Five years ago, I had my own immune system rebooted to (so far) eliminate my Stage IV melanoma cancer in a trial at the National Institutes of Health. At that time, without further treatment, I probably had six to twelve months to live.
In essence, the tumor infiltrating lymphocytes (TIL) adoptive cell therapy was as follows:
1. The doctors removed a melanoma tumor that was growing in my neck.
2. In the lab, white blood T cells (T lymphocytes) that were attempting to attack the cancerous tissue in my tumor were isolated into at least five different petri dishes. The white blood cells' growth was stimulated using IL-2.
3. Those samples that grew the most and attacked the cancerous tissue (2 of the samples, in my case) were then expanded to a total of 130 billion lymphocytes in the lab.
4. I returned to NIH for a week of immune system preparation, specifically the almost complete suppression of my own active immune system using harsh chemotherapy. This was to allow my body to accept the new lab-grown immune system.
5. Once my immune system was sufficiently suppressed, I received all 130 billions of the lab-grown lymphocytes. The immune system was then stimulated by having five large doses of IL-2 every eight hours over a two day period. (Note: This was hellish.)
6. After a week or so, my immune system had recovered and I was released from the NIH Clinical Center to return home. I was given an anti-biotic to take for 4 to 6 months to reduce the possibility of contracting a specific pneumonia (PCP).
7. I returned to NIH monthly for scans monthly for the first three months. After month one, my tumors had shrunk 33%. After month two, 66%. After month three, they were almost complete gone. My immune systems had essentially been immunized against some of the mutations contained in my cancerous melanoma cells.
8. I was declared NED (no evidence of disease after 15 months) and a complete responder to the treatment after 21 months.
Now, almost five years post-treatment, I have had CT scans and brain MRIs every six months with still no signs of melanoma. My doctors have told me that I'm likely cured.
Immunotherapy works. I chose this trial because the I liked the fact that my own immune system was being boosted to fight my cancer.
Also, besides the overall success of my treatment, other than regular followup scans, I don't require any further medications of any sort. It's a one-and-done treatment. I'm certain that Big Pharma doesn't like these treatments.
Congratulations on a successful treatment! It is so wonderful to hear stories like these. Immuno-oncology is bringing great hope to mutation-rich cancers like melanoma.
>I'm certain that Big Pharma doesn't like these treatments.
You would be certainly wrong on that part. Immuno-oncology has been "Big Pharma's" major focus for the past 5-10 years, inspired in no small part by the work of Rosenburg and many others. One of the most recent approvals discussed on HN was for a CAR T-cell targeted against CD19. Big Pharma would also be very happy to sell immune checkpoint inhibitors for use in combination therapy with adoptive cell transfer.
I hope that I'm wrong. Many more patients can possibly be saved with more widespread use of this treatment. Of course, the FDA needs to modernize their own approval processes to deal with such personalized treatments. It's my understanding that my lab-expanded lymphocytes needed to be individually approved by the FDA.
I do know that my specific trial at NIH was sponsored by Lion Biotechnologies as part of that company acquiring a license to reproduce the laboratory processing for the TIL ACT.
Yep. Novartis' new CAR was recommended for approval last week. ~100 are in the FDA pipeline, and now that the first was unanimously approved, expect a lot more.
I have had two melanomas so far luckily for now early stage. I am lucky to be treated and checked by one of the best at Sloan Memorial, but with more than a thousand moles my doctor told me to expect to get more.
I really hope if we don't catch one of these in stage one that I will be able to get treatment like yours.
With regards to big pharma as far as I understand the problem seems to be a little different namely that it's not a pill or a treatment as such but a combination of things which means big pharma wont necessarily be investing heavily in it as they can't turn it into a product (again as far as I understand).
Last but not least. Congrats on the lucky outcome.
At $300,000 each (from the article) I think they and their shareholders would offer it gladly. How many Viagras do they have to sell to match that revenue?
