#yervoy

GUYS GUYS

Prostate cancer, unlike other cancers, has not been nearly as responsive to immunotherapies, especially in monotherapy approaches, then other cancers. 

A recent phase II clinical trial described at the 2019 ASCO GU meeting using a combination of two immunotherapy drugs in metastatic prostate cancer has shown some positive activity.

The trial, the CheckMate 650 Study, evaluated the combination of ipilimumab (Yervoy) and nivolumab (Opdivo) in 90 men with mCRPC who were divided into two cohorts based on their prior treatment. Cohort 1 was comprised of both symptomatic and minimally symptomatic men who progressed after treatment with second-generation hormone therapy (Zytiga or Xtandi) and had not received taxane based chemotherapy for mCRPC, and cohort 2 which included men who had also progressed after taxane-based chemotherapy.

The study data showed that "In a malignancy where immune checkpoint monotherapy has shown limited activity, nivolumab plus ipilimumab demonstrated antitumor activity in patients with metastatic castration-resistant prostate cancer (mCRPC)," said study author Padmanee Sharma, MD, PhD, professor of Genitourinary Medical Oncology and Immunology at the University of Texas MD Anderson Cancer Center in Houston.

Subjects experienced, "Deep and durable object responses, as well as falls in prostate-specific antigen (PSA < 2 ng/mL) levels, were observed in a subgroup of patients," said Sharma, adding that the "preliminary data suggest that biomarkers have a role in identifying patients with mCRPC likely to respond to immunotherapy. "However, treatment tolerability was an issue.

Study subjects received nivolumab 1 mg/kg plus ipilimumab 3 mg/kg every 3 weeks for four doses, and then they received a maintenance therapy with nivolumab 480 mg every 4 weeks.

The combination showed an objective response rate of 25% in cohort 1 and 10% in cohort 2. There were two complete responses in each cohort, and partial responses were observed in six men in cohort 1 and one man in cohort 2. Additionally, 13 men achieved stable disease in cohort 1 and 11 men in cohort 2.

The authors concluded that there was a benefit regardless of prior exposure to chemotherapy, but the benefits appeared to be more pronounced in men who had not received prior chemotherapy.

Median time to response was 1.9 months in the first cohort and 2.1 months in the second cohort.

So much time has passed, and so much has happened!

Matt proposed in February 2017. I hoped it was coming though didn’t know when. The total shocker came shortly after he proposed, when he let me know he bought our first home! We had endlessly hoped that his dad would sell us the house, but I had no idea that time had come. You don’t know Matt, but I do. Taking on this task (a task I’d normally be the one to handle) speaks volumes as he doesn’t do well with this sort of thing. Even so, he shouldered the stress in between classes so I wouldn’t have to worry about it and he could surprise me. He wanted to make sure that I had one less thing to worry about since I still had to list my house and hope it sold quickly (which btw it did!).

Matt moved into our home at the end of March 2017. Max and I moved in towards the end of June. What has transpired since then? A real building, growing, cultivating and loving! Our hour commute to one another was long gone and we finally had an opportunity to coexist in the same space, uninterrupted. Everyone continued to ask me: sooooo, how is it adjusting to co-habitating? Instead of venting, I always find myself playing down how well it’s going since these people are - maybe - expecting me to validate their personal experiences. We’ve been lucky! Lucky, in that, we just.work. He quickly picks up on my need to decompress alone and do something meaningful for myself. He creates a space in which I can have that. He takes Max to the park, to walk the dog, on a long bike ride, to do something fun. And it goes both ways! When I see him unraveling, I suggest he go to the club, steam, go for a walk etc. Or I quiet Max down and try to engage him in something that doesn’t distract Matt from his work or practice. We both have the need to disengage, we both pick up on when the other is in need, and we both extend ourselves for the other because we see the value in it. Though we do have different recharging strategies and timelines ;) 

We’ve talked about how naturally it comes to us, and how much we’ve enjoyed being under the same roof-- building our forever “home” (both literally and figuratively). That being said, our new puppy has been a bit of a hangup! Though Matt’s idea (and let me just say: Matt doesn’t do ANYTHING without being sure of it), he’s found it to be challenging. Change has always taken him out of his comfort zone because it severs his routine --something he can control. We were in a good place, and sweet Winny uprooted that by being an untrained puppy. She made it difficult for any of us to regularly connect with one another, or as a family. In times of stress we’ve all gravitated towards what is immediately necessary: quiet time, alone time, free time. Or in Max’s case, I need attention so I’m going to bounce off of the walls in an effort to get it! 

