Stefanie Joho, 25, learned she had colorectal cancer shortly after graduating from college. Surgeries and two types of chemotherapy failed to stop the disease, but her tumor started shrinking after she began receiving Keytruda, an immune-boosting drug made by Merck. Credit 
Preview Promise and Progress at the Bloomberg~
Kimmel Institute for Cancer Immunotherapy
I first spoke with one of her sisters when Stefanie was slipping away in the summer of 2014. Her cancer was raging out of control, she was considered terminal, and she was in a very dark place.In fact, it took about nine months of cajoling before Stefanie was finally ready to meet with me in March of 2015 for additional support and empowerment.
Meanwhile, her other sister, searching for immunotherapy clinical trials, found a program at Johns Hopkins University, where doctors were testing a drug called pembrolizumab (now marketed as Keytruda).
Preview Johns Hopkins patient Stefanie Joho
describes her treatment with immunotherapy
Cancer Immunotherapy with Checkpoint Inhibitors
Keytruda is one of a new class of cancer drugs called immune checkpoint inhibitors. Checkpoint inhibitors work by releasing the molecular brakes that keep the immune system from attacking tumors.
The main checkpoint inhibitor drugs on the market so far are Keytruda (pembrolizumab, made by Merck) and Opdivo (nivolumab, from Bristol-Myers Squibb). Keytruda was approved by the Food and Drug Administration (FDA) for advanced melanoma in September of 2014, and the medication made headlines in 2015 when it helped treat former president Jimmy Carter for melanoma that had spread to his brain and liver.
The drugs had also been approved to treat squamous cell lung cancer, and a newer study showed that Opdivo also prolongs survival for patients with non-squamous cell lung cancer. In a trial of 582 patients with advanced cancer who had already been treated with platinum-based chemotherapy, patients who received Opdivo lived up to 17 months (as compared with 9 months for those who did not) and had far fewer serious side effects.
In other studies, Opdivo significantly shrank tumors in 19 percent of patients with advanced liver cancer, and Keytruda improved outcome in 25 percent of patients with head and neck cancer. However, prior to the Hopkins trial, checkpoint inhibitors weren’t making headway with colon cancer.
Why did the drugs work so well for some cancers and not for others? One explanation is that lung cancer and melanoma are often caused by agents that damage DNA, items like tobacco smoke and ultraviolet radiation. Thus they have “tons of mutations,” according to Dr. Luis A. Diaz, Stefanie’s doctor and former professor of oncology at Johns Hopkins University. That could make it easier for the immune system to recognize the cancer cells as something to be destroyed. And even more mutations are found in cancers with a certain defect known as mismatch repair (MMR) deficiency.
MMR fosters repair of mistakes in DNA that can arise as cells divide. As DNA copies itself, the deficiency prevents errors from being fixed, allowing mutations to accumulate. The abnormality — which can arise spontaneously or be inherited — is found in just four percent of cancers overall, including 15 to 20 percent of colon cancers and about 40 percent of endometrial malignancies (cancer in the lining of the uterus). MMR deficiency is found in Lynch syndrome, the inherited condition that also caused Stefanie’s cancer, accounting for about 5 percent of colorectal cancers, and in about 10 percent of colorectal cancers that are not inherited.In the United States, researchers estimate that at least about 15,000 people with the defect may be helped by this immunotherapy.
A New Frontier in Cancer Treatment
The Hopkins investigators found that tumors with the MMR defect had an average of 1,782 mutations, compared with only 73 for tumors without the problem. Theorizing that high numbers of mutations make cancers more susceptible to attack by the immune system— especially if it gets assistance from immunotherapy, the researchers decided to run a small trial with the experimental drug pembrolizumab to determine whether the defect could predict a patient’s response to immunotherapy.
Three groups of volunteers were recruited: 10 colon cancer patients whose tumors had the genetic problem; 18 colon cancer patients without it; and 7 patients with other malignancies who also had the defect. The first results, published in 2015 in the New England Journal of Medicine, were striking.
Four out of the 10 colon cancer patients with the defect and 5 out of the other 7 cancer patients with the abnormality responded to the drug with significant shrinkage of their tumors. In the remaining group of 18 colorectal cancer patients without the deficiency, there was no response.
