A Glass Half Full

Yesterday marked the beginning of cycle number six for my third-line chemotherapy treatment. In this regimen, one full cycle is comprised of four weeks. During week one, two different chemotherapeutics (carboplatin and paclitaxel) are given along with the requisite premedication (steroid, anti-nausea meds, and an antihistamine). During both the second and third weeks of a cycle, I receive only one chemotherapeutic (paclitaxel) and the same premeds. Week four is a holiday/break, with no scheduled treatment that helps provide recovery time for blood counts and other markers. Then the four-week cycle repeats.

Lorie and Michael Becker in the chemotherapy suite at Memorial Sloan-Kettering Cancer Center on 12/5/17

Having received five cycles over the past five months, my blood counts are slower to recover – particularly my white blood cells. As a result, my medical oncologist (Dr. David Pfister at Memorial Sloan-Kettering Cancer Center (MSKCC)) modified the last treatment to forgo the third week of chemo since that is usually about the time that my white blood cells are on the low side. In other words, the most recent two cycles of treatment have been “two weeks on, two weeks off” meaning that I get two chemotherapeutics (carboplatin and paclitaxel) on week one, only paclitaxel on week two and then a two-week break during weeks three and four before starting the cycle over again.

Considering that the latest 2/5 cycles have been reduced in terms of the total amount of chemo I’m receiving, it is encouraging to see that each CT scan still shows decreases in the size of some tumors. For example, take the largest tumor (on my spleen) that originally measured 6.4 cm on its longest axis and 6.0 cm on its shortest axis back in early January 2017. Since starting third-line chemo over the summer, those dimensions have decreased on each subsequent CT scan: 5.4 x 4.8 cm, 3.2 x 2.6 cm and most recently 2.9 x 2.0 cm. Many other lymph nodes in my lungs and abdomen are also now 1 cm x 1 cm or smaller, which is typically the size of a “normal” lymph node—although PET imaging would help inform whether or not there is still disease activity.

But just exactly how unusual or encouraging is all of this? During the MSKCC appointment, I gathered that the general expectation would have been decreased disease from the first treatment cycle, perhaps stable disease on the second cycle and then possibly progressive disease on the third or later cycles. Bottom line: my cancer continued to decrease across all three recent scans, which is better than normally expected.

I’m happy about the results and extremely thankful that I received strong encouragement to give chemotherapy another chance. And it’s not just about tumors shrinking, there have also been meaningful improvements in my quality of life. For instance, at the start of chemotherapy I had not one but two chest tubes placed to help reduce fluid around my left lung. Both have since been removed, as the fluid buildup is gone. Associated side effects with the fluid, such as coughing and difficulty breathing have also disappeared. Oh, and it is a lot easier to shower without wrapping your chest and abdomen in plastic wrap each time to avoid water getting into the tubes!

I’m a curious person by nature and seeking potential answers as to “why” my disease is responding a bit better than expected to the current chemo regimen. As a long-time champion of immunotherapy, I can’t help but wonder about my prior second-line therapy with M7824, an experimental bispecific fully human antibody designed to simultaneously block two immuno-inhibitory pathways (both PD-L1 and TGF-β) that are commonly used by cancer cells to evade the immune system. The aim of this investigational drug is to control tumor growth by restoring and enhancing anti-tumor immune responses.

While receiving M7824 at the National Institutes of Health (NIH) as a participant in their Phase I trial, results from biopsies of both my tumor and pleural fluid provided evidence of immune system activation in the vicinity of the tumor, indicating that the experimental agent M7824 was performing as designed. In particular, the presence of tumor-reactive CD8-positive T-cells, which have emerged as the predominant effector in most cancer immunotherapy settings[1]. In fact, one published study in head and neck cancer patients whose tumors were densely infiltrated by CD3-positive and CD8-positive T cells had a significantly longer overall survival (OS) and progression-free survival (PFS) compared with patients whose tumors were poorly infiltrated[2].

It’s quite possible that based on the large tumor burden in my body, the immune system activation resulting from M7824 might not have been able to overpower the disease. However, with my tumor burden now having decreased substantially through subsequent chemotherapy, I can’t help but wonder if M7824 could be playing a role in my ongoing disease improvement.

While answering this question is purely academic, it could help inform the design of future combination studies with M7824 and chemotherapy. From a personal perspective, it would also validate that I made the right decision to jump into the M7824 trial after failing first-line therapy (chemoradiation).

As someone with no formal medical training, my initial thought was to have the largest, most accessible tumor biopsied to look for residual immune system activation. Unfortunately, the largest remaining tumor is on my spleen and my oncologist frowned on the prospects of poking needles around that area. A good to time to remind readers that while I have a fair amount of working knowledge in biotech, I always rely upon the wisdom and experience of the treating physician. They’ve gone to med school…I have not.

But I do feel it is very important, to the full extent possible and without substantial added risk to me, to find some signal—even if anecdotal—that M7824 did something good. For my friends in the medical community, please feel free to email me any ideas or thoughts!

References:

[1] Targeting CD8+ T-cell tolerance for cancer immunotherapy. Stephanie R Jackson, Jinyun Yuan, and Ryan M Teague. Immunotherapy. 2014 Jul; 6(7): 833–852.

[2] Tumour-infiltrating lymphocytes predict response to definitive chemoradiotherapy in head and neck cancer. P Balermpas, Y Michel, J Wagenblast, O Seitz, C Weiss, F Rödel, C Rödel and E Fokas. British Journal of Cancer (2014) 110, 501–509. doi:10.1038/bjc.2013.640

Good Luck Charm?

It was July 18, 2017 when I started my third line of treatment (carboplatin/paclitaxel) for Stage IV squamous cell carcinoma of the head and neck. Things weren’t exactly going great at the time and I remember thinking that I wouldn’t make it until my 49th birthday in November.

For example, I had two chest tubes to manage a pleural effusion (buildup of fluid in the pleural lining of the lung). My tumors were slowly growing with each CT scan. Additionally, I had an IVC filter put in to manage clots since blood thinners had caused bleeding issues. I was a mess and in-and-out of the hospital constantly.

Earlier today, however, I received my third consecutive CT scan report since starting chemo again that showed further decreases in my lung, spleen, and pleural metastases (where the cancer had spread). It looks as though the cancer continues to respond to the treatment, which is great news.

It just goes to show the perils of trying to answer the question every cancer patient wants to know: How much more time do I have left? It doesn’t stop us from asking physicians, but as a dear friend consistently points out to me – you just have to live in the moment and enjoy every day. Much easier said than done, but sage advice nonetheless.

Our pup Humphrey

I can’t help but wonder if our 8-month old golden retriever puppy, Humphrey, is perhaps some kind of good luck charm? We got him about a month before I started treatment and things have been going relatively well since then. Not that we need another reason to love him! He’s such a clown, always making us laugh and smile. We love all of our other pets too, but there’s just something about Humphrey that makes him special. At the very least, he’s a great therapy dog for me.

In any event, today is a very good day. It will be nice to bask in the warmth of some good news as the colder weather of the season approaches.

Two Years Gone

You’ll know from the opening pages of my memoir A Walk with Purpose that it was the day before Thanksgiving in 2015 when I first discovered a large lump on the right side of my neck. The discovery catapulted me on a journey that I never could have imagined, full of twists and turns and changing the very fiber of my being—physically, emotionally and spiritually.

A lot has changed in the past two years—some good, some bad, some perhaps downright ugly. But Thanksgiving has always been one of my favorite holidays—a time of reflection and giving thanks for the goodness of the season past instead of complaining about what we don’t have.

Throughout the process of writing my memoir, I was constantly amazed to see how all the gifts and experiences of this world came together like tiny puzzle pieces to reveal the bigger purpose of my life. In particular, how an unlikely career path to the biotechnology industry would help forge key relationships, open new doors, and help me navigate a cancer diagnosis and treatment through the knowledge gained over decades of service and leadership. Most importantly, how I could use all of the aforementioned to help others facing head and neck cancer caused by the human papillomavirus (HPV).

In some ways, my revelation was reminiscent of the first time I saw the movie Signs written and directed by M. Night Shyamalan. In the movie, a father and former priest lives with his asthmatic son, his daughter who constantly leaves glasses of water sitting out around the house, and his younger brother, a failed minor league baseball player, on an isolated farm in Bucks County, Pennsylvania (coincidentally where we have lived for more than 15-years…). The father lost his faith and gave up his priesthood after his wife died in a local traffic accident. Towards the end of the movie, a crucial scene reveals the unlikely connection between asthma, glasses of water, and the mother’s final words to her husband instructing his brother to “swing away.” At the end of the movie, the father is shown returning to his priestly duties, apparently having regained his faith.

During 2017, I was fortunate to write and publish (then rewrite and republish…) my memoir. Since my diagnosis, I’ve also published a total of 70 posts (gulp!) on my patient blog. Supporting these efforts, I’ve worked with a publicist and conducted numerous interviews and penned guest editorials for various media outlets. All of these actions designed to: 1) help increase awareness of HPV and its link to six cancers in men and women; 2) underscore the need for additional prevention efforts for HPV-associated cancers, including efforts to increase vaccination coverage; 3) correct the misperception that HPV is mainly a disease affecting women; and, 4) highlight how HPV can be spread in the fluids of the mucosal membranes, which line the mouth, throat and genital tracts. Looking back at my efforts, I hope you’ll agree it has been a productive year.

