Cancer trials
An Auckland cancer centre is trialling new drugs and treatment combinations on patients with advanced cancer, giving them renewed hope. Jane Phare visits the centre.
A unit of Auckland Hospital was set up two years ago for Kiwis with terminal cancer to undergo trials of unapproved therapies.
In a small unit at Auckland City Hospital next to the oncology ward is a waiting room of people full of hope. You can see it in their faces: cheerful, stoic, grateful. They are the sufferers of cancer, this potentially devastating disease that threatens to end their lives too soon. They are in the waiting room as willing “guinea pigs” to trial new drugs and treatment regimens at the Auckland Cancer Trials Centre (ACTC).
They greet the centre’s medical director, Dr Sanjeev Deva, by his first name as he walks past, familiar as family. They know it is Deva’s drive and vision that helped create the unit and without it, palliative care would be the only option for many of them.
It is a place I hope I never find myself in but if I did, I would be extremely glad of its existence. Six years ago I was diagnosed with stage three breast cancer which had spread fast between mammograms. The breast had to go immediately and when cancer was found in a node I was referred to an Auckland oncologist, the gentlemanly and relentlessly cheerful Vernon Harvey.
On his advice I threw everything at it: ghastly chemotherapy that made me bald and more unwell than I thought possible, radiotherapy, a year of Herceptin infusions at Auckland Hospital, five years of Tamoxifen.
This year, Harvey retired. I gave him an electronic luggage weigher, he gave me the all-clear. . . or as clear as you can be with cancer. It’s a lurking disease. You never quite know what it’s up to.
At my final appointment, I asked him how I would know if it came back. You’ll know, he said. And what then?
I can’t remember exactly what Harvey said but in a nutshell, it was “curtains. . .eventually”.
And that’s what some of the patients in the ACTC unit have been told. To them, a chance at more months or, in successful cases, years of life is a no-brainer.
These are patients with an advanced or aggressive cancer, people who’ve discovered a tumour has returned or that traditional drugs aren’t working well enough, or that the only option is palliative care. To them, the option of taking part in a drug trial that could improve their outcome is, literally, a lifeline.
This second chance would not have been possible without the generosity of philanthropic Kiwis who back cancer research. The ACTC’s $1.7 million set-up cost to run for two years came from a $1.4m anonymous donation to the University of Auckland, with a top-up from the Gary Lloyd cancer research fund.
It was Vernon Harvey who was behind the establishment of the trust more than 30 years ago after treating Lloyd, then the head of McDonald’s in New Zealand, for metastatic melanoma in the late 80s.
The two talked about the lack of effective therapy for many cancers and after Lloyd died in the 90s, the McDonald’s head office requested donations in his memory for the development of new cancer therapies.
But the resulting trust, set up to support research of new drug therapies, proved restrictive because apart from the Cancer Society research laboratory there were limited opportunities for research that would satisfy the trust deed.
The fund steadily grew but remained largely unspent and in the late 90s, the management of the money was taken over by A+ Trust, the ADHB’s charitable trust. That was until Deva, a medical oncologist, returned from London four years ago where he had worked in early-phase cancer trials in order to bring skills back to New Zealand.
“I thought there was no reason why we couldn’t replicate something similar in Auckland,” he says. It was Harvey who told Deva about the unused pot of research money still sitting in the fund, money that helped fit out the new unit.
It took two years of behind-thescenes work to get funding in place and ADHB approval. Now, a dedicated team of doctors, nurses, trial co-ordinators and administrators work in the unit to complete the trials.
Auckland Hospital treats more than 4000 new cancer patients each year so there is no shortage of candidates.
To date, nearly 200 people with advanced or terminal cancer have agreed to take part in early-phase drug trials, and not all of them from the Auckland and Northland region.
Pharmaceutical companies wanting their new drugs tested on humans will pay to cover patients’ expenses to take part in the trials which means out-of-town candidates aren’t excluded.
And so here we are. A modern unit full of hope, with artwork on the walls that is worth stopping to admire. They’re inscribed, donated by grateful patients.
Not all will walk out of here with good news. It might be their cancer is too far advanced, that they don’t respond to the drugs or the drug simply doesn’t work the way scientists had hoped.
But all of them know it’s worth a shot, and that even if the treatment doesn’t work for them they will have helped other cancer sufferers in the future.
IN A private room where she’ll stay overnight under observation, Kristel Witehira lies huddled in bed. She’s wearing a hoodie and is covered in blankets but she’s still shivering.
“I’m not in pain,” she says. “Just cold.”
The shivering is a reaction to an infusion she’s just been given, a combination of two different immunotherapy drugs, one an established treatment, the other “novel”, or new.
Deva says the inflammatory reaction is not unusual but that it’s earlier than expected. Normally the body will react to the infusion several hours later.
Witehira insists we go ahead with the interview but we won’t record a video interview. She’s still shaking too much.
It was just a year ago that she was diagnosed with cervical cancer. She had chemotherapy and radiotherapy
I’m a bit of a gambler so I thought I’ll give this a go. I’ve got nothing to lose. Kristel Witehira
at the Jim Carney Cancer Treatment Centre at Whangarei Hospital and went back to work.
