Tag Archives: Lungevity Scientific and Clinical Research Roundtable

When noncompliance is your best option

Last week Lungevity hosted the Scientific and Clinical Research Roundtable in DC and I was invited to be the keynote speaker. Really. I could be wrong but I have a sneaking suspicion that most of my invitations to speak will not be followed up with a second invitation. I have transitioned unequivocally from advocate to activist and I’m not sure everyone is ready to hear what I now feel the strong need to say. In a nutshell, I feel that clinical trial participants are the graduate students/sherpas/indentured servants of the cancer world. We do the heavy lifting–it’s all guts and no glory but we can’t say no because we’ve got nowhere else to turn.

I’ve shared the entire transcript of my talk here. It’s a long haul and for those of you familiar with my story, there will be some repetition in the first half. But then I get down to nuts and bolts (or screws and nails, the way I describe my neuropathy).

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Good afternoon. I am happy to be here today. In fact, I am happy to be here every day.

It’s not something I take for granted, ever. The first thing I do when I wake in the morning is to say ‘I’m alive.’

The wonder never lessens. And that is because a little over eight years ago, I heard the words ‘there is nothing else we can do.’ Never one to turn away from the truth I wanted to know more, I wanted to know how much time remained. The answer was three to five months.

And so I began to let go of my life—and to help my family do the same. Both I and my youngest, then eleven, started individual counseling. I travelled to Colorado, for a hastily organized and tearful family reunion. I said my goodbyes.

But then at my next oncology appointment something totally unexpected happened. A recent biopsy had been submitted for genetic testing and had come back positive for a newly identified target in non small cell lung cancer, an ALK translocation. A phase I clinical trial for an experimental agent targeting ALK mutations had begun recruiting at my hospital. So far there had been only one other participant and he had died within weeks of starting the trial, in part because of side effects of the experimental agent.

It was not a lot of information to go on but I liked the sound of targeted and my oncologist, though cautious, seemed enthusiastic as well. I hoped the drug wouldn’t hasten my death, but I knew that if I did nothing, my cancer would surely kill me. I was between a rock and a hard place but the way I saw it, this clinical trial offered at least a sliver of hope where now I had none. And I said yes.

On October 1st of 2008 I became the fourth person in the world with non small cell lung cancer to take crizotinib. Seven weeks later, as we went over my scans, my oncologist characterized my response as flipping amazing. And all those goodbyes became hello, I’m back.

I got lucky, really lucky. I was at the right place, in the right time, and with the right oncologist. And I’ve been lucky ever since, having now been an early participant in three phase I clinical trials. Innovative medical research has extended my life far beyond what I ever thought possible.

This has meant the world to me and my family. In June, almost eight years to the day after I was told I had three to five months left to live, I watched my youngest graduate cum laude from Phillips Exeter Academy. Four weeks ago he began his freshman year at MIT.

And me? I’m loving life, all of it. 45 when diagnosed, I will turn 57 in November. Between my three kids, art, writing, advocacy and my plethora of friends, I couldn’t be busier.

Of course, I do still have lung cancer. Although I have enjoyed two years of stability on my current therapy, my most recent scan showed progression. I have scans again in two days, and by next week, I should know if it is time to switch things up again.

I hope that medical research will stay one step ahead of me. I also hope my body will hold out.

It has been my privilege to participate in clinical research. But it has also been my burden. I have shared my joy, my gratitude. Now I would like to share my concerns and I feel I have rather a unique perspective for doing so.

There was an old paradigm for clinical trials, and that was that they were usually a one off.

When I enrolled in the trial for crizotinib in 2008, it was with the hope that it might extend my life for several months, nothing more than that. Because honestly, there was no precedence.

Even once it became clear that I’d in fact responded to the experimental therapy, my joy was tempered with the knowledge that I would eventually develop resistance to the drug and that when I did, I was once again out of options. Because that is where things stood in 2008.

I never imagined that I would go from trial to trial, and, at that time, I’m not sure anyone else could have imagined such a scenario either.

But I have and my participation has kept me alive. However, it has come at a price.

Enrollment in a clinical trial requires a greater commitment of time, resources, blood and tissue. And often, additional scans as well.

The clinical trial that I am now enrolled in initially had a protocol that required not only a Chest CT scan, but an abdominal scan, brain MRI, and echocardiogram every six weeks. I might point out that a schedule more akin to every three months is the standard of care when it comes to scans for a metastatic patient. I might also point out that my histology, invasive mucinous adenocarcinoma, almost always stays confined to the chest when it metastasizes, and that I have never had brain, bone or abdominal mets.

Initially my trial also required a bone scan, every three months. I had the first one, and afterward was handed the the same little card that you carry around for three days after every PET scan, just in case someone in law enforcement or at an airport picks up remaining background radiation. This struck me as ludicrous, and also an unacceptable risk with neither scientific justification nor personal gain. I told my oncologist that I wasn’t going to get any more bone scans even if it meant dropping out of the trial. Fortunately she is as invested in my future as I am and as a PI in the trial, was able to contact the sponsor and had the protocol changed.