I’m currently going through my third treatment regimen (chemotherapy) with the simple hope of buying more time. My body is weary from repeated assault with toxic chemicals aimed to keep the cancer at bay—hoping to see the day when a better treatment option becomes available. Fortunately, my current quality of life allows me to continue my walk with purpose. In fact, today I am doing a couple of media interviews and meeting with a head and neck cancer patient support group in Princeton, New Jersey.

My next CT scan has been scheduled for the last week of November. The results of which will inform whether or not my cancer continues to shrink, stays stable, or is progressing. Regardless of the outcome, I strive to simply live in the moment and take advantage of the Thanksgiving period to consider how we can spread more happiness around, to look back at all the great memories and good people who came into our lives.

May the good things of life be yours in abundance not only during November but throughout the coming year. Thank you to everyone with an interest in my story for your continued support and for keeping in touch!

The Role of Social Media in Cancer Care

Possibly due to my early days of computer programming and/or work creating one of the first brokerage firm websites, I recognized very early on the power of the Internet to connect people. When I first started my cancer patient blog in December 2015, it was mainly an efficient tool for me to keep family and friends updated on my health. However, I quickly realized that social media (e.g., Twitter, Facebook, Instagram, blogging) also afforded me the opportunity to provide unprecedented access to my personal experience as a terminal cancer patient. In doing so, I felt that my insight could be beneficial to others dealing with a head/neck cancer diagnosis and the effects of treatment. Importantly, I hoped that sharing my story could also help create awareness for the cause of my cancer (human papillomavirus, or HPV) and how today’s vaccines can prevent it.

Writing about my cancer experience is cathartic and that alone made all of the blog posts, Tweets, Instagram images, and Facebook entries seem worthwhile. What I didn’t expect was how my social media activities actually helped me deal with my own cancer diagnosis. Accordingly, the purpose of this blog post is to highlight some of these interactions with the hope that other cancer survivors find similar ways to derive benefits from social media.

For example, some people have a talent for making new friends. Unfortunately, not everyone is born with the gift—including me (yes, it’s true). Some side-effects associated with cancer and its treatment make this situation even more difficult. Being fatigued and depressed can lead to a lot of time being secluded in one’s own home—not working and feeling isolated and alone. The ability to meet new people and establish relationships can be enhanced through social media and other Internet activities.

In this regard, I’ve been fortunate to have met several Twitter acquaintances during their visits to the East Coast from as far as Buenos Aires, Argentina (@BursatilBiotech), the Pacific Northwest (@SheffStation), and Lenexa, Kansas (@bradloncar). Meeting individuals in person was an unexpected yet pleasant surprise in view of today’s digital communication era. Of course, it doesn’t hurt that our family’s latest animal addition, a golden retriever puppy named Humphrey, has attracted his own cult following on social media.

Lorie and Michael Becker – click to enlarge (photograph by Paul Reitano)

In late September 2017, I received an unsolicited email from fellow head/neck cancer survivor Paul Reitano. His surgical oncologist had posted a story about me on Facebook that led him to both my book and blog. Beyond our shared cancer background, we both enjoy photography and Paul wanted to include me in his personal project regarding portraits of cancer survivors. We set a date for early October when he was in town and spent the better part of a beautiful autumn day talking about common interests as he clicked the shutter on his camera. By late afternoon, we were like old friends even though we had just met. Among many excellent captures, Paul took a beautiful photo of me and my wife, Lorie, that we treasure. Aside from an array of gorgeous photos, Paul and I keep in touch and it has been great to have another head/neck cancer survivor in my life.

More recently, I had the pleasure of connecting with another head/neck cancer survivor, Jason Mendelsohn, through social media. Jason was recently the subject of a NBC news segment reporting on the silent epidemic of HPV-related cancers among men. Like me, Jason is determined to help others by sharing his story and experience through his blog.

Another unexpected benefit from social media is the support from reporters and related contacts I’ve developed throughout my career or who have recently covered my cancer story. One of the more memorable experiences was when @adamfeuerstein dedicated his 2017 Pan-Mass Challenge (PMC) ride to me as a token of his support over the summer. PMC raises money for life-saving cancer research and treatment at Dana-Farber Cancer Institute through an annual bike-a-thon that crosses the Commonwealth of Massachusetts. Through social media, I’ve also been fortunate to make several new media connections, such as @BiotechSusan, editor of BioCentury, and @JohnCendpts, co-founder of Endpoints News, among many others.

Social media can also be a means for health education and public messaging. Through Tweets and sharing articles, I’ve enjoyed being able to help correct the popular misconception that HPV vaccination is only for girls and cervical cancer. Creating awareness about HPV’s link to six different cancers and the proven safety/benefits of HPV vaccination for both boys and girls is one of my personal goals, which has been enhanced through my participation in social media.

The role for social media in cancer care is embryonic and evolving, but my experience thus far suggests that there are many potential benefits. There are, of course, certain challenges, not the least of which includes the potential for sharing inaccurate medical information and the lack of privacy and confidentiality when discussing deeply personal situations.

As an example of both, one need look no further than Michael Douglas’ revelation in 2013 that his cancer may have been caused by performing oral sex has and the resulting embarrassment caused to his wife, Catherine Zeta-Jones. In fact, only a few studies have looked at how people get oral HPV, and some show conflicting results. Some studies suggest that oral HPV may be passed on during oral sex (from mouth-to-genital or mouth-to-anus contact) or open-mouthed kissing; others do not. The likelihood of getting HPV from kissing or having oral sex with someone who has HPV is not known. According to the Centers for Disease Control and Prevention (CDC), more research is needed to understand exactly how people get and give oral HPV infections.

Perhaps the world just wasn’t ready to hear about the links between oral sex, HPV and head/neck cancer at the time, but fast forward to today and Michael Douglas’ story may have helped create greater awareness and a sense of urgency to better treat and prevent what is becoming the one type of oral cancer whose numbers are climbing, especially among men in the prime of their lives. The world could use more support from celebrities affected by HPV and cancer to further increase awareness and/or raise research funds for new treatments and diagnostics.

In view of growing use, researching and defining the role for social media in cancer care represents an important area of unmet need. Certainly, this is a subject that merits further investigation and could be an interesting workshop at an upcoming major medical conference, such as the American Society of Clinical Oncology (ASCO) annual meeting. In the meantime, thank you to ALL of my social media connections who help make the world seem a bit smaller and a whole lot brighter!

Catheter’s Revenge

Back in early August 2017, I had my two chest catheters removed during one of my many hospital visits during the summer. While insertion of both devices was done under twilight anesthesia, the medical professionals who arrived at my room explained that lidocaine injections would hurt more than the actual extraction – so no local anesthesia would be used.

Figure 1: My Aspira catheter exit site seen as the larger, red area (click to view larger image)

I had two different catheters in my body. The first one was an Aspira® catheter, which was in my body approximately four months. The second was a PleurX® catheter that was used for a much shorter period.

Since the removal of both catheters, I’ve had issues with the area between where the Aspira catheter was inserted and the exit site (see Figure 1). The area was often sore and red, which got gradually worse during the past two months. This week, the exit site became raised and fluid started oozing from the previously healed exit incision.

Figure 2: Aspira catheter diagram (click to view larger image)

To help keep the catheter tube in place, a retention cuff is used to facilitate tissue in-growth (see Figure 2). Accordingly, the catheter must be surgically removed by first freeing the cuff from the tissue, then by pulling the catheter out gently and smoothly.

Yesterday, an ultrasound imaging procedure revealed that the Aspira cuff was left behind and was the source of my discomfort. There was no surgical procedure used in the removal of my Aspira catheter back in August and therefore the cuff, which became quite attached to my body, didn’t want to leave.

Figure 3: Michael Becker in surgical suite

Fortunately, I was able to see a surgical team late yesterday as well. After assessing the situation, they were able squeeze me in for a procedure. First, they numbed the area with lidocaine injections and then retrieved the rogue Aspira cuff. It was a quick procedure.

I’ll have plenty of time to rest, as my blood counts were once again too low for chemotherapy this week. Next week is my normal week off from chemo as well, so my next round of therapy should be on November 7th.

Book Re-Released

When I first started seriously writing my memoir in January 2017, I was in a bit of rush to get it completed. At the time, my disease outlook was less than favorable and I didn’t know how much time I would have to write. Somehow, I was able to complete and publish “A Walk with Purpose: Memoir of a Bioentrepreneur” before the end of April that same year.

Since then, my cancer has responded well to the current chemotherapy regimen. Six-months after publishing my book things are still stable — although I’m living from CT scan to CT scan.

After stepping away from my book for a while, I recently took the time to reread it with a fresh set of eyes. Besides, a lot has transpired over the last six-months. With the benefit of more time, I sought to revise some sections and remove others. I also updated the ending of the story to reflect my current prognosis.

If you have purchased an eBook version of the novel in the past, the new version is now available via Amazon at no cost. Simply update the content on your “Manage Your Content and Devices” page (www.amazon.com/gp/digital/fiona/manage).

Customers who download eBooks through Kindle Unlimited will receive the updated content as long as they haven’t returned the Kindle Unlimited borrow before the content update is initiated.

At this time, customers who download eBooks through Kindle Owners’ Lending Library don’t receive updated content.

Going forward, anyone who purchases either the paperback or eBook version will receive only the new, updated copy. To verify whether or not you are viewing the new/updated version, look for the text ***Second Edition*** on the copyright page.

While it’s not a complete rewrite, there are substantial updates throughout for those considering whether or not to reread the book.

