ability (i.e., we confiscate the cash/freeze the assets), then we might be able to make those lazy cops active again, and fight the cancer.  (if you a police office reading this, please don’t be offended).

The problem with these drugs – different drugs having different problems, is that sometimes we WANT the immune system to be turned off, and if we give a drug that makes the immune system more active (i.e. really stimulates the cops), and there is the possibility that they will not only fight the cancer, but also harass some of the local ‘good guys’ – such as the gut, skin, lungs etc.  So the drugs have potential side effects.

We are working on our patient information/education, as well as education for all of the people who might contact a lung cancer patient in terms of immunotherapy toxicities.  I promise I won’t try to make the education materials be in ‘musical theatre’ format.

 

Breaking Bad. News.

I recently listened to a podcast on ‘Breaking Bad’, where it was considered one of the best shows of the 21st century.  I have never watched an episode – mainly because I don’t like a show that reminds me of work.

No, I don’t deal/make crystal meth (the drugs I deal with are much more dangerous if you don’t use them right).  I do however deal with patients with lung cancer.  The main character in ‘Breaking Bad’ had incurable lung cancer, diagnosed in season 1, episode 1.  This was enough for me not to watch.  Breaking Bad lasted for 5 seasons.  The odds of a TV show making it 5 seasons is about 10%.

When I’m dealing with lung cancer patients, the vast majority are in Walter White’s situation – advanced and incurable.  With lung cancer, approximately 10% of patients are alive at 5 years.   With advanced and incurable, that number drops to about 5%.

At least several times per week, I meet with new patients who have lung cancer that has spread.

I approach each patient I see with similar questions – “What have you been told, and what information do you want to know?”.  The majority of patients say they want to know ‘it all’, others say “I don’t want to know any bad news, I just want to fight”.  When patients say “I want to know everything”, they are usually asking what the timelines are, and what’s going to happen (am I going to suffer?).

People ask me “Don’t you find oncology depressing, how do you handle it?” – to which I reply – gee, when I chose a career in oncology, I thought we cured everybody with lung cancer, way to ‘bait and switch’ me Mr. Career Path”…

Of course the news I give is depressing, and of course it’s emotional giving that type of news, but that’s the topic for another post.

If you want to know though, here is how that conversation often goes:

Patient:  “Yes doctor, I want to know timelines”.

Me:  “Ok, why do you want to know?  What will you do differently?”

Patient:”Well, I guess I want to know for my family, so I can make arrangements.  What’s going to happen to me?”

Me: “Ok.  Well, as Dan Quayle/Yogi Berra said “it’s difficult to make predictions – especially about the future”, so I don’t know exactly what is going to happen to you.  I can tell you a worst case scenario, a best case scenario, and a ‘most likely scenario’.  I can tell you if I had 100 identical people to you in a room, how long it would be before half of those people died, how long it would be expected before 10 of those people died, and how long it would be before 90 people had died.  What I can’t tell you is whether you are in the 10 who die early, the 50 who die by 8 months, or if you are around in the room after all others have left.  Plan your stuff, get your affairs in order (paperwork, relationships, letters etc.) in case things happen quickly, but hope for the best.”

 

Of course (and as expected), the conversation often goes this way, but I think sometimes patients just hear blah, blah, blah 8 months, blah blah blah and tune out.  I don’t take this as an offense – I think it’s common for people in doctors offices to only remember one or two things when they are given bad news.

Breaking bad.  I would have expected it to have lasted less than a year, but there it was, still pumping out quality in year 5.  (so I’m told, as I mentioned I never saw it…)