The price in Australia is AUD$30 (~USD$24) for a 12-pack of 100mg tablets [1]. That's totally unsubsidised, although you do need a prescription. How on earth could they literally cost thirty times more in the states?
I used to work at the National Cancer Institute (tumor immunology research in liver cancer). I've met Dr. Rosenberg a number of times -- everyone there wonders if he'll get a Nobel Prize for his discovery of IL-2.
It's really cool to see the patient's side of the journey though - and I'm very glad things turned out well for you. Thanks for sharing :).
Won't the cancer cells mutate again after it figures out that the immune system is working successfully against it ?
If they won't mutate why can't the body choose the white blood cells which are effective against it and amplify them ? Why does it have to be done externally in a lab ?
If they do mutate again, what makes this treatment effective ?
Excuse me for the basic questions,I have no experience in Biology or how antibiotics work.
Our immune system is a force to be reckoned with for any cancers - we don't have figures on how many cancers our immune system clears before it meets one it cannot clear.
So for cancer to survive, it has to thwart our immune system somehow, and one of the ways it does this is to use signalling pathways which dampen down the immune response. It communicates to the cancer 'calm down, don't call your friends'. The immune cells don't go away - instead they switch to a mode where they control rather than clear the cancer.
Adoptive TIL therapy (which is not the same thing as the article is talking about, though they are both T cells) takes the immune cells from the cancer. These cells recognise the cancer as being foreign ('non-self') and in need of clearing, but they have been suppressed by signals from the cancer. In the lab the cells are selected and bred so that you have a pool of hyped-up cytotoxic T cells, which when transfused back into the patient are so aggressive even the suppressive signals from the cancer don't stop the killing.
In fact, it's the mutations in the cancer which allow this therapy to work. Mutations are what makes the cancer 'non-self' - the more they have, the more attention they get from the immune system. If they try to hide their mutations (all cells must present the products of their DNA on the cell surface), they get removed by natural killer cells (so called because they naturally kill cells unless they display what they are meant to on the cell surface).
The article actually talks about another type of treatment called CAR-T cell therapy. This is a bit different. What you do in this case is you take a T cell from the patient (not a tumour-infiltrating T cell - instead you want an effective T-killer cell), and they graft an antibody which is specific* for the tumour onto the cell. There are a few other steps to make sure that the cell survives in the patient, but essentially when you infuse this cell (ok they give more than one) into the patient, it recognises the target (hopefully the tumour), divides and kills, divides and kills etc etc until the tumour is gone. Then hopefully it stops dividing, or you end up with a T cell tumour.
In this case - your question is right on target. The cancer can and does mutate to avoid this therapy. In this particular case the antibody is for CD19/CD20 (I can't remember), and it was able to clear the tumour before it could evolve to drop CD19/20 from the cell surface. In other patients subsequently treated, a proportion of them have relapse with tumour cells not displaying CD19 on the surface.
In fact, this is the achille's heal of CAR-T cell treatment. It is essentially a very powerful antibody, but for it to work it needs a few things - 1. The tumour must have the target marker on all of its cells - i.e. it can't evolve out, 2. You must be happy to lose any healthy cells which also have this marker.
In this case the patient lost all of his B cells. This is a powerful component of the immune system, but actually, you can get away without it, thankfully. This treatment wouldn't work for a T cell leukaemia/lymphoma. Removing all of your T cells gives you AIDS, which is no better than having a terminal cancer (when it's not caused by HIV, that is).
I just want to say that you have a fantastic way of writing that explains these therapies extremely well. I've learned about these therapies in class, but your explanations felt even more fluid.
Just a clarifying note: mutations and foreign proteins are not always responsible for the effectiveness of TILs in all cases. For instance, in a report from this year, patients with HPV (Human Papilloma Virus) positive cervical cancer were treated with TILs. It was expected that most of the TILs would be directed to HPV antigens or mutated protein (neo-antigens) because both would be maximally foreign to the immune system. However, it was determined that T cells against the wild-type protein CT83 (also known as KK-LC-1; which is a wild-type cancer associated antigen) dominated the response in at least one patient.