Good News and TGIF

Earlier this week, I had my periodic CT scan to determine whether or not the chemotherapy I’ve been receiving is continuing to work. I just received word from MSKCC moments ago that indeed many of the tumors continued to shrink compared to my last imaging procedure in August (which showed a decrease in tumor size almost across the board). Importantly, there weren’t any new lung metastasis.

Raspberry flavored, oral contrast agent to drink before CT scan

Clearly, this is very good news. In a perfect world, one would like to see all the tumors completely disappear. That would be highly unusual, so I will gladly accept serial decreases in the tumors from period-to-period.

This coming Tuesday, I should receive my chemotherapy doublet (provided that my blood counts are sufficient).

That’s all for now…short and sweet…as I am going to hug my family and enjoy the weekend.

Meeting a Fan

A couple of weeks ago, I received an unsolicited message on LinkedIn from a young woman we’ll call “Mary” for the sake of anonymity. Like me, Mary is extremely passionate about the biotechnology industry and she works as a scientist in the lab at a local company.

In her message, Mary stated that she recently read my memoir and found the story to be moving. She offered to meet for coffee and expressed an interest in hearing more about my career path. Knowing that I’m going through chemotherapy, she completely understood if I wasn’t up for meeting, but stated that she “couldn’t pass up the opportunity to ask, as she was so inspired by my work.”

How do you say “no” to that? It isn’t every day that a fan reaches out to me requesting to meet (in fact, this was a first), so I was quite flattered. We settled on a date and time to meet for coffee in downtown Yardley, PA that worked for our respective schedules.

I informed my family about the upcoming meeting with Mary and they reacted as one would expect. Who is this person? Why does she want to meet? She could be a homicidal maniac, etc. Obviously, they were just being protective and looking out for my best interests. After all, I’ll admit that my mind wandered ever so briefly to Stephen King’s 1987 novel Misery about a psychotic fan who holds an author captive and forces him to write her stories.

I arrived at the coffee shop first and attempted the daunting task of identifying Mary solely on the basis of her LinkedIn profile picture. Instead, she instantly recognized me (not too difficult given my recent “bald head and bold eyeglass” look) and came over to say hello. I admit to a certain sense of relief that she looked nothing like Kathy Bates who played the psychopathic Annie Wilkes in the film version of Misery.

We ordered drinks and sat at a quiet table in the back of the shop. What ensued was a lovely conversation about my background and our mutual interest in the exciting biotechnology industry. It was clear that we were both bitten by the biotechnology bug and it was nice to exchange thoughts and perspectives about the field.

When asked, Mary shared that she was introduced to my memoir by a college professor at a prestigious university where she is participating in an online degree program. Apparently, the professor suggested the book to his class and others were reading it as well.

My ego sufficiently bloated, I asked Mary to provide me with the professor’s contact information so that I could at least thank him for recommending my book, which she did. I sent out the note without even making the connection that the professor and I had several prior exchanges on social media and that he was also a research scientist at the National Institutes of Health (NIH). He promptly responded and reminded me of the connection. What a small world after all…

The meeting with Mary at the coffeehouse lasted an hour and a half, but it went by quickly and felt much shorter. However, the high from interacting with a “fan” lasted a lot longer and inspired me to get out more often and meet with others who have an interest in my story. This could be via book signings, meeting with book groups, speaking at events, etc.

When I wrote A Walk with Purpose: Memoir of a Bioentrepreneur, it was with a historical perspective of my life’s journey. But I’m continually amazed to see that my walk and purpose are not yet complete. For example, at first I was humbled every time I learned that my book inspired a parent to reconsider vaccinating their child against human papillomavirus (HPV). Now, through my brief exchange with Mary, I have also witnessed how the book can ignite and/or reinforce one’s interest in the exciting field of biotechnology.

So, thank you Mary…and all of the others who have taken the time to share how my book has positively influenced them. Each of you inspire me to continue my walk with purpose!

No Such Thing as “Risk-Free”

In a recent guest editorial that I penned for BioCentury, I referenced that a parent’s choice whether or not to vaccinate their child against the human papillomavirus (HPV) isn’t a “risk-free” choice. Every drug has risks – consider the following statement by the U.S. Food and Drug Administration (FDA): “although medicines can make you feel better and help you get well, it’s important to know that all medicines, both prescription and over-the-counter, have risks as well as benefits.” I would also point out that there are risks in forgoing a medication.

Let’s take a look at the HPV vaccine’s side-effects according to the prescribing information for Gardasil® 9 (Human Papillomavirus 9-valent Vaccine, Recombinant). The most common side effects include pain, swelling, redness, itching, bruising, bleeding, and a lump where your child got the shot, headache, fever, nausea, dizziness, tiredness, diarrhea, abdominal pain, and sore throat. These are adverse events disclosed by the sponsor (Merck & Co., Inc.) to the FDA from completed clinical trials of Gardasil 9. Since licensure in 2006, over 270 million doses of HPV vaccines have been distributed and the sponsors are obligated to report any new side effects to the FDA.

What’s that you say? You don’t trust the pharmaceutical industry? The Global Advisory Committee on Vaccine Safety (GACVS), an independent expert clinical and scientific advisory body that provides the World Health Organization (WHO) with scientifically rigorous advice on vaccine safety issues of potential global importance, first reviewed the safety data for HPV vaccines in 2007 and subsequently in 2008, 2009, 2013, 2014, 2015, and 2017. In each period, the GACVS examined various vaccine specific safety issues, such as links to Guillain-Barré syndrome (GBS) and other autoimmune safety issues. No other adverse reactions have been identified and GACVS considers HPV vaccines to be extremely safe. According to the WHO, there are now accumulated safety studies that include several million persons and which compare the risks for a wide range of health outcomes in vaccinated and unvaccinated subjects.

Early on, the GACVS was presented with signals related to anaphylaxis and syncope related to the HPV vaccines. According to the GACVS, the risk of anaphylaxis from HPV vaccines has been characterized as less than 2 cases per 1,000,000 doses, and syncope was established as a common anxiety or stress- related reaction to the injection. Anaphylaxis is a severe allergic reaction that needs to be treated right away with an epinephrine (adrenaline) shot. Anaphylaxis is rare, and most people recover from it. Syncope, also known as fainting, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. It is caused by a decrease in blood flow to the brain, usually from low blood pressure. For these reasons, the prescribing information for Gardasil 9 recommends observation of the individual for 15 minutes after administration.

Next, let’s consider the risks of not getting vaccinated against HPV. Again, according to the prescribing information for Gardasil 9, the vaccine helps protect girls and women ages 9 to 26 against cervical, vaginal, vulvar, and anal cancers and genital warts caused by 9 types of HPV. Gardasil 9 also helps protect boys and men ages 9 to 26 against anal cancer and genital warts caused by those same HPV types. Accordingly, individuals who do not get vaccinated against HPV are at risk for the aforementioned cancers and genital warts.

In addition, the 9 types of HPV that infect the genital areas can also infect the mouth and throat (called oropharyngeal cancers). HPV is thought to cause 70% of oropharyngeal cancers in the United States, with HPV type 16 causing 60% of all oropharyngeal cancers. The HPV vaccine was originally developed to prevent cervical and other less-common genital cancers and has been shown in clinical studies to prevent cervical and other precancers. However, HPV vaccines could also prevent oropharyngeal cancers because the vaccines prevent infection with HPV types that can cause oropharyngeal cancers.

HPV vaccines were not available until I was age 38, which is well-beyond the upper age limit of 26 when the vaccines are considered effective. In late 2015, I was diagnosed with poorly differentiated, oropharyngeal squamous cell carcinoma, HPV type 16 related. My three treatment regimens thus far have included: chemoradiation, immunotherapy and currently chemotherapy.

Side-effects that Michael Becker has experienced from cancer and its treatment (click image to enlarge)

My diagnosis is terminal, so “death” would be the primary side effect from the disease that I would gladly forgo in favor of any of the aforementioned HPV vaccine side effects. Setting my grim humor aside for the moment, there are more than a dozen other side-effects that I have personally experienced to date from either cancer or its treatment (see accompanying image for details). And these side-effects don’t include others that I haven’t personally experienced, such as kidney damage.

I’m an advocate of HPV vaccination and strongly encourage parents to speak with a physician when it comes to deciding whether or not to vaccinate a child. The purpose of this blog post is to underscore that deciding not to vaccinate against HPV isn’t a risk-free decision. In my experience, the diagnosis of any one of the six cancers resulting from HPV infection is associated with plenty of important risks for parents to also consider.

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The Space Between

The purpose of my blog and entries is multifaceted. Some are designed to entertain, while others focus on education and enlightenment for those suffering from cancer and the people who surround them. Others are simply updates on my disease for family and friends.

I don’t consider myself an optimist or pessimist, but rather a realist. Accordingly, I prefer to let the facts in my blog speak for themselves and let you, the reader, decide if the glass is half full or half empty.

For me, life is usually viewed in absolutes. Things are either black or white; rarely, if ever, shades of gray. And I like it this way…nice and neat. This is probably why uncertainty, which falls into the shades of gray zone, doesn’t sit well with me. Unfortunately, living with a terminal cancer diagnosis introduces a fair amount of uncertainty – almost from day one.

It starts with waiting for the initial diagnosis. Is it cancer or not? Usually this is a black or white analysis. The diagnosis of cancer then leads to a myriad of uncertainties. The patient wants to know details about the treatment options, their side effects and quality of life, and whether the potential for cure exists. Lots of gray zone issues suddenly appear.

