Another Reason for Celebration and Equipoise

Two weeks ago had my one month follow-up blood test and I also received my monthly IVIG infusion.  All my numbers remain the same, as I would have expected.  Now I get to wait another month and have a bone marrow biopsy to really see what is going on.  For the last 6 months I have been receiving Ofatumumab, which is supposed to manage the CLL, at least in the short term.  Next month it will have been 2 months since I received an infusion, so we will see what happens then.

The most exciting news in the Evans Family is the birth of our second grandchild on April 15^th.  Naomi Jean Evans came into this world very quickly.  We received a call around 5am saying Matt and Randi were going to the hospital and at 8:15 she was born.  Donna flew up that day and I followed the next day.  We stayed in Seattle at Matt & Randi’s  for a week and it was a real treat to be able to spend time with them, and the new family member, Naomi.

There was an interesting post 2 weeks ago by a prominent CLL expert named Dr. Susan O’Brien.  In this post she argues that there is no sensible reason for not allowing the 180 of us who were on the Clinical Trial and received Ofatumumab to now receive the trial drug, Ibrutinib.  The interesting thing is that ALL of the major CLL experts in the U.S. agree with her.  The problem here is the FDA.  They follow guidelines that are completely out of touch with reality.  It is well documented that Ofatumumab will give CLL patients a partial short lived remission.  So when I start to relapse, wouldn’t it make sense to move me over to the Ibrutinib which has had a 95% success rate in controlling CLL.  Although the trial officially closed in April, the documented results may not be available for over a year.  So, I suppose that you hope and pray that you can wait that long and have the drug approved for general distribution.  Seems like a crazy system to me.

http://www.ascopost.com/issues/may-1,-2013/ibrutinib-cll-trial-where-is-the-equipoise.aspx

So which category did you fall into?  Already knew what equipoise meant, didn't know, but looked it up, or didn't care?  I'm not doing your work for you.  Figure it out.

 

 I had an ‘end of trial’ CT Scan in March and results show that my lymph nodes have basically stayed the same (after initially shrinking at the beginning of the trial).  I am scheduled for another bone marrow biopsy in June to see how the drug impacted the marrow.  Then, in July, I will see Dr. Kipps and figure out what my next steps might be.  I’m still feeling well and enjoying life.

 

Terry

D(ONE) Once Again!

After 6 months of treatment I finished my Clinical Trial on Tuesday.  All of my numbers continue to look good and now we get to wait.  I will have monthly blood tests and another CT Scan at 9 months to check for disease progression.  End of short Report.

 I have now officially finished my 5^th treatment since 2007.  I have to say that this last treatment was the mildest of all the treatments that I have received.  I basically have had no side effects, and the only issue is to go down to La Jolla and spend 5 hours in the infusion chair.  All of my numbers looks good and my physical exam is very positive.  The one thing that we do know is that the treatment that I received (Ofatumumab), knocks the disease down, but does not knock it out.  So the big question is how long will this remission last?  No one really knows as everyone responds differently, but the hope is that it will be a while before I need treatment again.

 What I am really waiting for is the availability of the Clinical Trial drug Ibrutinib.  This is the drug that was on the other side of the trial that I was on.  As I have mentioned before, the hope is that if I do need treatment again, that Ibrutinib will be available to me because I was on the trial.  No one knows when this drug will be officially approved by the FDA, but they are thinking sometime in 2014.  The results from Ibrutinib have been nothing short of amazing.  About 97% of the people who received the drug have responded.  This is unheard of in the cancer treatment drug world.  Besides the response, this drug is a pill, not an infusion.  It also is not chemotherapy, but it is called a Bruton Kinase Inhibitor.  If you would like a technical description, here it is:

 

Ibrutinib was designed to specifically target and selectively inhibit an enzyme called Bruton's tyrosine kinase (BTK). BTK is a key mediator of at least three critical B-cell pro-survival mechanisms occurring in parallel — regulating apoptosis, adhesion, and cell migration and homing. Through these multiple actions, BTK helps to direct malignant B-cells to lymphoid tissues, thus allowing access to a microenvironment necessary for survival.