But this year, scans showed the tumour was growing again. By July, the 35-year-old was told she was terminal. She was offered more chemotherapy to buy her more time but was told there was only a 40 per cent chance of it being effective.
But then, a glimmer of hope. The Jim Carney centre referred Witehira to ACTC and she was accepted for an early-phase drug trial treatment.
“I’m a bit of a gambler so I thought I’ll give this a go. I’ve got nothing to lose,” Witehira murmurs from under the blankets.
Her fiance stands quietly in the room. The couple will need to make the trip from their home in Dargaville every three weeks for the infusion. The treatment will continue as long as it’s tolerated and as long as the CT scans show the tumour is either stable or, even better, shrinking.
“It’s a big commitment,” a nurse in the room remarks.
The hope is that the immunotherapy drugs will kick-start Witehira’s immune system to encourage it to fight the cancer, and do what last year’s chemo and radiotherapy failed to do.
She knows it may not work but also knows her effort won’t be wasted, that the trial could benefit others coming behind her.
“That’s why I signed up,” she says.
HAVING HIT the two-year mark, the day-to-day running costs of the unit are largely self-funded due to income from large international pharmaceutical companies wanting their new drugs tested.
“That’s the bread and butter of what we do,” Deva says.
But it’s the local cancer research that excites him. Across the road is the university’s faculty of medical and health sciences where New Zealand scientists are doing their own research into new drugs, the reduction of side effects, new treatment regimens using existing drugs, or identifying biomarkers so that treatments can be more specifically targeted.
It is Deva’s hope that many of the medical school’s translational studies can be used in the ACTC’s clinical trials, an arrangement he sees as a win-win.
If early-phase research can be done in New Zealand, it helps local scientists keep their intellectual property in the country and helps retain top cancer researchers.
Before the ACTC opened, effective drugs developed in New Zealand were often sold to a biotech company overseas.
With the proximity of the hospital to the medical school, Deva can give direct feedback to the scientists. “All I have to do is cross the road and tell them rather than on a teleconference call at 2am.”
THERE’S LITTLE doubt that the medical oncology landscape has improved remarkably since Vernon Harvey was treating Gary Lloyd back in the late 80s.
Cancer treatments continue to evolve. In addition to traditional chemotherapy, targeted treatments can be used in certain cases and, more recently, immunotherapies are used to manipulate the patient’s immune system so it can recognise and eradicate a foreign cancer.
In some cases, early-phase drug trials are used on patients as their first line of treatment, combined with traditional methods.
Glen Eden towie Brian Lineham is a case in point. He was diagnosed with colon cancer last year and underwent an operation to remove the tumour. But a scan this year showed tumours had spread to his liver and he was referred to ACTC.
Lineham, 58, has had nine treatments of what Deva describes as “a very complex regime”. He’s having a mixture of chemotherapy, a targeted drug and immunotherapy. Both the new immunotherapy drug and the treatment combination itself are under trial.
Lineham’s feet jiggle while he’s talking. “It’s the chemo,” he grins. When he muddles up his kidneys with his liver several times during the interview he blames that on “chemo brain”, too.
But he’s not too worried about jiggly feet or forgetfulness. He can recite the measurements of his tumours exactly.
Since treatment began the largest of Lineham’s tumours shrank from 37mm to 25mm in a few weeks. His latest scan shows it has shrunk to 12mm. Lineham is, he says, “very happy” and he’ll keep going as long as the treatment’s working.
“Trials are excellent. Even if it doesn’t work for me, if it gives somebody else an advantage that’s good.”
Every cancer case at ACTC is a little different. One patient has had a melanoma removed and although there’s no clear evidence of cancer, he’s undergoing a new treatment in an attempt to stop the cancer returning.
As for outcomes, they are difficult to determine because different earlyphase trials have different measures of success. By its very nature, the work is experimental, hence the small number of patients in early-phase trials.
Says Deva, “We’ve had patients who have done extraordinarily well. We have treated them here and they still don’t have any evidence of cancer in their body because the treatment has been remarkably effective.”
Those successful early-phase trials will go on to become second and third-phase trials, using larger numbers of patients. It is this area that Deva hopes will grow in New Zealand, and in centres outside Auckland because it can be carried out in standard oncology clinics.
Britain’s NHS (National Health Service) has an ambitious goal of wanting 20 per cent of people diagnosed with cancer to take part in a clinical trial, in an effort to improve outcomes. “We should have that same ambitious target in New Zealand,” Deva says.
Currently, in the Auckland region, 2 per cent of cancer patients are involved in early-phase trials, a figure that is unlikely to increase. But he’d like to see between 10 and 15 per cent of all cancer patients given the chance to participate in late-phase trials across the country.
This “bench-to-bedside” approach to cancer research and treatment is something the University of Auckland is working on, to improve the survival rates of New Zealand cancer patients.
Apart from the $1.4m anonymous donation to fund the ACTC, the university has received other generous philanthropic donations for cancer research in the past, says its Alumni Relations and Development director Mark Bentley.
The research is vital work, he says, and all donations — ranging from smaller amounts to pay for a clinician’s time to conduct research through to multimillion-dollar research projects — helped improve cancer outcomes.
Trials are excellent. Even if it doesn’t work for me, if it gives somebody else an advantage that’s good. Brian Lineham (below)