Dr. Mohammed Milhem stands by his “Iowa wall.” PHOTO / SHUVA RAHIM
By Cindy Hadish
To say advancements in cancer treatments are on a fast pace is an understatement.
Dr. Mohammed Milhem, deputy director for clinical research and clinical services at the University of Iowa’s Holden Comprehensive Cancer Center, has been placing about 100 cancer patients every year in clinical trials that use immunotherapy and combinations of treatments, some of which show marked improvements in survival rates.
Immunotherapy uses the body’s own immune system to attack cancer cells.
Its use traces back to the 1890s – when bacteria were deliberately injected into the body to stimulate the immune system and shrink tumors – but it wasn’t until a breakthrough in 2011 that progress in cancer immunotherapy began skyrocketing, Dr. Milhem said.
The Food and Drug Administration that year approved an antibody called ipilimumab, under the brand name Yervoy to treat advanced melanoma.
“I don’t think it was for lack of trying,” Dr. Milhem said of the previously slow progress in immunotherapy. “But we have not understood the immune system.”
Checkpoint inhibitors became one of the keys to that understanding.
Cancer tumors are sometimes able to evade an immune system attack by “disguising” themselves as normal cells, Dr. Milhem said, but checkpoint inhibitors can “uncloak” the cancer cells, allowing them to be recognized as cancerous and unleashing the immune system to attack those cells.
Since 2011, other types of cancer immunotherapy also have been approved. University of Iowa Hospitals & Clinics lists the following types available:
- Monoclonal antibodies: Manmade version of immune system proteins that boost the natural immune response
- Immune checkpoint inhibitors: These help the immune system kill cancer cells by making it more difficult for cancer cells to avoid the immune system; a common type is called PD-1 inhibitors
- Cancer vaccines: Put into the body to start an immune response against cancer
- Cellular therapy: Involves taking immune cells out of the body and manipulating them so they are more effective at fighting cancer. One form of cellular therapy is chimeric antigen receptor (CAR) T-cell therapy.
The Holden Comprehensive Cancer Center uses clinical trials – research studies that examine whether medical treatments are safe for humans – to explore new combinations of therapies, as well.
For example, Dr. Milhem pointed to the use of immunotherapy in combination with radiation and surgery in increasing patients’ survival rates.
Immunotherapy doesn’t work for every type of cancer, but has shown promise in the skin cancer melanoma, and sarcoma, a rare cancer that affects bone and soft tissue, among other types.
Dr. Milhem, who also serves as Holden Family Chair in Experimental Therapeutics, noted that the cost of immunotherapy drugs are high, with the price of a single dose running up to $24,000. Drugs that are FDA-approved are usually covered by insurance, while patients do not pay for drugs in clinical trials.
An “Iowa wall” in his office displays photos, messages and artwork from patients he has treated since arriving at the University of Iowa in 2007.
“These are my heroes,” Dr. Milhem said of the patients, who not only stand to improve their own survival, but contribute to the understanding of the therapies involved in clinical trials for other patients.
The number of immunotherapy doses – generally given intravenously or injected directly into a tumor – can vary, but could be weekly for as long as it is effective, Dr. Milhem said.
Side effects are typically less severe than conventional chemotherapy, which can result in fatigue, hair loss, nausea and other reactions. Immunotherapy can result in diarrhea, skin rashes and attacks on the liver and other organs, but Dr. Milhem said side effects usually occur in less than 10 percent of patients.
Denver Dvorsky, 74, of rural Toddville, underwent immunotherapy at the Iowa City Veterans Affairs Medical Center after having a tumor removed from his bladder.
Mr. Dvorsky previously had a kidney removed and was being monitored to see if the cancer spread when the tumor was discovered in his bladder last year.
He was given the option to have his bladder removed or undergo Bacillus Calmette-Guerin therapy, known as BCG.
Bacillus Calmette-Guerin, which also is used as a tuberculosis vaccine, is injected directly into the bladder through a catheter in treating early-stage bladder cancer, and is one of the older immunotherapy treatments for cancer.
Mr. Dvorsky said his weekly treatments for six weeks, followed later by three more treatments, left him with flu-like symptoms, including a high fever. He was bedridden for 12 hours after each session, but described the side effects as minimal, and so far, checkups have shown no recurrence of the cancer.
“It’s a very innocuous treatment, compared to what people think of as chemotherapy,” he said. “It seems to work so far.”