 I thought that was pretty humorous.  If anyone would like a more detailed description, you can email me.  Even if I don’t get Ibrutinib, there are a number of trials of non-chemo based drugs that are really promising.  The talk among all the CLL experts is that they expect that in 3-4 years there will be no chemotherapy used in the treatment of CLL.  This is really exciting news.

 There is always excitement in the Evans family.  We are now anxiously waiting for the birth of our Second grandchild (a baby girl).  The official due date for Matt & Randi’s baby is April 18^th, and we are just waiting for the call so we can fly up there.

 Some people may be wondering what the title of my blog posts actually means.  You have to have read this far to find out.  You will notice that the ONE is in parenthesis.  This is because the word DONE has a double meaning.  I received my last treatment on Tuesday, and on Wednesday I went out and played golf.  On the 3^rd hole at El Dorado I got a hole in ONE.  Hence the double meaning.  So you can tell that this treatment affected my golf game in a positive way.

 All for now.  I hope to be boring for a long time.

Terry 

8 Down & 4 To Go

I have finished my 8 weeks of Azerra (Ofatumumab) and now get 5 weeks off.  All in all the treatment was a non event for me; it just takes a long time to get.  It is usually an 11 hour day, which is probably why I am tired after the infusion.  I have no real side effects with the exception of some slight numbness in my fingers and lips and a slight cough , which I always had with Rituxan.  So I get to enjoy Christmas, the New Year, and a cruise to Mexico with the Barden side of the family in mid January.  Life is good.

After the ASH (American Society of Hematologists) 2 weeks ago, there is a lot of encouraging news of the drug front.  Ibrutinib, which is the drug in the other arm of my trial, has had a 96% progression free survival on patients 22 months out.  This is nothing short of amazing.  The drug is a pill, taken daily, and has very few side effects, all of which can be managed.  Here is a link to a talk by Dr. John Byrd from OSU talking about the Ibrutinib trials.  http://www.onclive.com/conference-coverage/ash-2012/Dr-Byrd-on-Ibrutinib-in-CLL

I am now on a monthly schedule and will get 4 more doses before I complete the trial comparison in April.  Even though my blood numbers are all in normal range, they are at the high end, and have not dropped to the low levels that I experienced in the other trial.  I did have a doctor exam on Tuesday and he said that everything looked good, but that he would have a better idea after my 5 weeks off. 

This is somewhat of a two edged sword.  If I completely respond, then I won’t need the Ibrutinib.  If I do respond, then I am not proving that drug A is better than drug B, which is the whole point of the study.  And if I don’t respond that well, and/or if I relapse quickly, then I will need treatment again, and hopefully they figure out a way to get me the drug A. 

Other than a few “over 65” medical issues, I have been feeling fine.  Everything is on track for a Family cruise in January, a trip to Seattle in February, a new grandbaby in April and a wedding in July.  All just part of the normal Evans family life.

Please keep my life long friend 'Tall Tom' in your prayers as he gets an experimental stem cell lung treatment at the end of December.

Wishing everyone a Merry Christmas, believing that there is a reason for the season, and a Healthy and Happy New Year.

Terry

4 Down 8 to go!

I just wanted to send out a quick update after my first month on the Trial.  I have had 4 weekly infusions and so far all the results are positive.  I have 4 more weekly infusions and then 4 months of monthly infusions.  So if all goes according to plan, I will be done in April. 

So far the only real issues have been the length of the infusions.  They take between 5-7 hours so it winds up being a very long day.  I have not had any infusion reactions, which are pretty common with this drug.  I have also not had any post infusion reactions with the exception of being a little tired for a day or so.  I did wind up getting a cold after week 2 and I am just now getting back to normal.  I don’t know whether it was lengthened because I was in treatment, because I have a compromised immune system, or because it was just a really bad cold.  I did start preventative antibiotics just to protect myself from a more serious infection.