The small trial in Baltimore was pivotal — and not only for Stefanie. It showed that checkpoint immunotherapy could attack colon cancer and other cancers thought to be unstoppable. Since then, newer data have shown that a high proportion of patients with the genetic anomaly can benefit from the treatment, often for a lengthy period. “If you have the signature, you should treat with these checkpoint inhibitors,” said lead author Dr. Diaz.
The study results, supported in part by the National Institutes of Health, were the foundation of the FDA’s decision to green-light Keytruda to treat cancers such as Joho’s, that is, malignancies with certain molecular characteristics. This approval signals an emerging field of “precision immunotherapy,” one in which genetic details are used to anticipate who will respond to treatments. The breakthrough, marking a new frontier in cancer treatment, was announced last week at the annual meeting of the American Society of Clinical Oncology as an approach that can benefit patients with some kinds of advanced cancer unresponsive to chemotherapy. Hopefully, insurance companies will follow with support. Keytruda treatments cost about $150,000 a year.
Stefanie Joho: Present and Future
By Stefanie Joho
When I was first diagnosed with colon cancer in 2013, I’d never even heard the word immunotherapy. I didn’t know that my doctors wouldn’t have all the answers. I thought clinical trials were last-ditch efforts rather than treatments that save countless lives.
I didn’t know that a treatment geared to fighting my specific type of cancer and the genetic components of my tumor would go on to potentially offer tens of thousands of patients a revolutionary new path to surviving cancer in 2017. Because I’m one of the very few lucky ones who looked into the abyss and made it out on the other side, I feel it is my duty to speak up and share some of the critical things that I have learned in what is now a new era in cancer care. Because a disease that should have killed me instead launched my career in patient advocacy.
First and foremost, it is important to remember that every cancer is unique. Your journey will be different from mine. Your cancer is yours and yours alone. So think of the following points as “road signs.” They’re ones that I wish someone had shown me when I felt lost, with nowhere else to turn. The goal of this guide is to potentially help shape your thinking as you become an active participant in saving your life. More than anything, I hope it prompts you to question the presumption of cancer care for nearly a century.
We look to doctors in their white coats to be the experts — partly because, in a moment of such despair, we want to be able to look to someone to just give us the answers. But you should know that you will not find that person in anyone but yourself.
In the beginning of my cancer journey, I felt intimidated by my doctors and made several decisions that I now regret. I also walked into my appointments and agreed to everything instantaneously, without even considering a second opinion. As my cancer kept coming back and the treatments kept failing, I decided that the only chance I had to make it out alive would be to become an active participant on my journey. I would have to educate myself. I scoured the Internet. I became an “expert” not only in my specific disease, but also in the current cancer landscape.
I’m in no way encouraging you to become your own doctor and understand all the science. And I’m certainly not encouraging you to take everything you read on the Internet as fact. But in 2017, with the amount of accessibility to information, I’m encouraging you to seek it out. Never take anything at face value or trust blindly. Make informed decisions, not decisions based on fear. Walk into appointments with your doctors as an equal, not as a passive bystander. Being an informed cancer patient today is a full-time job. As with any job, that means learning new skill sets and finding the resources needed to succeed.
2. Asking questions is not making trouble.
You will often be made to feel that being a “good patient” means not asking questions. But do not be afraid to speak up. Your life quite literally depends on it. Come into every appointment with a prepared list. If possible, bring someone with you who can take notes. If you are confused about something, ask. But If you think of it later, write it down. Remember: You’re the one whose needs are paramount. You’re the one who is fighting for your life. Make every thought, concern and feeling heard. If it isn’t received the first time, say it as many times as necessary.
If you begin to develop a symptom from a treatment side effect or from the cancer itself, understand that it is the system’s job to help you get relief. If your doctors aren’t taking you seriously, do not believe their judgment over yours. And if you feel that your physician doesn’t understand or listen to you, then perhaps it’s time to seek one out who will. In my opinion, an individual who does not have empathy is not a physician.