Although clearly outside of my comfort zone, I’ve been able to successfully navigate the sea of uncertainties for the past two years with one notable exception: how much time do I have remaining? Or at the very least, how much time remaining where my quality of life allows me to function as a productive member of society?

Right now, life isn’t horrible. Sure, I suffer side effects from weekly chemotherapy treatment, such as loss of appetite and fatigue. And I lost my hair but save a ton of money on haircuts and shampoo. Nevertheless, I’m able to enjoy time with family and friends and keep busy with my mission to help raise awareness of the human papillomavirus (HPV), six cancers that are directly linked to HPV, and the available vaccines that could prevent such cancers for others in the future.

Enduring weekly chemotherapy is made easier given the fact that my tumors decreased in size according to my last imaging procedure. Exactly what the tumor regression means in terms of extending my life is unknown. Reality check – published scientific literature still favors that celebrating the New Year isn’t a likely event for me.

However, every patient is different – and there is one absolute truth in life: no one knows exactly when or how they will die. While perhaps the exception versus the norm, we’ve all heard dramatic stories about people living longer than originally expected. My realist nature makes me reject such anecdotes, but it does allow me to consider the fact that progress in treating cancer is advancing at a rapid pace and perhaps my existing treatments will buy me just enough time to receive some new exciting approach that keeps my disease in check.

In the interim, my greatest challenge is what to do with the “space between.” I’m talking about the period between now and when I eventually die, which could be measured in as little as one, two, or three months or as many as several years. No one knows for sure.

For example, I could start to write a new book. Although having recently gone through that process, it is a tremendous investment of time and focus away from spending quality time with family and friends. While it could be a worthwhile sacrifice, I just couldn’t bear the thought of embarking down that road again without knowing that I had sufficient time to finish it.

My other passion, photography, is made challenging since I really don’t know how much energy or how I’m going to be feeling on any given day. This makes scheduling photo sessions weeks in advance to allow adequate preparation time a risky proposition at best. For example, I never could have predicted ending up in the hospital on three separate occasions in July/August (including a trip to the intensive care unit). While life has been quite calm as of late (thank goodness…) there is always the chance that something else is lurking around the corner.

Besides, I was already able to complete two significant bucket-list items this year with the publication of both my memoir A Walk with Purpose and large format, high-quality, coffee table photography book, Strength, Confidence, & Beauty. In the near future, could I really top what I’ve already accomplished in each area?

Equally important to projects that produce legacy materials of a life well-lived, there is that pesky task of providing income to help support my family. I haven’t quite found an appropriate place on my resume for “terminal cancer patient” and I suspect few employers would find that an attractive attribute. On the flip side, freelance work or part-time positions might be workable solutions.

Don’t get me wrong, I’m not laying on the couch every day pondering the “space between” and wallowing in depression. I’ve been keeping plenty busy promoting my books and taking advantage of the plethora of amazing media outlets that express an interest in helping me with my HPV awareness mission. Perhaps that is simply how I’m meant to fill the space between?

At first, I thought if I could simply touch one person’s life through my efforts then I made a difference. But I’ve been inundated with messages from family, friends, and complete strangers who share personal stories about having their children vaccinated for HPV as a direct result of my efforts. Is there anything else I could do that would be as gratifying?

If you or a loved one is affected by cancer, I’d love to hear how you deal with the space between. Rather than messaging me directly, please feel free to comment on this post so that others can benefit from your shared experience.

Calm

It’s been a few weeks since my last blog post, so I wanted to provide a brief update. The good news is that life has been rather uneventful – no trips to the emergency room, no new side effects, etc. Let’s face it, we were due for a break!

Last week was not only the Labor Day Holiday but also a scheduled break from chemotherapy to allow my blood counts, etc. to recover. As a result, as of Monday morning I was feeling better than any time in recent memory. My appetite has been good and my energy level afforded us an opportunity to take our puppy Humphrey with us to walk around a local art fair this past weekend.

This week, however, I’m back to week #1 of my treatment schedule starting with a doublet of chemotherapies (paclitaxel and carboplatin). For me, the carboplatin results in greater side effects, particularly stomach upset, decreased appetite, and fatigue. My typical four week treatment “cycle” looks like this:

Week #1: paclitaxel + carboplatin
Week #2: paclitaxel only
Week #3: paclitaxel only
Week #4: holiday/break (no treatment)
Lather, rinse & repeat

Before this week’s chemo appointment, I had time and energy to visit with another one of my social media connections for the first time (@BursatilBiotech). She traveled from Argentina to New York with a relative for vacation and we had arranged a brief meeting in the morning while she was in town.

@BursatilBiotech and Michael Becker

My next chemo break falls during the first week of October. At that time, I’ll have my periodic imaging procedure to see if the cancer is continuing to respond favorably to the treatment. Based on improved air flow to my lungs, I’m hopeful for some continued good news.

In the meantime, I’ve been keeping busy with my mission to raise awareness for the human papillomavirus (HPV), its direct link to six cancers, and the available vaccines that can prevent HPV. For example, my guest editorial on the topic appears in this week’s issue of BioCentury and is freely available to view on their website by clicking here. In addition, last Thursday I did a television interview with CURE Today and you can view the first segment on their website by clicking here. I’m so very grateful to these and other media outlets that have provided me with a platform to advance my mission!

Most importantly, today is another gift that I will truly treasure…as I get to celebrate my youngest daughter’s birthday. Happy 17th birthday Megan!!

Knock on Wood

Thankfully, yesterday’s cardiology appointment and weekly chemotherapy session were both uneventful. The mystery fever hasn’t come back and I haven’t had any more rapid heart episodes since my last visit to Memorial Sloan-Kettering Cancer Center’s (MSKCCs) urgent care facility.

Before my first appointment, we had a chance to stop by and say “hello” to Dr. Susan Slovin at MSKCC for a few minutes. She specializes in prostate cancer, clinical immunology, and other genitourinary malignancies. If you’ve read my memoir, you are aware that we’ve known each other for quite some time and that she is a trusted resource and friend. As always, she had some words of wisdom to share and put a smile on our faces. Truly a great start to the day – thank you Dr. Slovin!

The cardiologist did change my medication, as the beta blocker I was taking (metoprolol) also resulted in some fairly low blood pressure readings and lightheadedness when going from a sitting to standing position. But again, minor complaints compared to being in the intensive care unit (ICU) a short while ago. My latest EKG looked fine and I simply need to follow-up in one month.

The consensus seems to be that my rapid heartbeat was caused by a perfect storm consisting of a high fever, low electrolytes, and possible bacterial infection. So, my job is to help make sure not to repeat these circumstances by keeping hydrated and getting plenty of electrolytes.

In terms of chemotherapy, my blood counts are doing well – especially after last week’s doublet of carboplatin and paclitaxel. While I only get carboplatin every three weeks, it does seem to hit me much harder than the paclitaxel alone – especially with regard to appetite. In any event, yesterday’s chemo session went as planned with just the paclitaxel and various premedication.

Michael and Lorie Becker dining on a rooftop in NYC

We finished everything by early evening and planned on staying in NYC overnight rather than rushing to get home. Since I was hungry for a change, Lorie and I went to the hotel’s rooftop bar and enjoyed dinner outside under the stars. It’s moments like those that make everything worth it – and I savor every one.

Michael with sister Brandy and her family visiting from Chicago

The rescheduled visit by my sister and her family went well this past weekend. I haven’t made it back to Chicago to see them in a while and I was amazed by how much their two boys had grown since I last saw them. It meant a lot to be able to spend some quality time with all of them and I appreciate their long drive back-and-forth from Illinois to Pennsylvania just to see me (okay, perhaps they really came to see Humphrey…).

The plan for now is continued weekly chemotherapy with a possible break during Labor Day week. Treatment would then resume with an eye towards imaging in early October to see how things are progressing – or perhaps more optimistically “regressing.”

Knock on wood, things will remain calm for a bit as Lorie goes back to work and our girls return to school. It’s always a stressful time for them, so it would be nice for my disease to behave for at least a little while.

Lastly, I recently gave my book website a makeover, so please take a look and let me know what you think at www.awalkwithpurpose.com

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Back on Track

Bacterial cultures from the tips of two chest tubes that were recently removed revealed growth of a pseudomonas organism on one of them. These are fairly common pathogens involved in infections acquired in a hospital setting. Whether or not this was the source of my fevers, I was prescribed an antibiotic (levofloxacin, 500mg daily) since pseudomonas can lead to other nasty conditions.

I continued running fevers for a few days after starting the antibiotic, but was free of fever for the 48-hours leading up to my next scheduled chemotherapy round. Aside from the mystery fever, my blood counts have been good throughout the three weeks of chemotherapy that I received thus far. Accordingly, my medical oncologist (Dr. Pfister) supported resuming treatment.

Michael Becker receiving chemotherapy at Memorial Sloan-Kettering Cancer Center

On Tuesday, August 15, 2017, Lorie and I took the early morning train to NY so I could receive an intravenous infusion of paclitaxel and then carboplatin as planned. I was quite anxious to resume treatment after a one week break – especially after seeing the decrease in tumor size from the recent CT scan.

I looked at my blood test results from that morning and noticed my magnesium level was again low. Knowing that this “could” have played a role in the recent cardiac event, and that my daily oral magnesium isn’t keeping up, I requested an additional intravenous course of magnesium just to be safe and the medical staff agreed.

Michael Becker asleep on the Amtrak train home. Although my blood counts are okay, Lorie is appropriately cautious and likes me to wear a mask when on the train or in other public spaces.