I did have a 4 week check by the doctor and he commented that all my blood numbers are moving in the right direction, and my nodes and spleen have shrunk.  He did mention that the most dramatic results will be in the first 8 weeks, and after that we will probably not see much movement.

All in all it has been a boring first month, so let’s hope the remainder of the treatment goes as smoothly.

Terry

It has begun

On Tuesday I started the new Clinical Trial.  As you may remember the trial consists of two different arms with one being a pill (the one I thought I wanted) and one being an infusion.  By random draw I got the infusion.  The first infusion is now over, and I only have 11 more to go.  End of short report.

Before I could begin the trial I had to have a number of tests, sign paperwork, and be 'approved'.  All of this was done in the last two weeks.  Last Friday I got the word that I was accepted and which arm of the trial I would be in.

Tuesday turned out to be a LONG day.  Over 15 hours door to door.  I first had lab work, then a doctor’s appointment, more lab work, the pre-meds, then the infusion.  The total infusion time is about 7 hours.  At first I was a little disappointed that I got the infusion instead of the pill, but after talking to Dr. Kipps, I think that I will have a good response to this drug.  It is called Ofatumumab, or Azerra.  It is a monoclonal antibody like Rituxan is, but it is a second generation of the drug.  It is approved for use in CLL so it has been around for a while and even though there are side effects associated with it, they can be managed.  Tuesday I got what they call a TEST dose.  It was only about 1/6 of what I will get in subsequent doses.  They want to make sure that you don’t have a reaction to the drug and that is why they give such a small dose and give it over a long period of time.  My dose next Tuesday will be 6 times as much and given over a shorter period of time. 

I will get a weekly dose of this for the next 7 weeks and then I will get a monthly dose for the following 4 months.  So the total time will be 6 months.  We are not quite sure what happens after that.  There is some talk that the pill drug might be made available to those patients that need it.  Obviously if all my counts, scans and physical exams show I am back to normal there would be no need for the drug.  But if at some time in the future I would relapse, I may be first in line to get the pill drug, called Ibrutinib.  The main goal here is to buy me some more time and not burn any bridges for future treatments.  I think the Ofatumumab will accomplish this.

I have had very little side effects from the test dose and the nurses all expected that because of my past experiences with Rituxan I wouldn’t have very many with the Ofatumumab either.  The measure of how well I am doing can’t be really verified until another CT scan and a bone marrow biopsy.  But I think they will know in a few weeks if I am responding.

Thanks for all the well wishes and prayers, they are uplifting. 

Terry

Up Up and Away

I don’t know why this lyric by the Fifth Dimension (A 60’s group for all you youngsters) came to mind in writing this update, but it seems appropriate given what is now happening.  Tuesday I met with Dr. Kipps and I have tentatively been approved to start a new clinical trial on October 30^th.  I am feeling well with the exception of having shingles.  End of short report.
Well, our trip to Hawaii was very nice with the exception of getting shingles while I was there.  About 4 days into the trip I noticed a pain in my lower left shin, and then the next day it moved up to mid leg, then to my knee.  At that time I knew something was brewing, so I started my antivirals (which I always carry with me).  Two days later the rash broke out on my left lower back.  It is still there, and is bothersome, but yesterday I got a prescription for some medicine to block the nerve pain.  I don’t know what would have happened if I hadn’t started the antivirals that early, but Dr. Kipps said my outbreak would have probably been much worse.  A word of advice.  If you are able to get the SHINGLES VACCINE, get it.  You DO NOT want to get shingles.  If you have ever had chicken pox the herpes zoster virus is in your body.  When this is reactivated (no one knows why this happens) you get shingles.  It usually happens to adults over 50 and that is the age you should get the shingles vaccine.  30% of the adult population over 50 will get shingles, so the risk is there for just about everyone.  Some people can’t get the vaccine because it is a LIVE virus which is contraindicated for immune compromised patients, so check with your doctor before just going to prompt care and getting the shot.  By the way, I am NOT a doctor and cannot give medical advice, so this just my own explanation of what happened to me.

