)
One out of 10 people will be diagnosed with melanoma over their lifetime. While this used to be a death sentence of only months, research has made great strides over the last decade, extending life and hope by years. Dr. Sapna Patel, assistant professor in the Department of Melanoma Medical Oncology at the University of Texas MD Anderson Cancer Center and member of the Uveal Melanoma Assembly, is focused on bringing personalized medicine to melanoma patients. Melanoma mutations are either actionable and can be treated with readily available medications through what are known as Basket Trials, or they require deep genome profiling and access to higher levels of treatment. In both cases, drug therapy is focused on keeping the patient’s immune system “awake.” Using cutting-edge research, Dr. Patel is committed to improving melanoma survival rates and, hopefully, introducing the other “C”—cure—into the conversation.
Transcript
Andrew Schorr:
Hello. I'm Andrew Schorr. I'm sitting with Dr. Sapna Patel, a melanoma specialist from the MD Anderson Cancer Center in Houston. Thank you for being with us once again.
Dr. Patel:
Sure. Thank you for having me.
Andrew Schorr:
Dr. Patel, so melanoma when it spreads—melanoma is scary, period. When it spreads, whether on the skin or to other parts of the body, even the brain, patients are terrified, and let's face it, it was a death sentence for many people over many years. Now things are changing, not for everybody…
Dr. Patel:
Mm-hmm.
Andrew Schorr:
…but for some. And you have this sort of alphabet soup of genetic mutations you look at to see what's going on. Where are we with our understanding where you can personalize treatment? Where are we, and how far do we have to go still?
Dr. Patel:
Yeah, it's a good question. So we discovered mutations in melanoma over a decade ago and have been trying to act upon those mutations, but they're only present really and actionable in less than half of patients.
For another 20 percent of patients who have a mutation the second most common mutation in a gene called NRAS, there are trials and concepts starting to become developed just for those patients. But that still leaves a gap of about 20 to 30 patients where they may not have anything actionable just yet that we know of.
The Cancer Genome Atlas project in melanoma will be published soon, and that will show us there may be other mutations that are recurring amongst the population that we were unaware of, and then it's upon science to figure out what do those mutations do and can we actually target those.
Andrew Schorr:
Okay. So for you, let's say at MD Anderson, typically you do a genetic profile…
Dr. Patel:
We do.
Andrew Schorr:
…with patients to understand what are you dealing with biologically. And now you have some approved and other developing medicines. So where you are now is to see is there either an approved or an investigational approach that matches up with that individual, personalized medicine?
Dr. Patel:
That's the—that's the utmost of personalized medicine, is to sequence somebody's tumor, not rely on a database, you know, really sequence their tumor, their specific mutations, and then cross-match between FDA-approved drugs perhaps in other cancers or even in the cancer that you're studying to look for approved drugs or trials.
And what's becoming increasingly popular is something called basket trials. So basket trials are for patients who have a known mutation for which there is already an FDA-approved drug perhaps for another indication. So, for example, in melanoma we have a drug called vemurafenib (Zelboraf®) if you have a BRAF-positive mutation.
But melanoma is not the only cancer that has a BRAF mutation. And so if you have a hairy cell leukemia with a BRAF mutation, a glioblastoma multiforme, colon cancer, all of these cancers can harbor at a low frequency a BRAF mutation.
Those patients, technically their insurance may not approve them to get a standard of care of medicine for melanoma if they don't have the diagnosis, but a basket trial allows them access to these drugs based on knowing their specific mutations. And if you just sequenced a colon cancer for the common mutations or a glioblastoma for the common mutations, you may not pick up these 1 to 2 percent frequencies of other mutations that occur more commonly in other cancers.
And so really deep genomic profiling is the hallmark of personalized cancer medicine. It's really figuring out what is not just common in that cancer but what may be atypical and in your cancer what can we do to target it.
Andrew Schorr:
Okay. So for someone who is watching where their melanoma's spread, it seems like as part of their team, whether you become their doctor or you're a consultant in their care and they're getting it close to home, this sort of connection with a research center in melanoma may be really important.
Dr. Patel:
We think so. I mean, ultimately we think patients who have access to high?level research in melanoma have better outcomes. And that's probably because, as you alluded to at the beginning, melanoma used to be a death sentence at advanced stage. and now because the research is driving outcomes to be better if you have access to that great cutting?edge research, then you probably will have a better outcome.
The same may not be said in all diseases or even all cancer types. It may be very reasonable to get your, you know, certain diseases, diabetes or even maybe your breast cancer, other cancers, treated in a good hometown center. But for melanoma it is one?tenth of all cancer diagnoses, so it does not walk in the door very often to a general hospital or a general oncology unit. And therefore you want to go to a place, a research center that really sees a lot more continual melanoma to actually improve upon the research.
Andrew Schorr:
Hmmm. Okay. And certainly we're meeting patients now who would have been dead had they not participated in clinical trials…
Dr. Patel:
Right.
Andrew Schorr:
…with these new medicines that have been coming out, the immunotherapy drugs. Let's talk about that for a second. So is it the idea to try to break down the wall, if you will, between the cancer cell and your immune system so that with the help of the medicine the cancer cell doesn't have the defenses and the immune system can do its job?
Dr. Patel:
That's one way of thinking about it. The idea is classically we were putting poison in the body and getting the poison to try to chase down the tumor. But nothing directs poison to the tumor, and so as a result healthy cells get damaged as collateral—collateral waste.
But with immune therapy if you have a functioning, intact immune system, the immune system is capable of recognizing cancer in small volume. But when it gets quite large or overwhelming the balance shifts, and now the cancer is able to proliferate, overwhelm the immune system.
So what you try to do is get the cancer to see that there is—get the immune system to see that there is cancer in the body, and then the medicines are designed at keeping that immune system powerful, awake, if you will. The immune system, sort of like the natural body, has a sleep?wake cycle. And so it wakes up, and then it goes to sleep, and it wakes up and goes to sleep.
Cancer does not have a sleep?wake cycle. Cancer just grows, and so part of the drugs that we're using for immune therapy now are meant to eliminate the sleep cycle for the immune system, keep it awake all the time and get that to overcome a cancer that's continually growing.
Andrew Schorr:
Hmmm. All right. You know what's in the lab. You're involved in a lot of research. You mention there's still a percentage of patients who unfortunately some of these even the newest drugs are not effective for. How hopeful are you more generally in advanced melanoma that other tools are not that far off?
Dr. Patel:
Very excited. You know, really, truly since 2011 we have had some incredible breakthroughs with drugs, but they are not helping everyone. They're helping a fraction of the melanoma population. So generally speaking that means the majority of patients are still, you know, having poor outcomes.
But the newest things that are coming down the pipeline are leading to improved survival of years, and they're helping the majority of patients. Now, they are coming with some significant toxicities. Once you start combining immune therapies in the body, you have to be pretty careful. But the ability to now say we're going to help the majority of melanoma patients instead of the minority and we're going to help them for years, not just months, is pretty powerful.
Andrew Schorr:
Okay. Well, thank you for all you do in treating patients, advising people like this, and also in the research that goes on at MD Anderson and around the world. Let's hope we can talk that other C more often, cure, and certainly about prevention of melanoma, too.
Dr. Patel:
Sounds good.
Andrew Schorr:
Thanks so much. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Brought to you in partnership with PatientPower.info.
Published By :
Patient Power
Date :
Apr 09, 2015
