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>> Behind every heartbeat is a

story we can learn from.

As we have for over 80 years,

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Companies are working to use the

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members to better the health of

not just those we insure, but

all Americans.

Some call it responsibility.

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>> "Second Opinion" is produced

in conjunction with UR Medicine,

part of University of Rochester

Medical Center, Rochester,

New York.

[ Applause ]

>> Welcome to "Second Opinion,"

where each week we gather

medical experts to discuss a

real-life case.

I'm your host, Dr. Peter Salgo,

and I want to thank all of you

in our live studio audience for

being here.

And, of course, I want to thank

you at home for watching, as

well.

Our experts today are

Dr. Elizabeth Guancial, medical

oncologist from the

James P. Wilmot Cancer Center,

and primary care physician

Dr. Lou Papa.

And now I want you to meet our

special guest, Ronald Eckert,

who's here to share his story.

>> In the summer of 2011, I was

combing my hair, and I felt a

hard lesion on the top of my

head.

It was subsequently biopsied.

It turned out to be a melanoma.

I had extensive testing done.

It did not show any spread of

the tumor outside of the scalp.

I had an operation, a wide

removal of the skin lesion.

There was no evidence of spread

based on the tissue removed, and

I was feeling fine.

Five months later, I felt two

additional lesions on the top of

my head in a different location.

The biopsies at that time, one

was a melanoma, one was squamous

cell carcinoma.

Extensive testing was done

again.

There was no spread of tumor

found.

I had an operation to remove

both of those lesions, and the

pathology did not show any

spread beyond the scalp.

Three or four months later, I

had a third lesion.

It was biopsied.

Again, melanoma.

I had extensive testing at that

time, which indicated that it

had spread to both my lungs and

my liver.

I had the lesion removed.

At that time, I had three

operations with stage 4

melanoma.

>> Ronald, you're a physician.

>> Yes.

>> Sure during your career

you've had to deliver bad news

from time to time.

>> Yes.

>> What's it like being on the

other end of that?

>> Well, I always knew it was

more fun being the doctor than

the patient.

And it was difficult, because at

the time when I was diagnosed

with stage 4 melanoma, this was

back in 2012, there really

wasn't much out there for a

successful treatment of

melanoma.

And the prognosis was grim, so I

basically, at that time, felt I

probably had six months to a

year to live.

>> That's what I was taught in

medical school, too.

There wasn't a lot to offer.

It was a bad tumor.

It goes through the blood, so

you can't just excise it and

hope that you got all of it.

It's probably escaped.

You knew all of that.

>> Yes.

>> Lou, if he's in your office,

you're his primary care

physician, what's going through

your mind?

What are you telling him?

>> You know, years ago, my

mother-in-law, unfortunately,

passed away from melanoma,

pretty much as you said.

She was diagnosed.

Six months later, she was gone.

So once you have somebody who

has metastatic disease, depends

on where you are in time.

You know, in the past, the

treatments were really difficult

to tolerate.

Most people couldn't tolerate.

They weren't very effective, and

a lot of times you basically try

some treatment and get them

prepared.

>> Prepared -- Let me be very

clear.

Prepared to die.

>> Correct.

>> Let's be very straightforward

about that.

>> Absolutely.

>> You knew that.

>> Yes.

>> Right?

>> It's very important.

You don't want to -- You don't

want to, you know, squash all

hope, but you want to be

realistic.

You want to make sure that the

patient's aware of all the

possibilities, that as you're

going along in treatment, that

the odds are that you're not

going to see beyond six months

or more.

>> Now, Elizabeth, why don't you

take us back just a little bit?

What is a melanoma?

How does it spread?

Why is this prognosis, or was

this prognosis, as bad as it

was?

>> Sure.

So, melanomas are tumors that

develop within specialized cells

within the skin.

And unfortunately, even a small

melanoma can cause trouble.

The primary way that these

tumors spread is by getting into

the bloodstream, and then they

circulate throughout the body

and land in some typical places.

>> And to interrupt you, when

tumors spread via the lymph

nodes...

>> Mm-hmm.

>> ...the concede is if you get

those lymph nodes, you get all

the tumor, but once it's in the

bloodstream...

