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Asbestos Exposure from Unexpected Sources

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Exposure to asbestos during our lifetime can be a common occurrence. Depending on the house you grew up in, where your parents worked, what you did for a living, how your home was insulated, chances are you were exposed to asbestos. It is a known carcinogen, a naturally occurring mineral that has been used in products for centuries because of its fireproofing and insulating properties. Although the facts about asbestos exposure leading to illness have been known for decades, it continues to be used in products. Asbestos is not banned in the United States.

We know that asbestos is still used in certain industries. The most commonly known products are automotive brakes, pipes and flooring. We do not expect to find it in personal consumer goods, but in 2015 four types of crayons were found to contain asbestos. The crayons were manufactured in China and sold in the United States. We do not expect that asbestos would be in our children’s crayons.

This past week it has been reported that asbestos has been found in some makeup products sold by a popular store for young teenagers. Tremolite fibers, one of the forms of asbestos, were reportedly found in the talc of one of the lines of cosmetics. Currently in the United States the Food and Drug Administration does not permit the use of asbestos in cosmetics. However, the FDA does not require manufacturers to test their products, nor even recommend that the most effective means be used to identify asbestos. The store involved is conducting its own investigation. They have stopped the sale of the product while the investigation is ongoing. We do not expect to find asbestos in our children’s makeup.

Protecting our children from harm is a primary responsibility of parents. Sometimes the harm is hidden. The time between exposure and developing the disease is decades. Less than 1% of people exposed to asbestos develop mesothelioma. Of the less than 1% that do develop mesothelioma at least 80% is caused by identifiable exposures to asbestos exposure decades earlier. The remaining mesothelioma cases may very well be caused by other asbestos exposures that are now being uncovered, such as asbestos in cosmetic products.

Asbestos related diseases are preventable. Awareness about what asbestos is, education regarding where it is used and in what products is available. The Asbestos Disease Awareness Organization is a web site to check out to become educated and aware of the dangers of asbestos (www.asbestosdiseaseawareness.org).

Asbestos is not banned in the United States it is important that we all become aware of the potential danger of this carcinogen.

– Lisa

The Importance of Listening to Mesothelioma Patients

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As anyone who has ever spent time at a busy hospital knows, your appointment time and the time you are seen are sometimes hours apart. Reality and schedules do not often keep together. Over the years, I have seen many reactions to a delayed appointment and the range of emotions are as varied as the patients. No one likes to wait. Everyone’s time is important. Despite the efforts of many time management consultants, multiple new on time initiatives it remains a problem. One of the root causes of the problem is that you are dealing with people. The procedure that is scheduled for 45 minutes’ turns into an hour when an unexpected finding requires consultation with other experts. Patients are not kept waiting intentionally but it happens. Occasionally the system can work, and at that point it is important to remember why the health care team needs to actively listen to each patient and their individual needs.

It was 1:40 p.m. on a busy Friday afternoon. The next patient was scheduled to be in the room undergoing a palliative procedure that sole purpose was to make her feel better. She had flown in to have the procedure done and had a flight out at 5 p.m. There was eye rolling by some, mumbling by others, but some members of the team took it as a challenge. ” We will make this happen,” the nurse assured the patient. ” You will be in an Uber by 3:30 on the way back to the airport. ” This patient had a biopsy earlier in the week and the results would not be back for another week. She had been fighting cancer for several years and now it had started down an aggressive path. As she told her story from start to finish, it occurred to the nurse that her business-like attitude of not taking no for an answer, was the way she was fighting her cancer. It was not so much that she makes the flight, as it was that she felt you were working with her so she could have some control over a health situation that was quickly spiraling out of control.

The radiologist came in and after some non-invasive testing and comparing of her films could not find the fluid that would magically make her pain go away. After conferring with the patient’s team and lengthy discussions between all the team it was decided that there was not enough fluid to drain, no procedure on this day would make her feel better.

The doctors exited the room, the patient was momentarily flustered, when the nurse offered to page her primary oncologist so that they could discuss the plan going forward. The oncologist immediately called back and discussed with the patient for another 10 minutes the plan. There would be prescriptions to pick up, and a new medication regime as they waited for the biopsy results to come back. The patient was back in control. Now it was 2:45 how was she going to be in an Uber with her new medications by 3:30 as promised?