When there’s not enough time to have both connecting and alone time, we go for what can provide the swiftest recharge. As a result of being a unit, none of us are at our best without the understanding, patience, lovingkindness...and ultimately, assistance, of the other members of our unit. Managing one’s solo life is often challenging in and of itself, but it doesn’t hold a torch to taking on other people you love, a home, a dog, a teaching career, a new project, and for me, owning and operating a business! To attempt this without being mindful of the other pieces of the puzzle would be a fruitless, exhausting effort, that I suspect would feel more like an obligation. 

Both Matt and I are in touch with what makes us the best we can be as individuals. We know what we need in order to prevent straying from our center, and to more easily find it when it’s slipped from our grasp a bit. What I think I’ve learned (will be forever-learning!) is that a family unit is no different. In order for the whole to function, we all need to function. It doesn’t have to be at top-notch speed and it doesn’t come without bending. It does, however, come with an invaluable purpose, rooted in something beautiful and loving. A purpose that can’t be realized on one’s own. A selfless (for the whole) and selfish (also for the whole!) loving that doesn’t exist outside of the unit. 

We are flawed individuals --all three of us. But we are also smart, intuitive, aware (even: aware of our unawareness!), mindful, thinkers and feelers who have the tools and capacity to continue to cultivate something amazing. From the beginning Matt and I have talked about doing a special kind of work, and we’re doing it! We’re in the thick of it and we’re making it happen. Sometimes with little-to-no effort, and sometimes with effort we didn’t know we had or how to access. And that is the special kind of work! The kind of work that allows for growth as individuals, as partners and as parents. To those who think it shouldn’t take work; it should be “easy peasy lemon squeezy” (as Max would say), then I say, enjoy existing comfortably in the same place you started out. I’m sure it’s a cozy, safe space to exist in...but did you know, there is a deeper, cozier, safer, more rewarding space if you just work at tending to it? You’ll likely get banged up along the way, dig deeper than you knew you could (thanks to the strength of a patient partner and the love you two share), challenge yourselves to be better people, partners, parents, workers and students. As a result, you’ll grow as people and so will your relationship. The tiny little seedling that took root so long ago will spread its roots, stand upright, and grow tall and strong. Yes, the elements will sometimes jostle it around and rough it up a little bit, but what’s under the ground: that will continue to hold it and feed it. 

Just in case you happen to need a visual!

This morning I had a “teach” session at the oncology office to learn about the two drugs I’ll be getting for immunotherapy starting on August 30th. Opdivo -- generic name nivolumab -- and Yervoy -- generic name ipilimumab -- have some potentially nasty side effects that I’m somewhat worried about.

The main issue is that both drugs are stimulating my immune cells to become stronger and go after the cancer cells harder than they normally would be able to. But this also means that those strong immune cells could go after other parts of my body that are fine. So that means an increased chance I could develop any condition that ends in “itis” -- like colitis, hepatitis and the like. It means I have to keep a really close watch on how I feel and what my body is doing, and if there’s anything out of the ordinary, I have to report it to the Good Doctor and see if its something to worry about. This is something that can go on after the treatments are finished. 

The commercial for Opdivo is unnecessarily scary, basically just a list of all the terrible things that you can develop while you’re on the drug, “possibly leading to death.” The nurse who did my teach told me that (a) she can’t stand these drug commercials as a health professional because they’re so misleading and they encourage people to ask for drugs that they don’t need; and (b) they’re legally required to list out all of those side effects but the majority of people who take the drugs don’t get them. For me, the most likely side effects will be diarrhea, which I can keep under control by taking Imodium proactively, and fatigue, which I already have from radiation (radiation will be over by then but the fatigue continues for a couple of months).

The other issue is that since my immune system will be busy going after cancer, it will not necessarily be paying attention to the infections that people in crowded situations have floating among them. My primary care doc wants me to continue to work at home the entire time I’m having this treatment, which would take me into early November. My bosses will throw a canary if I do that, and the nurse suggested that I can go back to the office but bring a surgical mask with me and wear it anytime there’s a suspicion of someone being sick at the office. I’m going to see what the Good Doctor says and work from there. They can’t fire me if my doctors say I need to work from home, but they can be very pissed off. I’ll have to see what happens.