Thanks for that - I'll have to have a look at that when I get back on my network.
As you say, there are many reasons why cancer isn't self - neo-antigens are just a facet of that. Are cancer associated antigens the same thing as cancer-testis antigens? To be honest, I've never really groked CTAGs - they don't make sense to me. Why does the thymus not expose T cells to them? Why does cancer produce them? To many questions..!
Can this treatment be designed to target the mutations? ( So you didn't lose healthy cells ) I'm assuming the mutations present on the cell surface as well, but I am unsure.
In that case, would any cell that mutated to avoid there treatment, de-cancer itself?
That would be a sort-of holy grail of cancer therapy. The problem is that the best equipment to develop a high-affinity antibody, or find the correct T cell receptor to the mutation is the patient's immune system - and they've already done it.
Predicting what sort of antibody or T cell receptor will bind a specific mutation (more technically a piece of protein with the mutation in it - about 10 amino acids long) is hugely difficult - it requires a very good understanding of how all the amino acids fold and interact in a 3D spatial model, and we simply aren't there yet.
Your last question really depends on the mutations. Further mutations would stimulate more of an immune response, but a mutation could, for example, increase the ways a tumour cell hides from the immune system. On the other hand, it would be hard for the tumour cells to de-mutate itself to avoid TILs already specific for that mutation.
>I chose this trial because the I liked the fact that my own immune system was being boosted to fight my cancer.
I work in biotech and a very successful CEO of mine once told me "When I'm evaluating new (bio)technologies, always bet on tech that replicates/take advantage of a currently working biological system. Tech where everything is synthetic/relies on a custom designed system/etc is much more likely to not work in the long run."
Re: The IL-2 infusions being hellish, I can guess why that would be (pain, fever, delirium, and so on), but I'd be interested in a first-hand account from someone like you, who seems to be so able to communicate these experiences. In short, what was the hellish part of it?
You've listed the main side effects of the treatment: pain, fever, and delirium.
About 20-30 minutes after receiving a dose of IL-2 by infusion, my body would undergo violent bed-shaking rigors for 10-20 minutes. I had the worst chills I've ever had, followed by breaking out in a hot sweat when it had passed. This was very unpleasant.
After each successive dose, the effects would worsen.
Essentially, the doctors were trying to take my body to the brink of experiencing a cytokine storm (https://en.wikipedia.org/wiki/Cytokine_storm) to jump-start my immune system.
This was a pretty miserable part of the treatment, but (in the end) obviously worth it.
The research doctors at NIH have been refining treatments with IL-2 for almost two decades for thousands of patients. They've gotten enough experience to recognize and mitigate the issues that may develop.
In my specific case, they weee concerned that I might have a heart issue that was unknown (I don't). For the sake of my own safety, I was given the treatment in ICU. For most patients, this is unneeded.
Actually, my biggest risk was contracting a superbug with my severely weakened immune system. The last NIH patient who died from the superbug was a few rooms away in ICU at the NIH Clinical Center at the same time as me. (I knew the doctors were taking extra precautions with me, but I was totally unaware of was what happening down the hall from me.)
When I used to work in a lab, these types of reports were common and delightful to hear, but very few patients were as well informed and granular with their understanding as you are.
I just lost my mother to cancer and it was a hellish experience. It gives me joy to know someone out there beat it and that people in the near future may have a better chance than mom did. Congratulations on the recovery. Wish you many wonderful years full of life!
I might be doing this treatment at some point since I failed Ipi and PD-1. -- What were the long-term side effects for you? -- Have you had neurological/memory problems since?
My biggest side effect has been vitiligo, the loss of color in my skin. The treatment caused my immune system to attack my melanocytes in addition to my melanoma cells. This is actually a great prognostic indicator.
If that's the worst of it, I can handle it, especially considering the alternative.
Nope. As far as I know, I've retained my immunities.
However, I do know that my seasonal allergies have changed slightly since treatment–they've actually moderated. I don't know if that's due to the treatment or just an age-related occurrence.