>> Correct, correct.

So lymph node usually is an

earlier site of spread, and

sometimes even when it gets to

the lymph node, it's potentially

curable, specifically through

surgery.

And so your team did exactly the

right thing by cutting it out.

But unfortunately, even when you

catch things at what we think is

an early stage and it's small,

there could have been cells that

got into the bloodstream.

And so melanoma is very

well-known for landing in the

liver, and what we call that is

metastasizing.

So there's lots of different

words for it.

Whether we call it stage 4 or

advanced or metastatic, it

really all means this is

typically not curable.

>> Or bad.

>> Correct.

>> Make it a word of one

syllable.

>> Yeah. Yeah.

>> And so you knew the deck was

stacked at this point.

>> Yes.

>> Something else came up for

you.

You'd heard about some other

stuff.

Tell us about that.

>> Yes, at the time, I was

pondering what to do because the

therapies out there weren't very

good, and as luck would have it,

my wife's roommate from nursing

school is a nurse practitioner

in Fairfax, Virginia, working

with an oncologist.

And she had mentioned to my wife

that they had had several

patients referred up to the

Mass General that were actually

doing well with stage 4

melanoma.

So that's what led to me going

to that facility for further

evaluation.

>> Now, these were clinical

trials, experimental therapies.

>> Yes.

>> So, let's stop for just a

moment, again, because people

here, "Whoa, there's an

experimental, new therapy.

I want to get in on this."

>> Mm-hmm.

>> What is experimental therapy?

What is the promise?

>> Mm-hmm.

>> What are the risks?

>> So, within the United States,

we have a very highly regulated

medical approval system for

anything new, whether it's a

device or a drug.

And so the FDA, the

Food and Drug Administration,

everyone has a strong feeling

either pro or against.

But their ultimate job is to

make sure that therapies which

patients are receiving are safe.

And so understandably, there has

to be a very long, intensive

period of time where these

promising therapies are being

studied.

>> So how do they work?

Who gets in a trial?

Are you sure if you're gonna get

in the trial you're gonna get

the new therapy?

How does that all shake down?

>> So, each study is different,

and it's really important to

have multiple, ongoing

conversations about them, but to

give a brief overview, initially

when a drug is identified in the

lab, it's first studied in

animals.

And there, if there seems to be

some type of promising data,

then it's brought into a

phase one study.

A phase one study, the purpose

is to find the dose that's safe

in humans.

Not necessarily effective, but

something that people can

tolerate.

Then a drug goes on to phase

two, and there you're really

looking at "does it work?"

And so you're comparing new drug

against old drug or standard of

care.

>> So that means somebody in a

phase two trial, some of those

folks are gonna be on the old

therapy, some of the folks on

the new therapy.

>> For the majority of phase two

studies, yes.

There are some studies where

everyone gets the new drug.

It depends on the disease.

In most cases, we don't

currently use placebos anymore

for oncology drugs.

>> A placebo is the old sugar

pill concept -- ineffective, not

active drug.

>> Correct.

Because oncology has, I think,

developed the way it has, there

typically are some

standard-of-care drugs that you

can use to compare experimental

drugs with kind of the

old-fashioned, what we would use

right now.

So for each study, it's very

different, but the hope -- the

reason why patients participate

in clinical trials is hopefully

that they will get that new drug

in advance of when it's

approved.

It takes years for drugs to make

it to an FDA approval where your

doctor could just say, "Here you

go.

We're gonna give you this drug."

>> But just for the record to be

complete, you may get on that

new drug.

It may not work, and it may be

harmful.

>> Absolutely.

>> This is all part of the full

disclosure that you get when you

go on a research protocol.

>> Yes.

>> But you heard about it, and

you said, "What have I got to

lose"?

>> Pretty much.

>> Pretty much.

So, what happened?

>> I went on a phase one

clinical trial with an

anti-PD-L1 medication, and I can

remember the consent form was

literally 36 pages long.

And being a physician and

practiced for as many years as I

had, I recognized what every

side effect or toxicity

mentioned in that consent was,

so I knew the gravity of the

situation, but I also knew the

gravity if it wasn't treated, so

I was more than willing to take

a chance.