The chemotherapy infusions went well and we were able to take an afternoon Amtrak train back home. Benedryl® is one of the pre-medications they give me, so I slept a good portion of the trip home. Lorie was kind enough to capture me asleep with her phone.

After postponing their prior trip due to my hospitalization, my sister and her family are planning to visit us this weekend. Hopefully life is uneventful and we all get to spend some time together.

It was surreal that exactly one week after being in the intensive care unit (ICU) at Memorial Sloan-Kettering Cancer Center (MSKCC), I felt good enough to participate in a scheduled radio interview conducted in Philadelphia on August 10, 2017. Just goes to show there are good days and there are bad days. NPR member radio station WHYY host Dave Heller knew an awful lot about my book “A Walk with Purpose: Memoir of a Bioentrepreneur” and it was so great working with him during my first experience in a radio recording studio. Please take a moment to listen to a replay of this 20-minute segment and other events, along with reading newspaper and other media reprints, under the “In the News” menu tab at my memoir website by clicking here.

Michael Becker with WHYY’s Dave Heller. (WHYY photo)

Hopefully I continue to feel okay the next couple of days and look forward to seeing family while in town. It should take a week or so for the latest treatment effects to materialize. If not, however, I’m sure Humphrey will provide them with endless hours of amusement!

I would be remiss if I didn’t mention in closing that the start of the new school season is a great time to schedule an appointment with your pediatrician to talk about an important immunization that could prevent 6 cancers in boys/girls. You can learn more about this vaccine in an earlier blog post by clicking here. Had this vaccine been available when I was a child, it could have prevented the cancer that’s killing me. Start the discussion with your doctor – today! And help spread the word by using the #DiscussHPV hashtag in your social media posts.

Ending Up in the ICU

On Tuesday, August 1, 2017, I received my third dose of chemotherapy. Everything went well and the next day I was feeling excellent, although some of that can be contributed to the steroid pre-medication. As an added plus, I was looking forward to having family in town for the weekend. Life seemed pretty good.

In the back of my mind, I knew that I likely hadn’t reached the nadir, or lowest point, in my blood counts from the prior chemotherapy. As such, there was a possibility that I might not be feeling 100% for my visitors.

Sure enough, by Wednesday evening I started running a mild temperature. No big deal – it was below the 38 degrees Celsius (°C) cutoff for an “official” temperature. On Thursday I wasn’t feeling energetic and napped most of the day. Then the real fun started.

My temperature rose Thursday evening and the physician-on-call at Memorial Sloan-Kettering Cancer Center (MSKCC) recommended that I come to urgent care to get things checked out. So, Lorie and I made the drive from Bucks County, PA to New York City for the third visit to urgent care within the past three weeks! We debated taking the train as opposed to driving, which would have been faster.

By the time we arrived at MSKCC, my temperature was above 39 °C and I felt the familiar muscle aches and general fatigue that I associated with influenza. Coincidentally, it was the diagnosis of influenza during my first week of chemoradiation in early 2016 that resulted in my first trip to MSKCC’s urgent care facility.

Flu season doesn’t usually begin until October, so this time concern focused on bacterial infection. With my white blood cell counts negatively impacted by chemotherapy, it was possible that my body couldn’t fight off an infection in one of my chest tubes or another location.

I was triaged with the usual battery of blood tests and a chest x-ray before being placed in an exam room. Urgent care was very crowded and I was just happy to have a bed and looked forward to resting horizontally for a while.

I sat on the bed, preparing to relax when I clutched my chest from a sudden, stabbing pain. Lorie could tell from the expression on my face this was no ordinary situation and called for the nurse who arrived immediately to assess the situation. As various cables were connected, I felt my heart racing and Lorie was shocked to see my pulse was 225 on the computer monitor.

Normally, the heart beats about 60 to 100 times per a minute at rest. But in tachycardia, the heart beats faster than normal in the upper or lower chambers of the heart or both while at rest. The episode ended within a minute or so, but tachycardia can disrupt normal heart function and lead to serious complications, including heart failure, stroke, and sudden cardiac arrest or death. Patches were promptly applied outside of my chest wall, which could be used if needed to provide a brief electric shock to the heart to reset the heart rhythm back to its normal, regular pattern.

My heart wasn’t the only one racing as the medical team placed a crash cart outside my door and a sense of urgency filled the room. The contents of a crash cart vary, but typically contain the tools and drugs needed to treat a person in or near cardiac arrest. I was sure that the end was near.

Michael Becker in MSKCC’s ICU

Fortunately, no further cardiac events occurred and I was admitted to MSKCC’s intensive care unit (ICU), where seriously ill patients are cared for by specially trained staff. While I have never had the misfortune to be admitted to an ICU in the past, I was amazed by the both the medical staff and technology used to monitor my condition and knew I was in good hands.

I was placed on an antibiotic and medication to stabilize my heart rate while the team worked to determine the source of the tachycardia and whether or not my episode had caused any damage to my heart. Preliminary assessments ranged from one of my tumors or chest tubes rubbing up against the sensitive tissue surrounding the heart to low electrolyte levels, which are important minerals in your body that have an electric charge. Maintaining the right balance of electrolytes is key for your body’s blood chemistry, muscle action and other processes.

On Friday, my temperature returned to normal and there were no further cardiac events. Still, I couldn’t help but feel that perhaps it was time to contact hospice and let the cancer take its course. I had faced my share of obstacles since being diagnosed with cancer in late 2015 and three recent trips to the hospital resulted in further erosion of my quality of life with two chest tubes, being back on chemotherapy and its side effects, and now the prospect of potential cardiac issues. Lorie and I discussed the topic of hospice and she rightfully pointed out that such a decision shouldn’t be made while sitting in the ICU.

I shared my thoughts about hospice with one of nurses while he assisted me with walking a few laps around the floor. Much to my surprise, he shared with me that it was about 11-years ago that he underwent a bone marrow transplant at MSKCC and how it caused him to pursue a career in medicine. He discounted my outlook on hospice, stating that I was young, up-and-walking, and seemed otherwise quite capable of enjoying further quality time with my wife and daughters. When my quality of life truly diminishes, that would be the time to consider hospice.

Our daughters, Rosie and Megan, traveled by train to NYC and were able to visit me briefly in the ICU. However, they all stayed overnight in a nearby hotel thanks to my father and step-mother. Being in the ICU wasn’t conducive for the planned family visit, which unfortunately got cancelled.

I was released from the ICU to a regular room very late Friday evening. I’ll be here for at least another day or two because the source of the fever still hasn’t been identified. With the fever gone, it appears the antibiotics were successful in treating the infection, but without knowing the source or strain – treatment can be challenging.

Viewing my Twitter feed briefly from the ICU on Friday, I was delighted to learn that Adam Feuerstein, Senior Writer at STAT News (statnews.com), Tweeted that he was dedicating his Pan-Mass Challenge ride to me.

Adam Feuerstein’s Tweet

Each year the Pan-Mass Challenge brings together thousands of impassioned cyclists, committed volunteers, generous donors and dedicated corporate sponsors. Together, they strive to provide Dana-Farber’s doctors and researchers the necessary resources to discover cures for all types of cancer.

“Michael, we love you, support you. Your strength will inspire me tomorrow.,” Tweeted Adam. Well, Adam, your Tweet and the many acknowledgements on Twitter helped brighten my day and I’m still here giving cancer everything that I’ve got. Godspeed on your ride and thank you for an amazing gesture!

And special thanks to all of Lorie’s friends who have helped our daughters get to NYC and/or babysit our small petting zoo while we’re away. It’s a lot to ask, and we’re so grateful for the help since it is one less thing to worry about. Humphrey appears to have made new puppy friends, as evidenced by the photos and videos that I love seeing.

It’s Saturday afternoon as I finish writing this blog update. Lorie, Rosie, and Megan are able to visit longer since I’m in a regular room now. Seeing people in the hospital isn’t tops on most teen’s lists of favorite activities, but it means so much to me having them here.

Damned If I Do, Damned If I Don’t

As discussed in my prior blog post, the recent CT scan at the National Institutes of Health (NIH) didn’t turn out as we had hoped. Not only did the cancer show signs of progressing, but a blot clot was also found in my left iliac artery near my pelvis.

Blood clot illustration

I had been on Lovenox (enoxaparin) for just under one week, when I noticed that the daily drainage from my chest tube looked much more like blood than the usual straw color. Equally disconcerting, the volume of drainage was greater than usual.

At the suggestion of my treating physicians, we stopped at the emergency room at a local hospital in Bucks County (which will remain nameless) on Sunday morning around 10am simply to have a complete set of blood work done. The concern being that the loss of so much blood via the chest tube could necessitate a transfusion.

Fortunately, my hemoglobin levels were okay (low hemoglobin count may indicate you have anemia) and a transfusion wasn’t needed. However, a big problem remained – finding the cause of bleeding coming from my pleural effusion and how to stop it.

One thing was almost certain – the anticoagulant Lovenox likely played a role. Discontinuing Lovenox could help reverse the bleeding, but I would be left with an untreated blood clot that could cause major problems if it moved from its current location. Damned if i do, damned if i don’t.

Quite the conundrum and not one to take lightly. As such, after waiting around the local hospital until early evening with no solutions, nurses, or physicians in sight, Lorie took control and requested that I be immediately discharged. Shortly thereafter she drove us to New York City to visit Memorial Sloan-Kettering Cancer Center (MSKCC). I already had an appointment scheduled with my medical oncologist (Dr. David Pfister) for Tuesday to discuss possible next-steps for treatment, such as chemotherapy, and the drive to NYC is shorter than going to the NIH in Bethesda, MD.

