Chemotherapy may some day be a relic of the past, remembered as a poison that indiscriminately killed any rapidly dividing cell, cancerous or not. Cancer cells grow especially fast. But so do hair, gut and blood cells, rendering them vulnerable to chemo, hence the bald and nauseated cancer patient that comes to mind.
But Dr. CJ Nock, a lung cancer doctor, treats veterans with the newest treatment called immunotherapy. He thinks it is a game changer. “My guess it has already been tested in every [type of cancer] researchers can think of,” he said.
Without immunotherapy, Rick, a 73-year-old former Marine exposed to agent orange, would be dead. Instead, in 2016 after Rick’s metastasized tumor in his brain was removed but the cancer continued to spread, he met Dr. Nock who offered him experimental immunotherapy.
Dr. Nock remembers Rick’s response: “If it’s going to help someone else, let’s do it.”
Dr. Nock had to remind him that it may actually work on his cancer.
Rick still sees Dr. Nock for what is called surveillance, continuously monitoring for cancer should it reemerge. Rick, one of the nearly 200,000 veterans living the Cleveland/Akron area, is just one example of many lung cancer patients who now live cancer-free after immunotherapy, which has become standard treatment for some patients in the short time it has existed, alongside traditional chemotherapy.
What is Immunotherapy?
Immunotherapy is like a drone strike in its precision as compared to the “dropping of the bomb that chemo is,” said Dr. Nock. Chemo targets biochemical processes during a cell’s division and throws a wrench in the system, wreaking havoc in the body.
Whereas immunotherapy disables cancer cell’s ability to evade detection by our immune system. It’s as if immunotherapy susses out cancer’s fake ID badge, so that the immune system can identify it as foreign. Everyone always has pre-cancerous cells growing in the body, but these are constantly destroyed by the security system of our immune system, including our natural killer cells.
If you can block the trickery of cancer cells, you can “take the breaks off the breaks [of the immune system,]” said Dr. Nock. Immunotherapy targets just one of these signals (PD-L1) at this point, but Dr. Nock doesn’t think PD-L1 is a great marker.
“There’s got to be something better out there,” he said. He predicts that immunotherapy will become even more diverse, targeting other signals yet to be identified. The advent of genomics — huge amounts of genetic sequencing of cancer cells — and the collaborative efforts happening in Cleveland hospitals, it’s possible to imagine your tumor getting genetically sequenced, and you getting a specialized immunotherapy which blocks signals that your unique cancer expresses.
Big Goals
President Biden asked congress for $2.8 billion in March of 2023 for his ‘Cancer Moonshot’ program. Much of this money will be injected into experimental trials through the country’s largest medical system, the VA.
Dr. Nock, the director of clinical trials program at the VA in Cleveland, administers these trials. He has studies testing out immunotherapy given earlier, and without the adjunctive chemo that ravages patients bodies.
The Biden plan relies heavily on immunotherapy’s success, hoping to reduce cancer deaths by 50% within 25 years. This means the grants used for research in the labs (termed basic research) must entice pharmaceutical companies to take the leap of faith for the theoretical drugs that emerge and pursue clinical trials. Neither can succeed without the other.
“I think were all on the same team,” said Dr. Nock, quieting the skeptics concerned about the for-profit model. “My experience with industry is they are just as engaged and interested in getting rid of cancer as I am.”
He works closely with friends in the industry’s private sector, and thinks that multiple medical systems in Cleveland melding basic research and clinical trials is the perfect breeding ground for leaps forward in treatments.
“I don’t think there could be a better medical city to be in,” Dr. Nock said, noting that the moonshot effort needs not only oncologists, but all types of doctors to help detect and prevent cancer and see the mission through. “The less chemo I give in life, the better I’m going to be.”
Knowing When to Quit
Immunotherapy seems all that it is cracked up to be, but it’s not a cure.
“[Cancer] is a biological event…I don’t think its going to go away for ever,” said Dr. Nock. Knowing when to stop treatment is something doctors and patients struggle with alike. The cost of treating nearly all types of cancer has risen. Certainly the search for more tolerable and effective treatments such as immunotherapy carries a big price tag. And the cost of end-of-life care in the last year of life is known to eat up well over 10% of the Medicare budget, with some estimates putting it over 20%. But it remains difficult to know who will do well and who will not at the time of diagnosing cancer.
When discussing life expectancy with patients, Dr. Nock is much more optimistic.
“I use bigger ranges than I ever used to,” he said, owing much of this optimism to immunotherapy. He still toils with the fledgling patients who die while in treatment or within a month of stopping a therapy. It’s human nature to fight to live. Few other cohorts of people know how to fight like veterans. But cancer remains a valiant foe.
Dr. Nock reminded us that, “Cancer is so smart, it eventually mutates to avoid whatever we’re throwing at it.”
Dr. Corey Meador is a practicing family medicine physician in Cleveland who has written for PBS NewsHour and The Washington Post. He obtained degrees from Loyola Marymount University School of Film & Television in Los Angeles and Drexel University College of Medicine.
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This article appears in May 3-17, 2023.