The Memorial Sloan Kettering Cancer Center waiting room is well over fifty feet long and packed with patients and their companions. Everyone is here to see the Experts — for first or routine appointments or for second opinions on newly diagnosed or metastatic cancer (the latter the reason I'm sitting here). My anal cancer cells have slipped into the lymph system and showed up in the middle of my chest — not in the lungs but in the nodes of the mediastinum, which lies between them. On the PET scan, the new tumor appears as a gleaming star, as if it were physical evidence for the fourth chakra and not a harbinger of my last path.
Collective medical settings, like ERs, intensive care units, and this bloated waiting room, are the purgatories of modern life. There, uncertainty extends time and clouds consciousness and conversations. Couples and small groups whisper to each other between distractions — fidgeting with their phones, watching daytime celebrities shriek with inane happiness on giant TV screens, or staring into the darkness of their thoughts. Every few minutes, like a hostess in a high-end restaurant summoning diners to their table, an appealing young women strolls by calling a name. The doctor will see you now. With a sudden blank expectancy, the targeted patient and his or her companions hoist themselves out of their chairs, collect their coats, and follow her to their destinies.
The oncologist we are seeing is a cancer superstar, my referral obtained by a kind former colleague at WebMD who has worked with him. He is pleasant, academic, straightforward. He recommends waiting a month and a half before starting treatment, unless symptoms develop. He doesn't think it will affect any outcomes, and it will delay the difficult side effects.
We then discuss one of the new immunotherapies called checkpoint inhibitors, which I've been researching. From the work I did as a medical writer and editor, my image of diseases in general, and cancers in particular, has them swimming in a swamp filled with shifting molecular critters, moving up and down and back in forth among the innumerable layers of our organism. Researchers fish among the layers for the stuff on which these diseases feed or the entourages that protect them. Most of the time, scientists end up snagging pilot fish that may or may not indicate a direction toward their prey. If they're lucky, however, they catch a critical snack or an important guard and look for treatments to neutralize it.
I'm hoping the new check-point inhibitors may be such agents by blocking specific proteins known ominously as programmed death (PD-1 and its ligand PD-L1). When bound together, the pathway they form helps ward off attacks by the immune system. When the PD-1 combination is benevolent, it helps prevent autoimmune diseases by blocking immune attacks on healthy cells. When it occurs in cancer cells, however, these same protective actions become treacherous, preventing the immune system from destroying the foreign malignancies.
Checkpoint blockers jam the PD-1 pathway and open the way for an immune system barrage against cancer cells. They are, in fact, proving to be effective in many different cancers, including melanoma and lung cancer, even if they have metastasized. One of these immunotherapies, pembrolizumab (branded as Keytruda), has recently been the first drug approved by the FDA as "agnostic", meaning it can treat nearly any cancer in which biopsies show levels of PD-1 proteins and other factors that could make it a good target.
The day after my visit to Memorial Sloan Kettering, my Albany oncologist calls and she gives me the results of an in-depth assessment of my tumor; it is chock-full of PD-L1 – 90%. To me, this means that pembrolizumab should head toward my cancer like a torpedo aimed at a ship full of explosives. She thinks so too, and after talking to the New York expert, will be treating my metastasis first with this agent. (Ironically, if I were to be treated at Sloan Kettering, one of the world's best research hospitals, I wouldn't be using the new therapy first: I'd have to follow the current standard protocol: starting with chemotherapy, and, when it inevitably failed, follow with pembrolizamab. My Albany doctor, however, has more flexibility, and can start off with immunotherapy.)
Although the New York doctor has recommended waiting for another month to stall the onset of side effects, now that I have the company of my programmed death proteins I am eager to begin this next passage. I hope that it will be a long one.
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