3. No two cancers are the same. Become an expert in YOUR cancer.
No two cancers are the same. Increasingly, knowledge of such individual variation is being shown to lead to more effective treatments. Ask your physicians and understand every type of genetic testing available to you. The more granular you can get about the specifics of your disease, the more you will maximize your chances of identifying the best possible treatment for your “personal” tumor. (Discovering the genetic biomarker of my cancer saved my life.) Continue to expand your resources so that you can be an expert in your own cancer.
4. Take note of EVERY potential side effect. Report everything.
The incredible advances in cancer treatments have created a new set of challenges for clinicians, especially in how to identify the side effects. Given that these are new treatments, your doctors are not as practiced with them as they are with chemotherapy and radiation.
For example, immunotherapy is entirely different from traditional treatment. The former utilizes the patient’s own immune system, whereas the latter aims to attack only the cancer cells. Early recognition and proper management of side effects can make the difference between life and death.
Don’t hold back a single concern from your doctor and care team. Even if you think it sounds minuscule or irrelevant, your oncologist needs to know everything to best care for you. Listen to your body. Observe and report any changes.
5. Clinical trials are not a last-resort option.
The lines of treatment are rapidly changing, and, more often than not, getting access to cutting-edge treatments entails enrolling in a clinical trial. There’s an unfortunate misconception that clinical trials are reserved for those who have exhausted all other options. In reality, trials can actually offer access to the most individualized cancer treatment. And in fact, immunotherapy is more and more becoming the first line of treatment — and even being used before surgery to prevent relapses.
And just as individual patients can’t tackle their disease by themselves, we all ultimately must help one another by sharing and participating in clinical trials. Only 4 percent of cancer patients are currently enrolled in studies. Explore trials at cancer centers with a lot of experience in the type of therapy being tested. See if you have options outside of what has been standard of care for 70-plus years.
In the doctor-patient relationship, patients must understand that they are partners of science and as big a part of the cure as doctors. Without us, and our willingness to participate, medical advances would not exist. I will always feel a tremendous sense of pride for participating in a study that will save many thousands of people’s lives.
6. Cancer is not just a physical disease.
It is critical throughout your journey to address the mental, emotional and spiritual aspects of this disease. Seek help, support and healing from other places, too. There are many schools of thought about why people become ill and what can be done to help them recover. It’s important to maintain your anchor in generally accepted medical principles, but don’t be afraid to look further up- and downstream to see if other currents of healing can add value for you and your care team.
As only one example among many, learning about nutrition made me feel as though I were actively fighting and doing something every single day to help my body heal.
7. Hope is a lifeline.
Don’t let anyone ever take that away from you. I believe in hope. Period. It saves lives. When your mind tells you that it’s over, the body has no reason to keep fighting. If you find yourself drifting in that direction, remember: “You haven’t failed the treatments; the treatments have failed you.”
Of course, doctors must tell their patients the difficult truth. But the specific words used to deliver such news matter. If your doctor is unable to provide you with hope or encouragement to keep fighting, find the hope and strength from within yourself and the loved ones around you.
8. None of this can be done alone.
This might sound overwhelming. But with great power comes great responsibility. You are powerful, but you are not superhuman. Know your limits, and respect those limits.
Cancer is not a journey that you can navigate alone. The people and professionals with whom you surround yourself will alter the course of your journey. They will lend you strength when you feel you simply have nothing left to give.
If you physically or emotionally cannot actively advocate for yourself, then ask someone to be your advocate. When things were particularly bleak, my younger sister, Jess, often had to speak up for me. She knew what my doubts were, what my concerns were and what was important to me. She became my voice when I didn’t have one.
Create a health-care team that listens to you and cares about you and includes you in every aspect of your decision-making process.
Lastly, and so very importantly: Connect with others in the community. As much as your loved ones will do everything in their power to be there for you, they simply will not be able to understand the complexities of what you are grappling with on a daily basis. Making friends with other cancer patients (even through social media) enabled me to share the fears and anxieties that I was too ashamed or embarrassed to talk about with those who weren’t confronting their own mortality. I could speak openly about my side effects, the changes taking place in my body, my isolation. I could utter the words, “I’m ready to give up,” without the looming guilt associated with saying that to loved ones.
It certainly doesn’t have to be about only cancer, all of the time, but knowing that this kind of support exists is healing. It makes you feel understood.
Replace “what-ifs” and “should haves” with hell yeahs and no regrets. シ