Cutting edge scientific research is expensive. I don't know why people expect advanced medicine to be cheap. Synthesizing or extracting complex proteins, using rare medical radioisotopes, medical scanners based on the most cutting edge engineering and physics... Almost no endeavor besides physics and medicine makes regular use of superconductors, antimatter (for PET scans), etc.
> I don't know why people expect advanced medicine to be cheap
Nobody said cheap. People (me included) actually expect immunotherapy to be expensive. A course of Perjeta/Herceptin can go to $188k (per [1]). But many are already outraged by this number. A course of Rituxan can be about $14k to the patient, and you could say it's dirt cheap compared to Herceptin, but it appears the cost to the manufacturer is $300 ([2]).
As for superconductors, antimatter, and all other sci-fi sounding things, the cost of an PET scan is about $7k, and of an MRI scan is less than half that, so that can't explain the million we're talking about here.
I think we simply became insensitive to hearing big numbers in the context of healthcare. The birth of my second son cost my insurance about $130k (they covered 90%, but I still had to fork out about $15k), and he didn't have any surgery, or anything major. So yes, I can understand $1MM for cancer treatment, but allow me to be mindblown all the same. I don't think $130k was reasonable for a delivery, and I don't think $1MM is reasonable for immunotherapy (which again, does not involve surgery).
I'm going to assume the lion's share of costs in something as routine as a regular delivery of a baby (i.e. no complications) is probably going to be: Hospital expenses and doctor/surgery costs. IMO paying thousands of dollars to surgeons is definitely justified. I have several doctors in the extended fam, some of whom are surgeons. One of my cousins is studying to be one. Its just fucking crazy how much effort is required to be a doctor (not to mention all the costs assosciated with the education itself). So personally, I think the labor costs of surgery are justified.
The hospital charges make sense too as you're under supervision by trained nurses and living in a room built with specialized equipment.
I had an appendectomy recently. Everything included (surgery, hospital charges, drugs etc.) came to ~ $55k. Insurance paid most of it and I was ultimately charged around $5k. With that in mind $130k doesn't sound unreasonable for a delivery of a baby.
> $130k doesn't sound unreasonable for a delivery of a baby
While I'm accustomed to hearing this kind of thing from the USA, know that for citizens of any other developed country, that is an absolutely absurd amount, to the tune of 10x or 20x the proper cost.
I've recently had friends in both Japan and Australia, hardly countries with poor healthcare, give birth and in both cases the cost was around USD$5k. That's private, by the way - public would have been free (ie covered by the system paid for by the 2% medicare levy in the case of Australia).
I don't disagree the costs of heathcare are super inflated. My contention (and this is purely anecdotal, I don't have hard facts) is that healthcare workers in the US get compensated extremely well. I would like a comparison of doctor/surgeon compensation in different countries... I believe US healthcare professionals get compensated very well in comparison to those in other countries.
These numbers [1] are old but are probably still in the ballpark. US healthcare workers are compensated well, but not all that much more than comparable developed countries. And quality of healthcare in the US is top ten at best [2].
No, the prices are only explainable by profound inefficiency and corporate rent-seeking. The US is paying hugely inflated prices for (at best) similar outcomes to its peers - now that's market failure!
Needless to say I expect the US will adopt a single payer healthcare system within the next 10-20 years, like every single one of its peers, simply because the current system is unsustainable.
Even only taking salaries into account, you've got the surgeons and all associated staff in the removal of the tumour. The guys in the lab to cultivate the white blood cells, everyone who needs to fill out paperwork, more surgery, monitoring and check ups.
Then add into that all the costs of running a hospital, proprietary medication, regulatory compliance, cost of all the single disposables.
The costs very quickly add up to a few hundred thousand before anyone's even taken a profit.
I presume the incremental cost of treating each additional patient will be considerably smaller once the overheads of treating the first person are made.
Not necessarily. Even in regular use, this treatment will still involve killing off the patient's immune system, which will require days in hospital isolation. In addition, the culturing and screening of the immune cells to create a population that is primed to fight cancer is a labor-intensive process that has to be done for every patient.