Gathering her luggage, a wheel chair and a nursing student, the nurse pushed her over to the pharmacy, which involved a series of elevators and bridges, a total of 3 city blocks apart. The pharmacist had received the prescriptions, and was in the process of filling them. The medications were ready at 3:23 p.m. The Uber was called, in the car at 3:29 p.m. Patient on way to airport, in control with a plan, and on time for her flight.

In life, it is often the little things that people help you with that you remember. No one knows the road ahead for any of us, putting yourself out for someone else will not cure her cancer, but it will help her control her journey, and plan and cope for whatever is ahead. Listening is important!

– Ellie

Thinking of Mesothelioma Survivors on National Cancer Survivor Day

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Sunday June 4, 2017, was National Cancer Survivor Day. This day is set aside each year to “demonstrate that life after a cancer diagnosis can be a reality.”

When I see a familiar face cruising the hospital in a wheelchair or walking with a family member it gives me great joy. Remembering back to the days of their hospitalization and the unsure days that they faced, the turnaround is great to experience for the patient and the family.

This week I spoke to several mesothelioma patients. The first was a woman who was in her seventies, who had many complications, but is home with her daughter. She was thrilled and had a huge smile. She admitted that she was still unsteady on her feet, but she had no regret about her treatment. She was well supported by her grown children who continue to accompany her to her medical visits.

The next patient was a gentleman who has been out three years. His hospitalization was also complicated and lengthy. He appeared physically well, but he did not appear to be happy. He has a supportive wife and family, but is weighed down by the fear of the disease. We talked about his life and how he filled his days and what he did with his time. He is currently enrolled in a clinical trial and has felt good about that. He spends time with his grandchildren. When asked if he keeps in touch with anyone from the mesothelioma world he said no. The one person he had a relationship with has died.

I went home thinking of him and his family and what could help him. Treatment for mesothelioma can cause fear, anxiety, depression, and at the least uncertainty. The emotional toll of his hospitalization seems to have lingered with him. It would be helpful for him to join a support group to share his experiences with others who have also gone through similar experiences. His wife would also benefit from having someone to talk to as well as him.

Another patient was also back. He returns regularly for a thoracentesis. Once every two months or so he returns and has the procedure. He appears to be happy and is grateful for the treatment and the relief it provides for his breathing.

Dealing with a devastating diagnosis of mesothelioma brings a host of emotions. Everyone reacts differently and handles it as they see fit. Despite the progress in the physical treatment of mesothelioma, the psychological treatments need to be a part of the healing process.

There are many resources available to help live with cancer. There are support services including support groups, on line groups, and disease related groups. There are articles on the internet from cancer survivors and what worked for them. If you need help with this part of your journey you are not alone. “Too many of us are not living our dreams because we are living our fears.” Les Brown.

– Lisa

MESOTHELIOMA CLINICAL TRIAL REVIEW – INTRAPLEURAL CRYOTHERAPY FOR MALIGNANT PLEURAL MESOTHELIOMA

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We encourage participation in clinical trials for research leading to a cure for mesothelioma. It is known that nationally the statistics for participation in adult cancer trials is between 3-5% of adults who have a cancer diagnosis.

For mesothelioma patients and families that are interested in clinical trials, researching clinical trials and eligibility can be a time-consuming barrier to participation. The information about clinical trials is available on www.clinicaltrials.gov.

Our goal is to feature one mesothelioma clinical trial monthly and break it down to understandable terms, to decipher the eligibility requirements, and to possibly encourage participation in these trials.

Clinical Trial – NCT 02464904

Official Title: Intrapleural Cryotherapy for Malignant Pleural Mesothelioma

Listing on: www.clinicaltrials.gov

Sponsor: Mayo Clinic

Location: Mayo Clinic Rochester, Minnesota

Principal Investigator: Shanda H Blackmon, MD, MPH Mayo Clinic

Contact: Karlyn Pierson, RN, MAN 507-538-1960 pierson.karlyn@mayo.edu

Bettie Lechtenberg, MBA 507-266-4819 lechtenberg.bettie@mayo.edu

Purpose: To see if neoadjuvant cryotherapy be safely performed in patients with malignant pleural mesothelioma and will it trigger a systemic and or local pro-inflammatory response in the induction of anti-tumor immunity.

Primary outcome Measure Number of patients with adverse events. Patients will be monitored for adverse events that may have resulted from a pleuroscopy procedure.