Fast forward to July of 2015 when I happened to see a report in the Stanford Medicine newsletter regarding DNA damage seen in patients undergoing CT scanning. This line in particular jumped out at me ‘“We now know that even exposure to small amounts of radiation from computed tomagraphy scanning is associated with cellular damage.” I started to think about all the scans I’d had and would continue to get and wondered if anyone was keeping track. With access to my electronic medical records, I decided to tabulate the results myself and what I found shocked me. Now keep in mind that this only reflects care and clinical trial participation at my current hospital, and does not take into account previous imaging, such as the scans that led up to my diagnosis. Or workups for other health issues, or routine imaging such as mammograms or dental work.

When I sat down and counted I found that I’d had 19 chest x-rays but also close to 70 CT scans of my chest. For those of you who don’t know, each chest CT scan, even those that are low dose, has the equivalent radiation of 4-500 chest x-rays. Now multiply 400 times 70 and tell me if that is a number you are comfortable with. I was really surprised when I counted the number of abdominal scans I’d been given; 44. Given the complexity of the tissue in the abdomen, scans of that area of the body expose cells to an even greater amount of radiation. And keep in mind that I have no cancer in that part of my body. Yet. But I do have highly mutable cells.

The first CT scan of my chest saved my life. But is my scan schedule eventually going to lead to a secondary cancer?

I don’t know, but I can’t let that happen. And so I did what any reasonable person would do. I spoke not only to my oncologist, a PI in the trial, I contacted the sponsor personally. However, I really made no headway until I talked to the right person in a bar. That’s right. I have been a peer reviewer for the CDMRP for a number of years and after a session last fall I chatted up a fellow reviewer in the bar—told them my tale of woe. When I concluded he let me know that his wife worked for the sponsor and he was going to share my story with her.

Well sometimes the back door is the right one and this time the sponsor contacted me. I had a private phone conference where I spoke not only about my scans but about what I view as a rather prevalent disregard of the sacrifices clinical trial participants make. And I asked that they not only change the scan schedule, but that they pay for parking.

When I got my response it was from my scheduler. My scan schedule would not be changed. I told her to tell my oncologist that I now had no choice but to become noncompliant—that I would continue to get CT scans of my chest but there would be no more abdominal scans.

I am fortunate that my oncologist truly is as invested in my future as I am. She called me almost immediately and we discussed the situation. To my surprise, she was fully supportive, although she did explain what noncompliance put at risk for me personally as well as for the trial and my institution. I told her that if she asked me to go to Mars the next day I would do it, I trust her so implicitly, but that I simply could not keep getting scans every six weeks for the rest of my life.

The bottom line is this—currently clinical trials are monitored as discreet events, a residual of the old one-off paradigm. No one seems to be keeping track of patients such as myself, who are traveling from trial to trial. I am an outlier, an exceptional responder, and I am also a bit of an anomaly amongst the ALK positive population with my invasive mucinous adenocarcinoma histology.

But that is the point—I am first and foremost an individual, a human being. Participation in clinical trials does not cede my humanity, although it certainly does result in a certain loss of autonomy. And words like compliant and noncompliant only underscore that fact.

Per my scans—I really like to do things the right way. Also, as an advocate, this was never just about me but rather about everyone who participates in clinical trials. And so I would periodically contact the sponsor. What I didn’t realize is that my oncologist was also in continuing dialogue with them about the scanning schedule. Several months ago I got word that the protocol would be changed and that after a year on trial, participant’s scans would move out to every three months, the standard of care. When I spoke to my oncologist, I realized that it was her input, not mine, that made the real difference. But the important thing is, she respected my concerns which motivated her to request a change in protocol.

As for me, I moved to the every three month schedule as soon as I heard the news, even though it is not yet official. Jumping the gun a little, but then again, I remain noncompliant as to my abdominal scans, so what’s a skipped chest CT scan or two. And don’t think I am simply being cheeky—I donated my body to science a long time ago and I feel no guilt when it comes to a skipped scan or two.

I still wish I didn’t have to get brain MRI’s every six weeks—I’ve now had almost thirty and nothing causes me more anxiety than the loud clanking, claustrophobia of a brain MRI. Also, I am convinced that we don’t yet understand the risks—again, there is very little precedence for such a frequent MRI schedule in someone with healthy brain tissue. After reading that the contrast agent, gadolinium, is not readily cleared from the body I did request that we forgo contrast so that is one small victory.

The irony is, were this anything other than a clinical trial, say, a war or a sporting event, I and my fellow participants would not be fighting for our basic human rights. We would be decorated for our valor, celebrated, maybe even highly compensated. And we can’t even get our parking comped.

And yet, I am alive. It is a wondrous thing, and something most people take for granted.

I would do almost anything to stay alive. I already have. But I am also not willing to throw away this second chance at life by submitting to ridiculous requirements simply to satisfy the science and to speed drugs to market. As Richard Pazdur has said, ‘People are not for clinical trials. Clinical trials are for people.’ It’s imperative that we not lose sight of why trials exist in the first place. It is not to advance the careers of researchers. It is not to keep oncologists and hospitals in business. It is not to enrich sponsors and their shareholders.

Rather, it is to provide patients such as myself with an opportunity to hang onto our very dear lives.

*for a dose of happy/hopeful Linnea, check out this video interview about Clinical Trials from the Lungevity site.