We arrived after midnight, but the urgent care team at MSKCC promptly assessed my condition. More blood work was drawn along with a chest x-ray and CT scan. Simply looking at the chest x-ray, I could tell that the pleural effusion was quite large. This shouldn’t be the case, as I drain it daily.

For now, stopping the internal bleeding is more important than addressing the blood clot – although both issues require immediate attention. I’ve already discontinued the Lovenox and the MSKCC team will assess various options to access and drain the large amount of fluid still trapped in my left lung. The impact of the fluid is not insignificant, as I am short of breath walking short distances or up/down stairs. Coughing also has gotten worse and leads to feeling light-headed or dizzy.

Assuming the pleural effusion can be controlled, the next step would be to deal with the blood clot. One solution is to place a filtering device in the Inferior Vena Cava (IVC, a large vein in the abdomen that returns blood from the lower body to the heart) that could help prevent a pulmonary embolism, which is fatal in one-third of patients who suffer from it. The filter essentially traps blood clots and prevents them from reaching the lungs or heart.

Of course, aside from the aforementioned, I am interested in exploring potential new treatment options and look forward to upcoming physician appointments. Until then, I’ve been admitted to MSKCC for at least a day or two and will provide any meaningful updates via Twitter, etc.

It Could Always Be Worse

After a full day of activities yesterday, Lorie and I decided to grab an early dinner in Bethesda, MD at a restaurant recommended to us. We really haven’t explored much of the local establishments, so it was nice to venture out and try something new.

We sat down and I immediately focused on the cheese appetizer selection and ordered three different types. Half way through the appetizer, however, my cell phone rang. It was Dr. Strauss from the NIH.

I could tell from the initial line of questioning (are you still at NIH, where are you now, are you alone, etc.) that bad news would shortly follow. Sure enough, yesterday’s CT scan revealed a deep vein thrombosis (DVT) on the left side of my pelvis and Dr. Strauss requested that we promptly return to NIH to start treatment with Lovenox (enoxaparin). With that, we paid our restaurant bill and left our dinners behind to take an Uber back to NIH.

VIDEO CAPTION: 3D CT image from NIH showing tumor locations highlighted in green. The largest mass (lower right) is from my spleen.

Both Dr. Gulley and Dr. Strauss met us back at NIH in the day hospital and we went to an empty treatment room to talk in private. Unfortunately, the blood clot was merely a sideshow for the bigger news, which was that several tumors increased in size from the prior scan taken 6-weeks ago. For the first time, my outlook was black & white: the cancer was winning the tug-of-war with my body’s immune system. Receiving further treatment with the experimental agent M7824 would be hard to justify and more aggressive treatment, such as chemotherapy, appeared to be the favored next step.

After a brief tutorial on self-injecting Lovenox twice daily, we returned to the hotel and planned on meeting early the next morning to review the CT scans and have further discussion. The mood was somber and neither one of us slept very well.

Michael and Lorie Becker reviewing CT images with Drs. James Gulley and Les Folio of NIH. Photo credit: Daniel Sone of NCI

The NIH is only one of two places to have advanced imaging technology that was truly fascinating and dramatically improves the ability to visualize and follow specific tumors over time. Personally, I was amazed by the progress radiology has made since I last reviewed such images. We were engrossed in discussion about the various images displayed on the three monitor screens when Lorie’s phone rang. It was our oldest daughter Rosie.

The first few calls were easy to dismiss since we were in an important meeting, but then came a text – “emergency.” Driving home from class, Rosie apparently veered into the lane of oncoming traffic and hit another car going 30-40 MPH. All of the airbags deployed and the car is totaled. She was taken to the local hospital for x-rays, but nothing was broken and she was released. We understand the driver of the other car is okay as well.

Immediately, my mind wandered from my own mortality being visualized on the computer screens to how Rosie’s accident could have been far, far worse – perhaps even fatal. I’m not sure exactly how I would have reacted to that news on top of my disease update, but I do know it would pale by comparison to my own situation.

On more than one occasion, Lorie and I have uttered the words “it could always be worse.” Lately, it has been harder and harder to make that statement. However, with Rosie largely unharmed in what could have been disastrous, today definitely could have been worse.

I will blog more about my condition and treatment options in future posts after digesting all of the information from the past 48-hours. In the meantime, with no infusion of M7824 today, we are on the train home to be with Rosie.

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Help Eradicate Six Cancers Caused by HPV

As a sexually transmitted disease, discussions surrounding human papillomavirus (HPV) can understandably be uncomfortable and/or embarrassing. Interestingly, according to the Centers for Disease Control and Prevention (CDC), HPV is so common that nearly ALL sexually active men and women get the virus at some point in their lives. About 79 million Americans (~25% of the U.S. population) are currently infected with some type of HPV. About 14 million people in the United States become newly infected each year. Accordingly, I thought that a more detailed blog post on the subject was warranted.

HPV is a virus with the ability to infect skin and mucous membranes, or mucosa, that lines various cavities in the body and surrounds internal organs. It can cause normal cells in infected areas to turn abnormal. Most of the time, you cannot see or feel these cell changes. In the majority of cases, the body fights off the HPV infection naturally and infected cells then go back to normal.

There are approximately 179 distinct HPV genotypes, which can be divided into “low risk” and “high risk” groups based on their capacity to drive cancer transformation. Most people with HPV never develop symptoms or health problems; 9 out of 10 HPV infections go away by themselves within two years. Sometimes HPV infections will last longer and can cause certain cancers, warts, and other diseases. There is currently no test to find out a person’s “HPV status.”

The “high risk” HPV subtypes most clearly implicated in cancer are HPV16, 18, 31, 33, 35, 45, 51, 52, and 56, which are capable of causing cancers of the cervix, head and neck, anus, vagina, vulva, and penis. Every year in the United States, HPV causes 30,700 such cancers in men and women.

Most of the time, people get HPV from having vaginal and/or anal sex with an infected partner. In fact, “genital HPV” is the most common sexually transmitted infection (STI) in the U.S.

However, the same types of HPV that infect the genital areas can also infect the mouth and throat. HPV found in the mouth and throat is called “oral HPV.” Only a few studies have looked at how people get oral HPV, and some of these studies show conflicting results. Some studies suggest that oral HPV may be passed on during oral sex (from mouth-to-genital or mouth-to-anus contact) or simply open-mouthed (“French”) kissing, others have not. The likelihood of getting HPV from kissing or having oral sex with someone who has HPV is not known. According to the CDC, more research is needed to understand exactly how people get and give oral HPV infections.

Oral HPV is about three times more common in men than in women. Overall, HPV types 2, 4, 6, 11, 13 and 32 have been associated with benign oral lesions while HPV types 16 and 18 have been associated with malignant lesions, especially in cancers of the tonsils and elsewhere in the oropharynx. The most commonly implicated subtype in oropharyngeal cancer is HPV16, accounting for over 80% of HPV positive cases. Not surprisingly, my initial biopsy results showed that tumor cells were positive for HPV16.

Patients with oral HPV cancer present at a younger age and are less likely to partake in excess alcohol consumption or heavy tobacco use that are associated with corresponding HPV-negative cancers. Additionally, HPV-related tumors more frequently arise in the oropharynx – the part of the throat at the back of the mouth behind the oral cavity. It includes the back third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils (where my cancer started). Smoking-related tumors arise more commonly in the oral cavity, larynx, or hypopharynx.

Oral HPV tumors are more likely to be smaller and poorly differentiated, with a higher incidence of advanced lymph node metastases in comparison to HPV negative tumors. Despite a more aggressive clinical presentation, HPV status is the best independent predictor of survival in these patients.

Signs and symptoms of oral HPV may include persistent sore throat, earaches, hoarseness, enlarged lymph nodes, pain when swallowing, and unexplained weight loss. In my case, the first sign of disease in November 2015 was an enlarged (3-4cm) lymph node on the right side of my neck where the cancer had spread from my right tonsil. Some people have no signs or symptoms.

While there is currently no cure for the virus, there are commercially available prophylactic vaccines against HPV available today: the bivalent (HPV16 and 18) Cervarix®, the tetravalent (HPV6, 11, 16 and 18) Gardasil®, and newer Gardasil 9 (HPV6, 11, 16, 18, 31, 33, 45, 52, 58). Since the HPV subtype 16 was included in each of these vaccines, and this subtype was found in my tumor cells, it is very likely that my cancer could have been prevented had such vaccines been available to me when I was younger.

The HPV vaccine was initially developed to prevent cervical and other less common genital cancers, which raised questions regarding the ability to also prevent oral cancers. In one of the first large studies to explore the possible impact of HPV vaccination on oral HPV infections, researchers found it may confer a high degree of protection. The study of young adults in the U.S. showed that the prevalence of high-risk HPV infection was 88% lower among those who reported getting at least one vaccine dose than among those who were not vaccinated. Researchers reported the results at the recent American Society of Clinical Oncology (ASCO) 2017 annual meeting.

To be an effective preventive strategy, HPV vaccination should start before “sexual puberty.” The CDC recommends routine HPV vaccination for girls and boys at age 11 or 12 (two doses six months apart, a 2016 revision of guidelines that previously recommended three doses). People who get vaccinated later (up to age 26 for young women and up to age 21 for young men) will need three.