So I started on this protocol,

and I received an infusion every

three weeks for a year.

>> The other thing that's

important is your wife went with

you for these interviews up in

Boston.

Isn't that right?

>> She did.

>> Why do you think that was

important, other than it's good

to have your wife with you?

>> Well, I think emotional

support, you know, and

knowledge.

She needed to have the knowledge

of what I was facing, too.

>> I always thought it was good

to have somebody with a patient

because that person was

listening and not as emotionally

involved as you.

I mean, she clearly was

emotionally involved, but she

can hear more clearly.

>> Right.

>> Yes?

>> Absolutely.

>> Lou, good idea?

>> Absolutely.

And I think it's important.

I mean, there's also specific

guidelines that protect the

patients in these trials.

So there's certain things, as

you talked about, some of the

trials don't have placebos

because it's felt in

international guidelines that

there's certain things that

would be more harmful to the

patient.

So there's guidelines for that.

But it's also I let my patients

know that if they're gonna get

involved in a trial, it's great

if you have benefit, but the

over-arching role of you getting

involved in the trial is for the

benefit of the management of

that disease and the benefit of

society.

'Cause you always hear about the

successes.

You don't hear about the

failures.

>> You're facing a

life-and-death moment here.

>> Yes.

>> With your wife.

>> Yes.

>> All right.

And she's in our audience here,

so we're gonna talk with her,

too.

Donna, when you heard this

diagnosis for your husband, what

was that like?

What were you feeling?

>> Well, to hear the word cancer

is frightening enough, and then

you hear stage 4, and just the

anxiety is overwhelming.

>> I mean, that must have been

terrible.

It must have been an awful

moment.

>> It was.

You can't even think rationally.

You're all over the place and

trying to decide whether to tell

the children or not.

So, he didn't want to, but I

said, "We have to.

I need to talk to them."

>> These are major life

decisions.

And then you heard about these

clinical trials.

You were the one who heard.

>> Yes.

>> So, when you heard about

them, was there a change in the

way you looked at this picture,

or not?

>> I think not until we got to

Boston and we actually heard the

doctor say, "We have things that

can help you."

And he was very positive, and so

that gave us a lot of hope right

there to move forward.

And, in fact, that he responded

so quickly gave us even more

hope.

>> Just looking at you now with

a smile on your face, there's a

medical term for what you were

going through at that moment.

It's called "whew!"

>> Yes.

[ Laughter ]

>> I looked it up once.

It's in all the textbooks.

So, you know, I want to continue

this story, but in every

episode, "Second Opinion" looks

for game changers, medical

innovations that are making a

difference.

So, here's what's going on in

the area of immunotherapy.

>> Conventionally, cancer

treatment is just mainly based

on chemotherapy and radiotherapy

and surgery.

But our body by nature has

actually an even better way to

treat cancer.

We can actually simply use our

own immune system to recognize

cancer better and kill cancer

better.

Tumors sometime become very

smart, so even though you infuse

many highly educated immune

cells into the patient's body,

the cells cannot find tumor very

easily.

So somehow this T cell has to

find their target tumor,

otherwise they cannot kill

tumor.

We have a LED that we made so we

can attach this LED at the tumor

area.

T cell recirculate through the

blood vessels, and they happen

to see the light and migrate

into the tumor area.

Something like there, we can

shine light and guide their

migration to the light.

But then they're changing it.

The wavelength's different.

>> Yeah.

So which one's...

The green's recruitment, isn't

it?

>> T cells shouldn't see light.

To make them respond to light,

we need genetic engineering.

To do that, we use a molecule

that we got from green algae.

You know, those small cells

actually has to respond to light

for their survival.

So we can kind of borrow those

light-sensing molecules from

different cells and transport

them into the T cell.

Unlike novel drug, you know,

this is very non-invasive way,

and I really hope that we can,

someday soon, make procedure a

little faster so that we can

actually test this technology in

patient.

>> So, we're back.

Ronald, you got a terrible

diagnosis of a terrible kind of

cancer -- a melanoma,

metastatic.