Small question: How do you get into a trial like this? Did someone choose you? Are trials like this announced somewhere and you did apply? Word-of-mouth? Someone related who works in this field?
It's hard to imagine how it feels to be diagnosed with cancer but I guess in many cases, if the outlook looks dim, a trial like this would make the most sense? Or not?
Getting into a trial usually involves a lot of criteria that the patient has to fulfill (age, subtype and stage of the disease, results of various tests, all kinds of other treatments not working, mutations or lack of them, good performance status, good organ function). If the patient fulfills them their doctor just asks them.
This research and your story give me so much hope for people who have inoperable cancers and can't handle chemo. I look forward to the day that we can rank cancer among syphilis, tetanus, and all of the other past disease scourges of man made completely eliminable by a non lifelong treatment.
My melanoma was initially an ugly black mole that grew on the side of my face, which I had removed by my dermatologist and sent to pathology for analysis, where it was determined to be a melanoma of intermediate depth.
Because of its depth into the skin tissue, I had a wide excision (where more skin tissue is removed) and a sentinel lymph node biopsy which removed four lymph nodes that were most closely connected to the tissue that was removed. Of the four nodes removed, three were negative (clear) and one had a micro metastasis (micromet) sized 0.18mm. This placed me at Stage IIIa.
The melanoma developed as tumors in my lung just over a year later, putting me at Stage IV.
The primary symptom I had was the mole. I felt completely normal.
As far as the treatment, read my answer about the "hellish" nature of it in another reply.
Thanks for the info. This is one of the most terrifying cancers imo, metastating so fast, and with so few symptoms in the beginning. Congrats on your recovery !
Woah. That is seriously cool, that we can do that. Congratulations on your recovery, and thanks for going through that for science.
Can you maybe elaborate a little on how they selected the cells to lab-grow? Step 2 and 3, in particular. By what criteria did they divide them between petri dishes and how did they test how efficient they were at destroying cancer cells? (Did they feed them parts of your tumor or something?)
In essence, the tumor infiltrating lymphocytes (TIL) adoptive cell therapy was as follows:
1. The doctors removed a melanoma tumor that was growing in my neck.
2. In the lab, white blood T cells (T lymphocytes) that were attempting to attack the cancerous tissue in my tumor were isolated into at least five different petri dishes. The white blood cells' growth was stimulated using IL-2.
3. Those samples that grew the most and attacked the cancerous tissue (2 of the samples, in my case) were then expanded to a total of 130 billion lymphocytes in the lab.
4. I returned to NIH for a week of immune system preparation, specifically the almost complete suppression of my own active immune system using harsh chemotherapy. This was to allow my body to accept the new lab-grown immune system.
5. Once my immune system was sufficiently suppressed, I received all 130 billions of the lab-grown lymphocytes. The immune system was then stimulated by having five large doses of IL-2 every eight hours over a two day period. (Note: This was hellish.)
6. After a week or so, my immune system had recovered and I was released from the NIH Clinical Center to return home. I was given an anti-biotic to take for 4 to 6 months to reduce the possibility of contracting a specific pneumonia (PCP).
7. I returned to NIH monthly for scans monthly for the first three months. After month one, my tumors had shrunk 33%. After month two, 66%. After month three, they were almost complete gone. My immune systems had essentially been immunized against some of the mutations contained in my cancerous melanoma cells.
8. I was declared NED (no evidence of disease after 15 months) and a complete responder to the treatment after 21 months.
Now, almost five years post-treatment, I have had CT scans and brain MRIs every six months with still no signs of melanoma. My doctors have told me that I'm likely cured.
Immunotherapy works. I chose this trial because the I liked the fact that my own immune system was being boosted to fight my cancer.
Further info: https://en.wikipedia.org/wiki/Tumor-infiltrating_lymphocytes
My doctor is Dr. Steven Rosenberg of the National Cancer Institute.