The same research reported at ASCO 2017 found that from 2011 through 2014 fewer than 1 in 5 (18.3%) young adults in the U.S. reported receiving at least one dose of the HPV vaccine before age 26. The vaccination rate was much lower among men than women (6.9% vs. 29.2%) at this time.

“The HPV vaccine has the potential to be one of the most significant cancer prevention tools ever developed, and it’s already reducing the world’s burden of cervical cancers,” said ASCO President-Elect Bruce E. Johnson, MD, FASCO. “The hope is that vaccination will also curb rising rates of HPV-related oral and genital cancers, which are hard to treat. This study confirms that the HPV vaccine can prevent oral HPV infections, but we know it only works if it’s used.”

More research is needed to understand exactly how people get and give oral HPV infections that resulted in my oropharyngeal cancer. Recent studies confirm that the HPV vaccine can prevent such oral HPV infections, but only when they are used – and vaccination rates are extremely low. This is disappointing, as vaccination is widely considered one of the greatest medical achievements of modern civilization. Childhood diseases that were commonplace less than a generation ago are now increasingly rare because of vaccines (although the measles are making a comeback since elimination was first documented in the U.S. in 2000). In order to be effective at eliminating communicable diseases, vaccines must be administered to sufficient levels of persons in the community.

If you have a son or daughter, please talk to your doctor about the HPV vaccine. HPV has become a recognized driver of six cancers affecting more than 30,000 people each year, yet there are available vaccines to prevent the majority (about 28,000) of these cases from ever occurring.

 

Sources:

American Cancer Society. Cancer Facts & Figures 2017. Atlanta: American Cancer Society; 2017.

From HPV-positive towards HPV-driven oropharyngeal squamous cell carcinomas. Cancer Treat Rev. 2015 Oct 31.

Centers for Disease Control and Prevention: Human Papillomavirus (HPV) Statistics

J Clin Oncol 35, 2017 (suppl; abstr 6003)

Watching the Calendar

Earlier this week, Lorie and I made our biweekly visit to the National Institutes of Health (NIH) for my infusion of the experimental agent M7824. The two day trip was uneventful and included a variety of imaging and other diagnostic tests, including an ultrasound of my spleen and a chest x-ray to monitor the pleural effusion in my left lung.

Fortunately, all of the tests came back fine and I was cleared to receive my regular infusion of M7824. As with all the previous treatments, there were no adverse reactions and we returned home later that evening.

However, with the month of July rapidly approaching, I can’t help but start to feel quite anxious. This is due to the published results from Bristol-Myers Squibb’s “CheckMate 141” phase 3 trial with Opdivo® (nivolumab), an anti-programmed death 1 (PD-1) monoclonal antibody also known as a checkpoint inhibitor. In that study, 361 patients with recurrent squamous-cell carcinoma of the head and neck (SCCHN) whose disease had progressed within 6 months after platinum-based chemotherapy were assigned, in a 2:1 ratio, to receive Opdivo every 2 weeks or standard, single-agent systemic therapy (methotrexate, docetaxel, or cetuximab). The primary end point was overall survival.

Treatment with Opdivo resulted in longer overall survival than treatment with standard, single-agent therapy. The median overall survival was 7.5 months (95% confidence interval [CI], range 5.5 months to 9.1 months) in the Opdivo group versus 5.1 months (95% CI, 4.0 months to 6.0 months) in the group that received standard therapy.

Recall from prior posts that M7824 is a completely novel, first-in-class, bispecific fusion protein of an avelumab-like, anti-PD-L1 antibody linked to two molecules of TGF-beta trap. Therefore, I always viewed M7824 as a “potentially” superior alternative to Opdivo given its added mechanism of action, hence my strong interest in participating in the M7824 clinical trial.

Assuming for a moment that M7824’s treatment effect is at least comparable to Opdivo, and considering that my disease recurred around December 2016, an expected survival of 7.5 months would translate to the July/August 2017 timeframe.

To be fair, an apples-to-apples comparison of Opdivo and M7824 isn’t possible. However, the results of Bristol-Myers Squibb’s “CheckMate 141” trial serve as a contemporary data set for checkpoint inhibitors in the treatment of recurrent SCCHN and are definitely something that I keep my eye on.

Lorie and Michael Becker enjoying ice cream in Bethesda, MD

Barring any surprises, I’ll continue biweekly treatment with M7824 and then repeat imaging in July to see whether or not my disease has progressed. In the meantime, I’ll continue to savor simple moments like enjoying ice cream on a warm summer evening with my wife (see photo).

Roller Coaster

It’s been a couple of weeks since my last clinical post, so I wanted to provide an update following this week’s NIH appointments.

Michael Becker pleural effusion
Xray images of Michael Becker’s chest showing pleural effusion both before and after drainage

First, surgical insertion of my Aspira® drainage system has dramatically improved the pleural effusion in my left lung. It’s essentially a chest tube/catheter that allows me to drain the fluid buildup on an as-needed basis into drainage bags at home. The image to the right shows before and after chest x-ray images that demonstrate just how blocked my left lung was before being drained (nearly 2/3 blocked). It also shows how my left lung is now “close” to normal following drainage.

Second, I’ve been on prednisone (steroid) to help “sculpt” the inflammatory response, which is also helping keep the fluid from building up so quickly in my left lung. Whereas I was emptying 100 mL or more on a daily basis previously, I am now only draining 15-20 mL every other day or so.

Now that the pleural effusion can be managed, attention returned to whether or not to resume treatment with M7824, a completely novel, first-in-class, bispecific fusion protein (see prior posts for more details). My last infusion of M7824 was several weeks ago.

Following another CT scan and constructive discussion with the NIH team, we came to the conclusion that there is essentially a tug-of-war occurring between the cancer in my lungs and my body’s immune system, the latter of which appears to be benefiting from M7824. The hope is that eventually M7824 will tip the scale in favor of my body’s immune system and control the cancer.

Michael D. Becker receiving IV infusion with M7824 – a novel, first-in-class, bispecific fusion protein on May 16, 2017

Accordingly, the decision was made to keep moving forward with M7824 and I received an infusion on Tuesday, May 16, 2017. As with past administrations, there were no issues and I returned home to Pennsylvania with Lorie later that evening.

The pleural effusion will be monitored closely and managed via the catheter and steroids. As long as there are no major issues in terms of fluid in my lung, I will continue to receive an infusion of M7824 every other week. A repeat CT scan will be done in a month or so to reassess the situation.

Memoir Published

Well, gulp! My memoir is finally done and published.

Memoir book cover – “A Walk With Purpose” by Michael D. Becker

A Walk With Purpose chronicles my career path from an investment advisor to chief executive officer of an oncology-focused biotechnology company, and finally into a terminal cancer patient confronting his own mortality. It is a memoir about both my life and illness, battling stage 4 head and neck cancer.

Both paperback & digital copies available via Amazon:

To visit the Amazon ordering page, please click here

PS – Good, bad, or indifferent, if you have read the book please do take a moment to leave an honest review on Amazon

Honestly, Not Such a Good Friday

This past Wednesday, I had a thoracentesis procedure in which a needle was inserted into the pleural space between my lungs and chest wall. This procedure was done to remove excess fluid, known as a pleural effusion, from the pleural space to help me breathe easier.

Michael Becker blogging from his laptop at NIH on April 15, 2017

During the procedure, Dr. Elliot Levy, an interventional radiologists at NIH trained in radiology and minimally invasive procedures, drained 1.5 liters from the pleural space. Almost immediately, I felt better and even while I was being wheeled back to my recovery room, I asked my wife Lorie to grab me a turkey sandwich from the cafeteria as I was quite hungry. It’s possible the large amount of fluid on my left side was putting some pressure on my stomach, which could help explain why I haven’t had much of an appetite lately.

By Thursday, however, the fluid was returning, prompting yet another thoracentesis procedure on Friday to remove 1.5 liters of fluid. The rapid nature of the fluid buildup means that I will most likely have an Aspira® drainage system surgically installed to conveniently let me drain the fluid buildup at home via a small catheter and drainage bags. That procedure is planned for Monday, so I have been staying at NIH since Wednesday and will be here over the weekend.

More importantly, however, a CT scan was also done on Friday morning with disappointing results. The cancer nodules grew since the last CT scan on March 7, 2017. This reflects true disease progression as opposed to “pseudo-progression” as discussed in a prior post. I have been taken off the clinical study with M7824.

My individual results do not reflect poorly on the future of M7824, but rather underscore that we still have a lot to learn about immunotherapy and cancer. While I may not have benefited from the drug, the resulting knowledge and clinical data may help guide future development and I am proud to play a part in that process.

At this point, if I received no further treatment and went on hospice, my likely survival would be about two months – although every patient is different. I have scheduled an appointment with my oncologist at MSKCC to discuss the pros and cons of chemotherapy at this stage, but the balance between quality of life and quantity of life is not trivial and I haven’t made a firm decision to go in this direction. Chemotherapy may only add a month or two of survival with a negative impact on my quality of life.

While I have been very open about my disease since originally being diagnosed in December 2015 and enjoy blogging, I will now be focusing much more time with my wife and daughters and finishing up my memoir, which I hope to have published. This will unfortunately mean less time for updating this blog and responding to emails.

Thank you to everyone who has offered their best wishes, thoughts, and prayers during my cancer journey. Having such an amazing support network of family, friends, and social media contacts has been a great source of strength and inspiration. Special thanks to my wife, Lorie, who has been by my side the entire time.