And you then heard about

clinical trials, and you went to

Boston to see if you can be

enrolled in one, and you could.

Now, you mentioned it was a

PD-L1 that you were given, and

it was an infusion.

How was that given?

>> It was an infusion.

Initially it was given over a

couple of hours.

It was only a 10cc.

It was a very small aliquot.

But as it became apparent that I

was tolerating the infusions,

while with no immediate side

effects, the infusions were sped

up a little bit, so literally

over an hour or two I would get

the infusion.

>> Elizabeth, big picture here.

What is immunotherapy?

He got a PD-L1.

That doesn't mean much to me,

either.

>> [ Chuckles ]

>> So help us out here.

>> Sure.

So, immune therapy is a

completely new class of cancer

treatments in contrast to

chemotherapy, which you alluded

to.

And really what it does, it

tries to activate your immune

system so that the drug itself

is not doing anything directly

to the cancer, but instead it's

activating the immune system in

order to recognize the tumor.

So what PD-1 and PD-L1 are, it

stands for "programmed death

receptor 1" or "programmed

death-ligand 1."

>> I'm not happy with

"programmed death" in there.

>> Right, but you want it to be

there.

So, essentially what happens is

tumors are able to express this

receptor on the surface of the

cell, and what happens, when it

binds to an immune cell, it

prevents the immune cell from

recognizing the tumor.

So it's like the cancer has a

cloak on.

>> The cancer's being tricky.

>> Exactly.

>> Okay, so then how do we fix

that?

>> So the drug that Ronald

received put a break in between

there, and it allowed the immune

cell to go back and recognize

the cancer and ultimately, I'm

hoping, kill it.

>> So that was the plan anyway,

that you would allow your immune

system to recognize the cancer

that it didn't see before...

>> Correct.

>> ...go in there and chew it

up.

>> Yes.

>> Now, why wasn't the immune

system chewing up cancer before?

How did this cancer elude his

immune system to begin with?

And by the way, are we all

getting little cancers all the

time and is our immune system

keeping us safe?

>> We probably are.

That's the truth of it.

Over someone's lifetime, most

cancers, most solid tumors are

related to aging, and so as we

age, the body has more time to

accumulate these abnormal cells.

The immune system probably is

doing that, keeping things in

check so they never become

clinically relevant.

But occasionally, because tumors

are tricky, they're able to

devise ways to get around the

normal surveillance that the

immune system has.

>> Want to make a distinction

here, Ron.

How did it feel while you were

getting all of these infusions?

I know that chemotherapy is

associated with all kinds of

horrible side effects -- the

nausea, the vomiting, the hair

loss.

How does this compare?

>> I can honestly say I had

absolutely no side effects the

entire time.

Nothing.

>> Nothing?

>> Nothing.

>> Lou, you've been in practice

a long time.

Here's a guy who's getting

therapy for cancer, and he's not

throwing up, his hair's not

falling out.

>> Right.

>> Pretty impressive.

>> It is.

This is a very exciting time,

especially in primary care.

As I was talking with Elizabeth

beforehand, a lot of these drugs

not only have that dramatic

effect with his little side

effect, but patients live

longer, and not only they live

longer -- a lot of patients when

they get chemotherapy, they may

be living longer, but it's not

great living.

They're very debilitated,

they're in bed, they're sick.

Patients five years out with

lung cancer, melanoma are riding

horses, you know, going to work.

I mean, it's really a remarkable

thing to see.

>> You know, what I'm hearing

over here is something so

rare -- an oncologist laughing.

>> I know.

We have great reasons to be

happy.

>> I mean, this is -- no,

oncologists in my era before

this were like, "This is really

bad."

>> Yeah.

>> And you're not saying that.

>> No.

I mean, in all seriousness, I

honestly can't imagine

practicing this field of

medicine 20 or 30 years ago.

I think, you know, we always are

able to provide some benefit to

our patients.

Even if we can't make them live

longer, we let them know we

care.

We're there for them and their

families.

We hope to manage symptoms.

But now to be able to really

make a difference in tumors that

otherwise, within six months,

most people would have passed

away, it's incredibly

gratifying.