Estimated Enrollment 15

Study Start time July 2015

Estimated study completion date June 2017

Estimated Primary completion date June 2017

The study is still open and actively recruiting

Interventions: Patient will have their blood drawn prior to pleuroscopy for staging purposes. The biopsy will consist of pleural fluid and pleural biopsies that will have consist of 4-8 biopsies. During the procedure, there will be 2-3 applications of cryospray applied to the disease. (Usually the chest wall area). The minimum area is a 2×2 cm area which will continue for 15-20 seconds then thaw for 60 seconds followed by 1 to 2 times of cryotherapy before moving on to the next area. The freezing procedure will be video recorded and freezing locations and times will be recorded. Approximately 14 days following the staging pleuroscopy patients will undergo surgical treatment as per standard of care. Blood and pleural fluid and tissue collection will be performed as well.

Description: Patient that have been diagnosed or thought to have malignant pleural mesothelioma. Prior to surgery for treatment a pleuroscopy or video camera exam of the pleura will be conducted to establish diagnosis or extent of the disease. The purpose of this research is to gather information on the safety and effectiveness for cryotherapy in patients with malignant pleural mesothelioma.

Eligibility: Must be 18 years old male or female

Inclusion Criteria

  • Patients provide informed consent
  • Patients 18 years of age
  • Patients competent for making informed decisions
  • Patient will undergo pleuroscopy as part of their standard care for pre-operative clinical staging of malignant pleural mesothelioma.
  • Pregnancy test is required to be negative
  • Patient is mentally capable of understanding process of study

Exclusion Criteria

  • Patient that have an INR 1.5 or greater
  • If patient is on anticoagulants such as heparin, warfarin, and other types of anticoagulation have not been held for the standard time
  • Vital signs will be stable heart rate greater than 120 unless deemed stable with these values by the surgical or interventional pulmonary attending physician. Also, systolic blood pressure will also not be less than 90 mmHG unless deemed stable
  • Hypoxia with oxygen saturation less than 88% or a PA02 less than 60 measured from arterial blood gas.
  • Participating in another study involving the investigational drugs or investigational medical devices
  • If there is limited access to the pleural space or absence when performing medical pleuroscopy
  • Inability to read and understand the necessary study documents

Sources:

www.ClinicalTrials.gov

With any clinical trial, all participation is voluntary. Before enrollment a detailed consent form will be reviewed with the participant and signed. The participant can withdraw from a clinical trial at any point in time. Think about participating if able, the only way to progress to a cure for mesothelioma is through clinical trials.

Please do not hesitate to contact us with any questions.

Definition of Terms

Cryotherapy- is the therapeutic use of cold, is a technique that uses extremely cold liquid or an instrument to freeze and destroy abnormal cells. Used on common benign conditions such as warts and certain skin cancers.

Pleuroscopy- is the examination of the pleural cavity with an endoscope, through an incision on the thorax (chest).

Cryospray- the use of liquid nitrogen spray in cryosurgery

Cryosurgery- an operation using freezing temperature as an agent or an independent agent in an instrument to destroy tissue. It is the destruction of tissue using extreme cold: silver nitrate, and carbon dioxide are commonly used.

Source: www.medical-dictionary

Go For A Walk: Benefits for Mesothelioma Patients and Others

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In this day and age of high tech personalized medicine, there are still some simple tasks that we all can do, if able, to improve our overall health. When you are dealt a diagnosis of malignant mesothelioma there is one thing that everyone can benefit from doing every day – walking. No matter what stage your cancer is, what cell type or course of treatment that you elect, walking everyday has proven health benefits. Walking can ease the recovery after surgery, contribute to the use of less pain medication and allow you to potentially be released from the hospital earlier.

How does walking have such positive benefits? As noted in http://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/walking/art-20046261 walking can help maintain a healthy weight, prevent or manage various conditions, including heart disease, high blood pressure and type 2 diabetes, strengthen your bones and muscles, improve your mood and improve your balance and coordination.

In 2015, research was presented at the European Society of Cardiology Congress, that walking may slow down the aging process and that exercise buys you three to seven additional years of life. It can act as an antidepressant, improves cognitive function, and there is new evidence that it may retard the onset of dementia.

One study found that walking for two miles a day or more can cut your chances of hospitalization from a severe episode of chronic obstructive pulmonary disease (COPD) by about half.