If you’ll indulge me, I would like to end this post with three requests:

  1. If you have a son or daughter, please talk to your doctor about the HPV vaccine, which protects against cancer of the cervix, vagina, and vulva in women; penis in men; and cancers of the anus and head/neck (including the base of the tongue and tonsils) in both men and women. HPV is a very common virus; nearly 80 million people are currently infected in the United States. About 14 million people, including teens, become infected with HPV each year, resulting in 30,700 cancers in men and women. HPV vaccination can prevent most of the cancers (about 28,000) from occurring.
  2. Help preserve federal funding levels by communicating with lawmakers about the critical importance of investing in medical research. There are far too many people suffering from cancer and this is not the time to cut the budget for the National Institutes of Health (NIH) by 18.3 percent, about $5.8 billion, as has been proposed. In an Op Ed by Harold Varmus appearing in the New York Times on March 22, 2017, he states that  only about 10 percent of the NIH’s budget supports the work of government scientists and that “over 80 percent of its resources are devoted to competitively reviewed biomedical research projects, training programs and science centers, affecting nearly every district in the country.” Harold Varmus, a professor at Weill Cornell Medicine and a co-recipient of the 1989 Nobel Prize in Physiology or Medicine, was the director of the National Institutes of Health from 1993 to 1999 and of the National Cancer Institute from 2010 to 2015.
  3. If you or someone you know is battling cancer or another disease, please talk to a physician about available clinical trial options. Clinical trials are a key research tool for advancing medical knowledge and patient care. Such trials are important to learn whether or not a new approach works well in people and is safe and which treatments or strategies work best for certain illnesses or groups of people.

Time to Drain the Swamp

Draining the swamp is a metaphor used by American politicians, referencing actions to clean up government corruption. In my case, however, I’m referring to a treatment that involves draining the fluid from my chest cavity, either with a needle or a small tube inserted into the chest. This will treat my pleural effusion, also called “water on the lung,” which is an excessive buildup of fluid in the space between my lungs and chest cavity (see diagram).

Diagram showing a pleural effusion

The pleural effusion is likely the source of my coughing, shortness of breath, and other recent symptoms. I haven’t been feeling well at all lately, but once it is drained – I should feel much better.

Thin membranes, called pleura, cover the outside of the lungs and the inside of the chest cavity. There’s always a small amount of liquid within this lining to help lubricate the lungs as they expand within the chest during breathing. Certain medical conditions, such as malignancy, can cause a pleural effusion, which is likely my situation. The excess fluid prevents the lung from expanding normally.

Sometime this morning I will have the procedure and hope to provide updates when I am awake later on.

I may need this treatment more than once if fluid re-collects, but we’ll cross that bridge another time.

 

Keeping the Faith with M7824

As evidenced by the extensive discussions following my biopsy from last Friday, a tumor is indeed a very complex structure. It comprises cancer cells and stromal cells, tumor infiltrating cells—both cells of the immune system and cells not by convention being of the immune system, as well as an extracellular matrix mainly of proteins and carbohydrates.

Following my recent CT scan, the hope from obtaining core biopsies from one of my lung nodules was to get a better sense of the cancer at a cellular level, which may help shed some light on whether or not treatment with M7824, a completely novel, first-in-class, bispecific fusion protein is working (see prior posts for more details).

In particular, the presence of immune system cells (T cells, or T lymphocytes) in tumor biopsies and their potential impact on prognosis have been studied for decades. T cells are a type of white blood cell that circulate around our bodies, scanning for cellular abnormalities and infections. Broadly speaking they can be divided into two different types, “killer” CD8-positive T-cells and “helper” CD4-positive T-cells. CD8-positive T cells are critical mediators of adaptive immunity. They include cytotoxic T cells, which are important for killing cancerous or virally infected cells, and CD8-positive suppressor T cells, which restrain certain types of immune response.

Despite contributions by other immune cell subsets, CD8-positive T cells have emerged as the predominant effector in most cancer immunotherapy settings¹. Accordingly, many immunotherapeutic strategies (including checkpoint inhibitors, such as anti-CTLA4, PD1, and PD-L1 antibodies) are dedicated to stimulating, enhancing and maintaining responses by tumor-reactive CD8-positive T-cells.

Favorable outcomes have been demonstrated in patients where high numbers of CD8-positive cells were found at the tumor site in patients with head and neck cancer, breast, colorectal cancer and also for others solid cancers. In one study, head and neck cancer patients whose tumors were densely infiltrated by CD3-positive and CD8-positive T cells had a significantly longer overall survival (OS) and progression-free survival (PFS) compared with patients whose tumors were poorly infiltrated².

While there seems to be a consensus that CD8 infiltration is a good prognostic marker in most malignancies analyzed, however, the impact of CD8-positive T cells on clinical outcome may differ and is difficult to quantify. Not only is the type of T cell important, but also its location, and moreover the specific phenotype and function of those cells in the particular environment.

Nonetheless, based on the preliminary results from my recent tumor biopsy and other factors, it appears that there is sufficient evidence of immune system activation in the vicinity of the tumor to indicate that the experimental agent M7824 may indeed be performing as we hoped. Accordingly, I am in 100% agreement with my doctor’s recommendation to continue on the therapy and will receive my next infusion this coming Tuesday at NIH. After a few more cycles of therapy, another CT scan will be taken in the future with the hope of demonstrating that the recent tumor growth was from treatment effect “pseudo-progression” rather than true disease progression, which has been previously described with immune checkpoint inhibitors like M7824.

References:

¹ Targeting CD8+ T-cell tolerance for cancer immunotherapy. Stephanie R Jackson, Jinyun Yuan, and Ryan M Teague. Immunotherapy. 2014 Jul; 6(7): 833–852.

² Tumour-infiltrating lymphocytes predict response to definitive chemoradiotherapy in head and neck cancer. P Balermpas, Y Michel, J Wagenblast, O Seitz, C Weiss, F Rödel, C Rödel and E Fokas. British Journal of Cancer (2014) 110, 501–509. doi:10.1038/bjc.2013.640

 

 

 

Collecting More Information

Following Tuesday’s news that several of the tumors in my lungs actually increased in size and a new spot appeared on my spleen, Lorie and I headed back to the NIH on Thursday for more tests to help better guide subsequent treatment decisions.

The first test was a CT image of my brain taken Thursday mid-afternoon, which would be used to rule out the spread of cancer to that particular organ. Patients with brain metastases are often excluded from clinical trials due to historically dismal survival and concerns about blood brain barrier drug penetration. Fortunately, we learned the next morning that this test came back negative for cancer progression to the brain.

The second test on Friday was an image-guided biopsy of a single lung nodule to help guide between cancer progression and inflammation as the reason for the increase in size seen on the recent CT scan on the lungs. In my case, a core needle biopsy was performed, which is less invasive than surgical biopsy and doesn’t require general anesthesia.

Early Friday morning, Dr. Elliot Levy, an interventional radiologists at NIH trained in radiology and minimally invasive procedures, met with us first to discuss the procedure. He pulled up a cross sectional image of my lungs, which showed several of the suspicious nodules.

CT scan of my lungs, showing target nodule for biopsy with two lines representing potential needle angles for biopsy. Other nodules within the lungs circled in red, which could be more dangerous to biopsy.

One in particular was located in the pleural cavity – normally a thin membrane that lines the surface of the lungs and the inside of the chest wall outside the lungs. In the bottom of my left lung, however, fluid built up in the pleural cavity where one of the nodules was located. Dr. Levy explained to us how this nodule could be biopsied without puncturing the lung lobe, which can result in a longer hospital stay.

Sometimes, a collapsed lung (pneumothorax) occurs after a lung biopsy.  As a precaution, a chest x-ray is taken after the procedure to check for this before sending the patient home.

After meeting with Dr. Levy, I was escorted back to the biopsy procedure room and placed on my right side on a table. I was consciously sedated, produced by the administration of two medications: a single dose of fentanyl given intravenously that can produce good analgesia for 20-45 minutes, and midazolam, which has a fast-acting, short-lived sedative effect when given intravenously, achieving sedation within one to five minutes and peaking within 30 minutes. The combination produces an altered level of consciousness that still allows a patient to respond to physical stimulation and verbal commands, and to maintain an unassisted airway. Midazolam is a primary choice for conscious sedation because it causes patients to have no recollection of the medical procedure.

Dr. Levy worked out of sight behind me to perform the biopsy, as he went through my back side. I was fairly nervous going into the procedure, but everything went extremely well with absolutely no pain or unexpected events due to the sedation.

After recovery, a subsequent chest x-ray confirmed that the lungs were indeed fine after the biopsy and we left NIH shortly thereafter to head back home to Pennsylvania.

Thumbs up; recovering after biopsy procedure at NIH

The preliminary results from the biopsy should be available early this week. If the biopsy shows ample evidence of immune stimulation, an argument could be made to stay on the current drug and that the “pseudoprogression,” or the initial radiologic appearance of an increase in tumor burden, might actually be inflammation and followed by tumor regression. A remote possibility in my type of cancer, but worth confirming.

Should the biopsy results instead demonstrate increased tumor burden, then we could consider switching to another investigational agent or even chemotherapy to shrink the tumors before proceeding again with one of the immunotherapy clinical trials.

Lorie and Michael Becker in front of cherry blossoms

Determined to stay positive, Lorie and I took advantage of the warm spring day on Thursday to stop outside NIH and snap a picture in front of some cherry blossoms. Unfortunately, snow and cold returned on Friday for the commute home.

We’ll know more this week, so stay tuned…