>> It's very exciting because

chemotherapy in the past is more

like carpet bombing, you know,

in terms of trying to take out

the cancer cells.

And this is probably getting as

close as we can to personalized

medicine.

>> It is.

>> Exciting stuff.

>> Absolutely. Right.

>> Now, one of the things you

read about that you tell

patients who are on

immune therapy is you've got to

let folks know you're on

immune therapy and not

chemotherapy.

Why is that important?

>> It's important to tell people

about this because it changes

how we manage their side

effects.

If you know someone's on chemo

and they show up to the

emergency room vomiting, you

say, "Well, you need to take

your anti-nausea medicines."

When someone's on immune

therapy, there's a whole list of

other things that could be

causing it, so it's important to

let all the physicians caring

for you -- emergency, primary

care doctors, and

subspecialists -- know, "I'm not

on chemo.

I'm on an immune therapy," which

could cause immune activation.

>> So, Ronald, I'm guessing

things went pretty well.

>> Very well.

>> Tell me about your

experience.

What was it like?

How did things progress?

>> Well, I tolerated the therapy

very well.

You know, every three weeks we'd

have an infusion, and throughout

that time, at least initially,

after the first six weeks of

treatment, I had repeat CT scans

of the chest, abdomen, and

pelvis.

And at that first viewing of

those CAT scans, six weeks after

starting therapy, the lesions

were half the size that they

were before.

>> Waiting for the results of

that CT scan must have been

nerve-wracking.

>> Worse than that.

>> [ Chuckles ]

You kept going.

What happened?

>> Well, the infusions were

going very well.

I was responding very well, and

then six weeks after that, they

were half the size again on CAT

scans, and six weeks after that,

everything was gone.

>> Gone?

>> Gone.

>> For a tumor which

previously -- I'm getting

excited here.

>> You should.

[ Laughter ]

>> Tumor which previously would

have killed you...

>> Yeah.

>> ...by that time.

>> Yes.

>> My goodness.

I like being a doctor in the

21st century.

>> Not to sound like the wet

rag, we've seen that before with

chemotherapy.

>> We have.

>> We've seen tumors disappear,

and it not necessarily means

that the cancer is gone or

cured.

>> Right.

>> Well, let me ask you.

Do you think your cancer's

cured?

>> Two or three years ago, I

would have said absolutely not.

Now I'm hopeful that's true

because I'm told that in people

that receive immunotherapy, that

respond as well as I did and

have and are this far out from

therapy -- I've not been treated

since May of 2013.

>> They stopped therapy four

years ago.

>> Yes.

>> And the tumor's not come

back.

>> No.

>> Now, the word "cure" --

[ Applause ]

Yeah.

That's amazing.

I never thought professionally I

would live to see the day where

the word "cure" and "metastatic

melanoma" were in the same

sentence.

>> Absolutely.

>> Would you use that for him?

>> I think as oncologists, we

always want to.

And I think chances are very

good that that is the case.

But this is also new.

We don't have people who were

treated with these drugs and now

are alive 10 years later because

the drugs are so new.

We certainly hope that's the

case for you, and I think

chances are very good.

But it's too soon to say.

>> Right.

But he got this as part of a

research protocol, right?

And he had a terrific result.

>> Yeah.

>> Is it time for this to break

out?

>> It has.

>> Is it time for everybody to

get this?

>> It has broken out.

The number of patients who've

received these drugs has

skyrocketed.

There's now three different

PD-L1 inhibitors approved, two

PD-1 inhibitors approved.

The number of tumor types is

just expanding literally by the

week.

>> So it's amazing.

>> It really is expanding very,

very quickly, much more quickly

than we've seen with any other

tumor chain.

>> Couple of quick questions

before we have to go.

If this is such a dramatic

improvement, and it's only

available, at least at first, in

the big medical centers, what

about folks who are far away

from those centers?

How do they get treated?

>> Once drugs have been approved

by the FDA, your physician

anywhere can use them, whether

you live in a rural area or

you're close to an academic

center.

The big limitation is with

clinical trials.

So even though Buffalo is not a

small city, the trial that you

participated in, you had to go

to Boston for that.