Another study found that daily walking reduced the risk of stroke in men over age 60. Walking for at least an hour or two could cut a man’s stroke risk by as much as one-third, and it didn’t matter how brisk the pace was.

Walking triggers your body to release natural pain-killing endorphins, and the more steps people take during a day, the better their mood tends to be.

Walking daily around 10,000 steps or more is good, if you can do it out in the sunshine and barefoot for grounding it is better. In an article published online in March of 2015, ‘The effects of grounding (earthing) on inflammation, the immune response, wound healing, and prevention and treatment of chronic inflammatory and autoimmune diseases are remarkable.”(www.ncbi.nlm.nih.gov/pmc/articles/PMC4378297/) Grounding is defined as direct skin contact with the surface of the Earth, such as with bare feet or hands, or with various grounding systems. This research investigated the effects of walking on inflammation and concluded that grounding can be a simple, natural, and accessible health strategy against chronic inflammation.

Established in 1996, America Walks, is an organization which is trying to make America a great place to walk, by providing a voice for walking and walkable communities with federal agencies.

Walking is easy, free, and available for everyone. Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention is quoted as saying walking is “the closest thing we have to a wonder drug.”

The Harvard Health Publication of Harvard Medical School recently published the 5 surprising benefits of walking. Walking counteracts the effects of weight-promoting genes, helps tame a sweet tooth, reduces the risk of developing breast cancer, helps to ease joint pain and boosts immune function.

The benefits of walking are many, take advantage of them!

– Ellie

Reaching Out In Response to a Mesothelioma Diagnosis

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When someone is diagnosed with mesothelioma or any serious illness, it is not unusual that family and friends do not know what to say or how to acknowledge what is going on. Once diagnosed with mesothelioma, hopefully the patient’s friends and family will rally around them.

Some people, with the best intentions, will tell you it will be Ok. Some will offer their opinion on chemotherapy, and how they feel it is just “poison”. The intentions are good, the delivery and message can be distressing to the patient and family to hear. There are also the group of people upon hearing the news, that disappear and you do not hear from them. It can be surprising that some that you thought would be with you are not. For your own health, try not to dwell on the ones that cannot handle your diagnosis.

To be helpful, according to www.cancer.org , take your cues from the person with cancer, some will want to talk about their illness, others prefer privacy. Let them know you care. Respect their treatment decisions. Listen without always feeling that you need to respond. Offer to help in concrete, specific ways. The advice continues about what not to say. Don’t offer advice they don’t ask for, or be judgmental. Avoid being patronizing, or telling the person with cancer “I can imagine how you feel.”

During you or your loved one’s journey with mesothelioma, you might discover that you have formed new relationships. Sometimes the people who surround you at your darkest moments may be not the ones you expected to be there. We have seen bonds form between people that they were even surprised about. Two women from totally different walks of life and completely opposite interests had formed a tight bond, so much so, that they made their husbands appointments on the same day so they could support each other. For these patients and families this was the positive that they were taking from the diagnosis of mesothelioma. For some, these are reassuring positive relationships, for others it might be too much to handle.

If someone you know is diagnosed with a serious illness, reach out. Listen instead of talking. Expect the person to have good days as well as bad days. Cancer is an equalizer. It reminds us all that our time on this earth is limited, make the most of it, and reach out to others who are having a rough time.

– Ellie

MESOTHELIOMA CLINICAL TRIAL REVIEW – NYU IMMUNOTHERAPY

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We encourage participation in clinical trials for research leading to a cure for mesothelioma. It is known that nationally the statistics for participation in adult cancer trials is between 3-5% of adults who have a cancer diagnosis.

For mesothelioma patients and families who are interested in clinical trials, researching clinical trials and eligibility can be a time-consuming barrier to participation. The information about clinical trials is available on www.clinicaltrials.gov

Our goal is to feature one mesothelioma clinical trial monthly and break down to understandable terms, to decipher the eligibility requirements, and to possibly encourage participation in these trials.

