In the film adaptation of “Brighton Beach Memoirs,” a young boy named Eugene sees a funeral procession coming down the street in 1937 New York.
A woman leans in and whispers to Eugene, “He had cancer” — the word cancer barely audible.
Aside from being one of the funniest and resonant movies of my youth, “Brighton Beach Memoirs” reflected the attitude of the times toward cancer: It is a dark, terrible thing that we don’t know much about and can’t do anything about and, thus, don’t talk about.
Fast forward 80 years, and you can hardly wade through your social media stream or pick up a paper and not find a story about cancer. Here you are again.
I’m the executive medical director of St. Luke’s Mountain States Tumor Institute (MSTI), president of the Idaho Society of Clinical Oncology, a practicing oncologist and the son of a practicing oncologist. I’ve spent the vast majority of my life thinking and talking about cancer and the last 12 years taking care of people with cancer.
I’ve never been more excited and more optimistic about our prospects for controlling cancer — we are at the very beginning of a golden age in oncology.
Here are updates on some of the advances taking place:
Targeted therapy — hope or hype?
We have begun to identify individual gene mutations that cause cancer and to develop precise therapies that hone in on the specific mutation.
Traditional chemotherapy can be very effective for curing some cancers, like testicular cancer, breast cancer and lymphomas. However, these treatments can come with side effects like hair loss, mouth sores, nausea, diarrhea and suppression of the immune system because they kill any rapidly dividing cells and are not specific to cancer cells. It’s like swinging a chemical sledgehammer when what we’d really like is a molecular scalpel.
The classic success story of targeted genomic therapy is in the case of chronic myeloid leukemia (CML), a disease that used to be universally fatal unless a patient received a risky bone marrow transplant. We now can control CML, and in some cases cure it, with a pill that targets the gene that creates CML.
We know that there are hundreds of potential gene mutations that can cause other common cancers, like breast and lung cancer, but we are not quite there yet in having developed therapies. At St. Luke’s MSTI and other centers around the state, we are participating in a cutting-edge trial called the NCI-MATCH, in which we biopsy individual tumors and have them sent for genomic sequencing. If a certain mutation is detected, then the patient can be “matched” to one of 24 different experimental agents that targets that specific mutation.
At this point, you may be wondering — is this “the cure?” It’s more complicated than that. CML is the poster child for targeted therapy, but it is caused by one mutation and one mutation only, whereas most other cancers have multiple mutations and may require multiple targeted therapies to control them.
Immunotherapy — harnessing our best hope
In the late 18th century, doctors first noted an occasional cancer regression in patients who survived severe infection. That observation led a New York surgeon, Dr. William Coley, to inject cancer patients with a mixture of bacteria he termed “Coley’s toxins.” The idea was to stimulate the body’s immune system with an infectious agent and hope that the cancer would be eradicated in the process. Admittedly, it was a primitive and dangerous way to activate the immune system.
So, we’ve known for more than a century that the immune system — an orchestra of B and T lymphocytes, antibodies, NK cells, macrophages, dendritic cells, cytokines and other molecules — can be a potent way to combat cancer. We’ve just never had a great way to tap into it — until now.
Anti-PD-1/PD-L1 agents are new drugs, known as checkpoint inhibitors, that are revolutionizing the way we treat cancer and are approved to treat melanoma, lung cancer, head and neck cancers, Hodgkin lymphoma, kidney cancer and bladder cancer.
Many of these cancer cells evade our immune system by coating their surface with a protein called PD-L1. These PD-L1 proteins are an oncologic Jedi mind trick that tells our immune system, “These are not the cells you’re looking for.” The new anti-PD-1/PD-L1 drugs block this maneuver, essentially uncloaking the cancer cells and re-directing our immune system to attack them.
Although these checkpoint inhibitors do not work in all patients, as oncologists we’ve seen remarkable responses in patients with bad cancers. Cancers are devious. They mutate and evolve in the midst of treatment. As it turns out, our body’s immune system is the only thing in nature sophisticated enough to mutate and evolve in lockstep, and thus offers hope for curing even advanced cancers.
Cancer can be sexually transmitted — what?
It turns out my family medicine colleagues are doing a better job than I am of curing cancer.
How so? By preventing cancer before it even has a chance to start.
I witnessed this last month when I took my sons in for their first round of HPV (human papilloma virus) vaccination. The vaccine works like a flu vaccine — it tells our immune system to fight off the sexually transmitted virus before it can get into the cells lining the genital tracts, where it likes to set up shop and emit a protein that slowly causes mutations to accumulate and eventually lead to cervical cancer, anal cancer, penile cancer and oropharyngeal (throat) cancer. As my son Ben explained to his younger brother Jack as we made our way to Capital City Family Medicine, “It’s so you don’t get cancer on your junk.”
If you have children or grandchildren ages 11 and 12, please get them vaccinated against HPV.
What? You’re thinking, “My kids aren’t sexually active yet!”
Exactly. Neither are mine. The idea is to vaccinate before they’re ever exposed to HPV.
Doesn’t the vaccine cause autism? No. Won’t getting them the HPV vaccine encourage them to be sexually active at a younger age? No again.
For all the fascinating advances in treating cancer I’ve described earlier, there is still nothing more effective as being able to prevent cancer in the first place.
Why don’t we all get cancer?
One of the most common questions posed to me is, “Why did I/my mom/my friend get cancer?”
My answers vary. In general, medicine and the scientific method are well-equipped to answer questions that start with what, where and how, but often fall short in addressing questions that start with why. The “why” humbles us, and reminds us of the limitations of human knowledge and the need for answers that are spiritual and philosophical in nature.
Second, it’s not our fault if we get cancer. Whether fully articulated or not, I often can hear that thought below the first question.
Whether it’s hereditary, from an environmental exposure or from who knows what, we can’t blame ourselves if we get cancer. There are more than 80,000 chemicals in the environment that we’re constantly exposed to and that didn’t exist before World War II. It is part of our modern condition.
The question often prompts me to think of this discomfiting question: “Why don’t we all get cancer?”
Just to be alive, every day we have billions of cells in our body that are dividing, growing and dying off. In each of these cells are 23 chromosomes with 3 billion bits of information called base pairs that must be faithfully copied and passed on to the next cell.
Any mistake in this process is a mutation that could lead to cancer, and for the vast majority of us, for the vast majority of our years on earth, this process goes on without a hitch. This biologic task is larger than asking every man, woman and child in the United States to write 3,000 copies of Moby Dick on a chalkboard, every day, without a single person making a single mistake. We call it the “miracle of life” for a reason.
Thanks for reading. I’m thrilled to live in a time when, unlike my kindred spirit Eugene and his family in 1937 New York, we can talk about cancer in a way that is loud and spirited and hopeful and without fear.
Dr. Dan Zuckerman is an oncologist and the medical director at St. Luke’s Mountain States Tumor Institute. Learn more about St. Luke’s MSTI at stlukesonline.org and search for MSTI.