Jing’s last post “On Empathy” highlighted a short video including a number of unpleasant and saddening images. Being completely fair, there is one case at around minute 2:40 with a doctor in a white coat looking pleased about being seven years cancer-free. My plan is to look just as smug when I celebrate my seven year anniversary. Nevertheless, to cleanse myself, etc. of the image of a daughter visiting her father in the hospital, I recommend the following alternatives:
Robot drive-thru prank:
After a re-watching this one, I see that drive-thru pranks are something of a youtube genre. I haven’t watched them all, but I doubt there are many essential ideas left undeveloped by this one.
“Newport state of mind”:
If you’re Welsh, there aren’t many opportunities to be transcendingly pleased with one’s heritage (“Chips, Cheese, Curry makes you feel brand-new”). In all honestly, I’m proudest to be Welsh while watching this fair and necessary mockery of JayZ and Alicia Keyes’ “Empire State of Mind“. Seriously, can anyone out there come up with a more asinine refrain than “big lights will inspire you…”? I don’t see how you can write that line down and never, at any point, question whether it really is a worthy addition to our cultural stew.
Ok, now that I’m cleansed from the saddest video ever, I did want to write a short update to my favorite post on this blog to date: “(Hopeful) predictions about the management of glioma“. It’s my favorite because I am instinctively an optimist, and I’ve built my professional life around biomedical research; the idea that we live in an epoch when the end of brain tumors is imaginable fills me with both visceral, emotional, and professional pride. And for the record, I want to emphasize that my optimism is based on informed readings of the literature instead of simply wish-thinking. The first supporting data point Jing and I had was while seeking a second opinion on my treatment options from one of WashU’s glioma experts who said that “time is on [my] side, because the literature is moving faster than [he’s] ever seen.” Also, my surgeon (bless him), while discussing long term treatment options, mentioned that a second surgery (if necessary) is possible, with “hopefully more specific and better targeted chemotherapy” to follow.
In addition to those two anecdotes, I’d like to direct motivated readers to a paper in “CA: A Cancer Journal for Clinicians“, which is a really excellent summary of the progress being made in the treatment and management of brain cancer, including discussions of some very promising technological advances. I caution you that they write mostly about GBM (i.e. high-grade) instead of low-grade glioma, like I had, so their stats and their sense of urgency are a little more grim than is appropriate for my illness. But, that being said, they make many of the same general predictions that I laid out earlier: (1) better imagery technologies to identify every last tendril of invasive glioma cells, (2) non-invasive means to diagnose and genotype brain tumors, and (3) a better understanding of the molecular genetics of tumors to design precisely-targeted and patient-specific treatment regimens. In addition, they discuss improved radiological methods for inhibiting tumor growth, improved surgical methods, real-time monitoring of drug efficacy, and several alternative chemotherapy strategies, including anti-angiogenic, and anti-invasive treatments.
The authors conclude with their vision of brain cancer being more or less under control by 2020. I quote their conclusion at length: “Of course, the goal is to see malignant cerebral neoplasms treated in a curative fashion by 2020. However, not attaining that goal would not reflect defeat. It would still be of great value to patients to convert this disease to a chronic condition that is treated with nontoxic, tumor-directed agents and followed by disease-specific and treatment-specific imaging or regular serologic or CSF analysis of circulating nucleic acid or protein markers.”
Basically, they’re hedging their bets a bit like I did in my earlier post with the slightly cowardly use of the word “hopefully”. Like all clinicians, they don’t want to promise cures and then be proven wrong. For reasons I haven’t quite worked out yet, medical schools apparently teach that giving “false-hope” is the worst thing a doctor could possibly do. My working theory is that doctors live in constant fear that a patient or their family will confront them by saying “you said this wouldn’t happen!” And Jing’s video notwithstanding, most every doctor I’ve encountered through this whole thing has had a superabundance of empathy, even if they try to hide it behind their professional training.
In any case, there are informed, educated people in the field that strongly believe that the end of brain tumors is imaginable, and at the least, we ought to be able to convert brain tumors into a chronic condition like HIV or diabetes or MS in the short term. All of these are unquestionably serious diseases and potentially life-threatening, but manageable with the right care.
How we’re going to beat brain cancer:
My personal, technical belief is that immunotherapies are the most promising avenue for ending brain cancer. Glioma have a diffuse, invasive nature, so it’s hard to imagine surgical interventions being reliably curative. Likewise, since many glioma cells aren’t actively dividing at any given time (in my tumor, at most only 5% of cells were actively dividing, which is a good thing for me), many are insensitive to chemotherapy and radiation. Only the immune system has access to every corner of the brain with the specificity to destroy every last problematic cell. The strategy is pretty simple: educate (i.e. immunize) the immune system against the parts of the tumor that differ from normal brain tissue, and let T-cells do all of the really hard lifting. I note that earlier this week a phase I clinical trial from Japan showed that dendritic cell vaccines against glioma were safe and potentially effective. The challenge for tumor vaccines is that glioma — like many cancers — have evolved mechanisms to escape immune detection. My vision for ending brain cancer is a combination of anti-tumor vaccines paired with drugs to prevent the tumor from escaping immune-surveillance. Many of these drugs have already passed trials, and unfortunately they’ve have had a somewhat disappointing history. But in the post-genomic age, we ought to be able to rapidly identify novel tumor antigens, prepare patient-specific vaccines, and use these drugs to maximize the efficacy of immuno-therapies. I also note that this basic strategy is currently funded as an RO1 to UCSF by the NIH.
How I’m going to beat brain cancer:
As mentioned above, time is on my side. So, although there’s a risk of recurrence, every day and every month, and every year matters. Naturally, I’m doing everything humanly possible to delay or prevent recurrence for as long as possible. Besides, I believe strongly that my tumor initially escaped immune surveillance during a time when I was temporarily and uncharacteristically in poor immunological heath. Which I’m happy to say is ages ago now. I know as well as anyone that everything in the lab takes much longer than we ever expect it to, but there’s really no other choice than to stay healthy and fight back relentlessly.