CLINICAL TRIAL- NCT02718911

A Study of LY-33022855 in Combination With Durvalumab or Tremelimumab in Participants With Advanced Solid Tumors

Official Title-   A Phase 1a/1b Trial Investigating the CSF-1R Inhibitor LY3022855 in Combination With Durvalumab (MED14736) or Tremelimumab in Patients With Advanced Solid Tumors

Listing on   www.clinicaltrials.gov

Sponsor: Eli Lilly and Company – Collaborator Astra Zeneca

Location: Multiple locations throughout the world

Principal Investigator: Leena Gandhi M.D.at NYU – Study Director 1-877-285-4559 at Eli Lilly

Contact: NYU- 212 731 6199

Number of Participants: Estimated 178

Purpose: -The focus of this study is to evaluate the safety of the colony-stimulating factor 1 receptor (CSF-1R) inhibitor LY3022855 in combination with durvalumab or tremelimmab in patients with advanced solid tumors

Screening: – Must be willing to undergo pretreatment and on-treatment core needle or excisional tumor biopsies

Lab test that include:

  • absolute neutrophil count> 1.5 x 10.9/Liters
  • Platelet count. 100,000/ cubic millimeters
  • Hemoglobin >9 gams per decliter
  • Serum creatine, 1.5 x institutional upper limit of normal (ULN)
  • Total billrubin <1.5 x institutional ULN
    • Asparate aminotransferase (AST) and alanine aminotransferase (ALT), <2.5x institutional ULN or <5 x institutional ULN for participans with liver metastasis
    • International normalized ratio (INR) or prothrombin time (PT) INR, 1.5 x institutional ULN or PT <% seconds above institutional ULN

Eligibility Criteria: Must have histological or cytological evidence of a diagnosis of cancer that is not amendable to curative therapy

Part B must have a type of malignancy that is being studied

Part A (all cohorts): Have the presence of measurable and/ or no measurable disease as defined by the Response Evaluation Criteria in Solid Tumors (RECIST)

Part B (all cohorts) Have the presence of measurable disease as defined by the RECIST

PTT or activated partial thromboplastin time (aPTT) < 5 seconda above institutional ULN

Thyroid stimulating hormone (TSH) or free thyroxine (T4) within the normal limits

Have a performance status 0 or 1 on the Eastern Cooperative Oncology Group (ECOG) scale

Exclusion Criteria: Are currently receiving or have used immunosuppressive medications within 28 days

Have symptomatic central nervous system (CNS) malignancy or metastasis

Have had any prior Grade>3 immune-related adverse event while receiving any                                             previous immunotherapy agent

Have experienced a Grade>3 AE or a neurologic or ocular AE while receiving prior                                          immunotherapy

How the Research Study Is Designed to Work: Trying to find the maximum dose tolerated by patients of drug LY3022855 when given in combination with Durvalumab- one group – another group LY3022855 and Tremelimumab. One group given escalating doses, the endpoint would be the maximum tolerated dose and measure the response through progression of disease, stable disease, complete response or death.

Sources: www.ClinicalTrials.gov

With any clinical trial, all participation is voluntary. Before enrollment a detailed consent form will be reviewed with the participant and signed. The participant can withdraw from a clinical trial at any point in time. Think about participating if able, the only way to progress to a cure for mesothelioma is through clinical trials.

Please do not hesitate to reach out with any questions.

Definition of Terms

Phase 1a/1b- initial phase of testing of an investigational drug in humans. Used to determine the side effects of the drug and how it works. Phase 1 is sometimes sub-divided into phases 1a and 1b with different doses being measured. New drug being combined with standard of care to find out what dose is best tolerated

Colony- stimulating factor 1 receptor (CSF-1R)- protein encoded by this gene is the receptor for colony stimulating factor 1- cytokine which controls the production, differentiation and function of macrophages. macrophages are important cells of the immune system that are formed in response to an infection.   They are large specialized cells that recognize engulf and destroy target cells.

LY3022855- Human monoclonal antibody designed to target CSF1R, preventing ligands CSF1. Being investigated in phase 1 clinical trials, including a collaboration clinical trial with another immuno-oncology agent.

Durvalumab- another name is Imfinzi-ANTI pd-L1 antibody- blocks PD-l1 binding to PD-1 and CD 80- monoclonal antibody being used in treatment of some cancers

Tremelimumab- human immunoglobulin (Ig) G2 monoclonal antibody directed against the human T-cell receptor protein cytotoxic T-lymphocyte- associated protein 4 (CTLA4 with potential immune checkpoint inhibitory and antineoplastic activities.