That's still the case today that

larger centers have more trial

options.

>> Very quickly, he already had

metastatic disease, which was

one of the reasons he got an

experimental therapy.

Is this now the standard therapy

for people without metastatic

disease?

>> Not yet.

That is still being studied.

>> Close?

>> Close.

I think within the next two

years, we'll probably have good

data to say that that is now an

approved indication, but we're

not there yet.

>> And this is immunotherapy

against cancer, but it strikes

me that if it's good against

some systemic disease like

cancer, this could be

expanded -- it is being expanded

to lots of diseases.

>> It likely is.

As an oncologist, I keep my eye

mostly on the cancer studies.

>> Lou, you're in private

practice.

You see the whole waterfront.

Immune therapy is everywhere.

>> It is everywhere.

And I think the big thing that's

important, and coming back to

the personalized aspect of it,

knowing that you have the right

fingerprint for this type of

cancer, that the therapy work,

'cause some patients will ask,

"Blank it, you know, can I get

one of those immunotherapies?"

And it depends on the

fingerprint, correct?

>> Correct.

>> It depends on those genetic

markers to make sure it works.

>> I'm gonna ask you, Ronald, as

we come to the end of our show,

what's the best thing about

having had this therapy other

than "I'm here"?

What makes you the happiest?

What is it giving you?

>> Well, obviously it saved my

life.

Since then, I think it's -- I'm

happy to participate in

something like this so that

other people can be benefited,

you know.

And when I was first treated for

metastatic disease back in, I

think it's June of 2012, there

was only one checkpoint

inhibitor that the FDA approved.

It didn't really work that well,

and it was very toxic.

Now I think, as Elizabeth said,

there's five now or something?

>> There is five checkpoint

inhibitors, and Ipilimumab is

what you were talking about --

very toxic.

>> Very toxic drug, and, you

know, when they reviewed that,

that was not interesting me

because it only worked I believe

in 10%, and it was very toxic.

You had to be in the hospital

and all these other things.

I was much more in favor of

trying a clinical trial, which

was encouraged by the

oncologist.

>> Let me ask you one thing.

>> Yes.

>> How great is it for grandpa

to still be here?

>> Wonderful.

Feel great.

>> I just thought you'd --

I just want to get that on the

table.

This is what medicine is all

about.

I am so glad you're here.

I think we can all agree.

That was terrific.

[ Applause ]

You know, Ronald, I want to

thank you for sharing your story

with us.

The panel, of course, I want to

thank you for being here, as

well.

And to end the show today,

here's Ronald's advice to people

who have been diagnosed with

advanced cancer.

>> My advice to anyone diagnosed

with advanced cancer, stage 4,

is to try to get to see

oncologists that are up to date

with the latest therapy, and if

they can't provide that

information, go somewhere where

you can -- if you can.

And it's important to keep a

positive attitude because there

are so many trials available now

for people with advanced disease

that are doing very well.

In just six months to a year

ago, they would not be doing

well, so I would say seek second

opinions and third opinions if

you have to and then make a

decision, and then just follow

through with it and hope for the

best.

And if one treatment doesn't

work, potentially they could

start you on something

different.

>> I want to thank all of you in

our live studio audience for

being here today.

It was great to see you.

I want to thank you for watching

at home, too.

Remember, you can get more

second opinions and patient

stories at our website at

secondopinion-tv.org.

You can continue the

conversation on Facebook and

Twitter, where we are live every

day with health news.

I'm Dr. Peter Salgo, and I'll

see you next time for another

"Second Opinion."

[ Applause ]

>> Behind every heartbeat is a

story we can learn from.

As we have for over 80 years,

Blue Cross and Blue Shield

Companies are working to use the

knowledge we gain from our

members to better the health of

not just those we insure, but

all Americans.

Some call it responsibility.

We call it a privilege.

"Second Opinion" is funded by

Blue Cross Blue Shield.

>> "Second Opinion" is produced

in conjunction with UR Medicine,

part of University of Rochester

Medical Center, Rochester,

New York.

The Description of SECOND OPINION | IMMUNOTHERAPY IN CANCER TREATMENT | BCBS | Full Episode