Solid Tumor- is an abnormal mass of tissue that usually does not contain cysts or liquid area. Solid tumors may be benign (not cancer), or malignant (cancer). Different types of solid tumors are named for the type of cells that form them. Examples of solid tumors are sarcomas, carcinomas, and lymphomas. Leukemias (cancers of the blood) generally do not form solid tumors.

Source www.cancer.gov

Identifying Emotions at End of Life with Mesothelioma

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No matter what the age, the diagnosis of an aggressive cancer like malignant mesothelioma is devastating to the patient and the family. For most of us, facing our death, or the death of a loved one can bring up intense feelings that are at a minimum uncomfortable to deal with. Reality is different than the expectations a lot of people have of the dying process. Dealing with the emotional aspects of mesothelioma, is important both for the patient and their loved ones. There are many emotions that come up and a lot of them cannot be neatly wrapped up and dealt with without help.

A family member of a patient who was not doing well recently confided in me that the illness really had “brought out the worst in them.” There are a lot of emotions to deal with and unlike television they do not get wrapped up in an hour show. There is the feeling of shock with the diagnosis. Shock is also present with fear. Fear is present from the beginning. Fear of the unknown. Fear of dying. Fear of being alone. Fear of suffering. Fear of being a burden to your loved ones. There are many fears that you and your family face. Fears are best identified and managed by pinpointing exactly what the fear is and dealing with it. This is not easy.

Anger is often directed at the ones closest to you. The family member that I was talking with explained that her husband was so angry about the diagnosis that everything she did annoyed him. She was trying her best but she could not deal with his remoteness. His anger was directed totally at her. She knew that he needed to redirect his anger to the disease but he was not there yet.

Some of the other emotions that pour out at this time are grief. Grief at what you are losing – your life, your relationships. Coming to terms with what has given your life meaning, your past, accomplishments and your regrets. Anxiety, depression, the symptoms can also be identified and managed

We have seen many different people deal with dying in different ways. Often family members ask us what to say, what not to say. A lot of the time the answer is to just listen. Sometimes it is the smallest act of kindness- a cup of coffee, a smile, a hug that can make a difference. There is no one size fits all approach.

There is help available. Someone who is not as emotionally connected to the family can help with coping with these overwhelming emotions.

My patient’s wife was able to talk with her pastor. Her husband is doing better emotionally. Reality is different than television. Dealing with death and dying is real. Life is short and the important things are the relationships and memories that you create.

– Lisa

Cancer Immunotherapy and PD-L1

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Different medical terms are used in defining other medical terms. When advertisements on the television for new immunotherapy drugs say that in order for the new drug to be effective the tumor must “express PD-L1”, what are they talking about? Although the words are long and foreign the new classification of therapy and its results are exciting for all patients and families.

To review, the immune system as defined on www.cancer.gov:

“A complex network of cells, tissues, organs, and the substances they make that helps the body fight infections and other diseases. The immune system includes white blood cells and organs and tissues of the lymph system, such as the thymus, spleen, tonsils, lymph nodes, lymph vessels, and bone marrow.”

It is long known that the immune system plays a vital role in keeping us healthy.   The way the immune system functions are to recognize and fight foreign invaders that will change the cell metabolism.

It was discovered over 100 years ago that somehow the immune cells allowed other infiltrates to produce cells that are undetected and cause disease. Why or how this happened was a mystery. What controlled the switch to allow this to happen? In the 1990’s the breakthrough discovery by scientists that human cells carry certain proteins on their surface that enable them to escape attack from the body’s immune system. This led to the discovery in 2000 by scientists at Dana Farber Cancer Institute in Boston. The scientist credited with its discovery is Gordon Freeman PhD and his associates. What Dr. Freeman discovered is that the protein PD-L1 (programmed cell death 1 ligand 1) was on normal cells. Their research discovered that PD-L1 binds to the T cells co-receptor PD-1 as a result the T cell does not start the immune system from attacking. In 2001 Dr. Freeman and his associates published that PD-L1 appears not only on some normal cells but on certain cancer cells as well. From that it was thought that the agent that blocks PD-L1(or a related ligand PD-L2) could release the brakes on the immune system and attack the cancer. From these discoveries, pharmaceutical companies started to look at drugs that could block PD-1, PD-L1, or PD-L2. The drugs that block these and other proteins are known as immune checkpoint inhibitors.

The definition for immune checkpoint inhibitor, according to www.cancer.gov:

“A type of drug that blocks certain proteins made by some types of immune cells, such as T cells, and some cancer cells. These proteins help keep immune responses in check and can keep T cells from killing cancer cells. When these proteins are blocked, the “brakes” on the immune system are released and T cells can kill cancer cells better. Examples of checkpoint proteins found on T cells or cancer cells include PD-1/PD-L1 and CTLA-4/B7-1/B7-2. Some immune checkpoint inhibitors are used to treat cancer.”

Our immune system is comprised of many cells including T cells. T cells help fight off diseases like cancer. On the surface of the T cells are certain proteins known as programmed cell death receptors, or called PD-1. The cancer cells can escape T cells by expressing a protein called PD-L1. This protein activates t cells. PD-L1 attach to T cell receptors called PD-1. The scientists have theorized if we could prevent the cancer cells from expressing PD-L1 we could treat the cancers that express this gene.

The goal of cancer immunotherapy is to increase the immune systems response to cancer. Targeting PD-L1 is very important in cancer research. Cancer immunogenicity is the ability of a tumor to start an immune response. The more mutations a tumor has, the higher the chance that tumor antigens can trigger the immune response.

The drugs that are targeted as PD-1 inhibitors are Pembrolizumab (keytruda) or Nivolumab (Opdivo). Currently these drugs have had positive effects on certain types of cancers: Melanoma of the skin, non-small cell lung cancer, kidney cancer, bladder cancer, head and neck cancers, and Hodgkin lymphoma.

PD-L1 inhibitors include Atezolizumab (Tecentriq) and Avelumab (Bavencio). These drugs have been used to treat bladder cancer, non-small cell lung cancer, and Merkel cell skin cancer (Merkel cell carcinoma).

For patients with malignant mesothelioma there are currently clinical trials available with immunotherapy. In the Mesothelioma Clinical Trial Digest, you can find listings of the sites and the drugs they are trialing.

So, the next time that you hear the cancer must express PD-L1 to be eligible for a certain medication, this is what PD-L1 is.

– Ellie

Simple Questions

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As a nurse, you never know what patient’s story will have an impact on you. I recently had the honor of meeting a patient who was undergoing a thoracentesis.

Thoracentesis are procedures done frequently for many reasons, in mesothelioma often patients have them at the beginning of their journey, and sometimes at the end of their journey for comfort. They can be done for diagnostic reasons, the fluid is sent for testing, or for therapeutic reasons for the comfort of the patient. The procedure is usually done with local anesthesia only and patients feel better afterwards. A thoracentesis is a relatively quick procedure which can take 50-60 minutes. It is ideal if the patient can sit up   The proceduralist then uses an ultrasound machine to find the fluid and inserts the needle under visualization. In the institution that I work in we usually limit the fluid draining to 1000cc’s. The needle is inserted into the pleural space between the lung and the chest wall. The goal is to remove excess fluid – usually there is approximately 30 cc in this space.

Mr. W. had one other thoracentesis in December of 2016. He was having one now because he was feeling short of breath. He was quiet and had a beautiful smile. It was evident without any questions or conversation his disease was taking over. As we explained the procedure we talked about his life and his family. He proudly told us he had 4 children. His eldest recently purchased a restaurant and was a big success. The pride he wore on his face was undeniable. He spoke of his daughter who would graduate from college, and planned to come home and stay with him this summer because he did not know how much time he had left. The silence in the room at this time was deafening. He continued to tell us how proud he was of his other two children and how he loved his wife. He told his story with humor and grace.

At this point, the young resident that was assisting with the procedure, asked him a simple question. How is your family doing with all this? Usually we think of these questions but they are not asked. People don’t like to talk about death and dying it can become the elephant in the room.   He was at ease with this question and almost seemed relieved that someone was willing to listen to him. He spoke how he was a different man now than he was 3 months ago. His physical appearance had changed and he was dealing with more physical obstacles. He is not always able to do the tasks that he used to do around the house. He has grown weaker. His appetite is poor and he is unable to maintain his weight, and requires a lot of rest. He was stating these changes as facts. He has high hopes for this procedure to improve his quality of life. Being short of breath and feeling tired he said gets old and is limiting.

For Mr. W. the procedure was a success, he felt better and was going to be headed home. He was anxious to get home with hopes that his quality of life improves.

Sometimes the simplest questions are the hardest to ask but do the most good.

– Lisa

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