Now on to the fun stuff.  Yesterday we met with Dr. Kipps and he once again said I am coming out of remission.  My blood numbers are moving in the wrong direction, he can start to feel the spleen, and my lymph nodes are increasing in size.  So the question is, what do we do?  We could wait, but with my history, it doesn’t seem like a good idea.  There is no real benefit of waiting except I wouldn’t have to have my life revolve around weekly appointments.   The consensus between Dr. Kipps and me is that it is better to start the treatment now while I am feeling well and have no other issues.  I think I will respond better and have fewer side effects if we start now.

The Clinical Trial we selected is a two arm trial, which means you will get either drug A or drug B.  Drug A, which is called PCI-32765, Ibrutinib, or the new approved name of Resonate.  Drug B is called Ofatumumab or Azerra.  This is a humanized monoclonal antibody that works on the CD-20 marker of the cell.  It is also called the son of Rituxan which was the first CD-20 monoclonal antibody, but was mouse based.  I know some of you are asleep, but too bad.  Dr. Kipps thinks that I will have a positive response with either drug, and I am not burning any bridges for future treatments by taking either one of these drugs.  It is also a plus that neither of these drugs are true Chemotherapy, so the side effects (which there will still be some with either drug) are much less than with conventional chemo drugs.

The arm I really want is drug A, or Resonate.  This drug is a pill you take every day.  There are 3 outcomes possible.  You get worse, stay the same, or get better.  In the over 400 patients on this drug, only 3 have gotten worse, and the majority have gotten better.  This is REALLY good news for the CLL community.  We now may have a drug that you just take every day and it keeps you in remission.  It is the talk of the town and the company’s stock has gone from 7 to 65 in 9 months.  The company name is Pharmacyclics or PCYC for anyone that cares.  Johnson & Johnson thought so much of the company that they loaned them $800 million to continue their development of the drug.  Even though there are still side effects, they seem to be manageable, and as they say it beats the alternative.

So what happens if I get drug B?  I could just stop the trial, or I could hope I get a positive response from drug B.  Dr. Kipps thinks I will, so that is good news.  The first part of the trial is only 6 months, and I have been told that if I complete the 6 months that I would be first in line to get drug A sometime in the future.  So this makes you stay in the trial no matter which arm you are assigned.

There is a lot to be done before the 30^th.  They still have to go over my records to determine if I ‘qualify’.  I also have to have a boatload of tests to establish the baseline of BEFORE the treatment.  So next Wednesday I will have a bone marrow biopsy, my monthly infusion of IVIG, a CT scan, and EKG and an Echocardiogram.  All of this in one day.  I told them I would rather do it this way than have to make multiple trips to La Jolla.  So it is really my choice and I am glad they could accommodate me.

The good thing is that I am feeling well, and we just got back from 2 weeks in Hawaii.  We spent a week on the Big Island of Hawaii and a week on Maui.  The nice thing about Hawaii is that it always the same, pretty much paradise.  We are taking a couple of short trips before I begin treatment because that is going to tie me down for about 2 months.

Terry

It was fun while it lasted!

A week ago I visited Dr. Kipps for my 3 month follow-up.  Since I go down every month for my IVIG Infusion, he had 3 months worth of data to look at.  Unfortunately it looks like I am coming out of remission.  My blood numbers are definitely trending upwards, and he is starting to see my lymph nodes increase in size.  So it looks like I will have to begin some sort of treatment before the end of the year.  End of short report.

This is not totally unexpected.  Because I had all the blood tests, I could see where this was going.  I could also feel the nodes increasing in size.  I always knew it was going to be a matter of not if, but WHEN.  I am a little disappointed that the last Clinical Trial that I was on did not give me a longer remission.  From the time I stopped the Clinical Trial, I got about 20 months of remission.
He wants to see me as soon as we get back from Hawaii, and begin the process of bone marrow biopsies, genetic testing, etc.  After he gets the results of that back, we will sort out all of the trials that make sense and don’t make sense.  Why am I looking at trials again?  Isn’t there anything else that is a non-trial treatment?  The answer is maybe, but probably not.  I have already had 2 different treatments (one twice) and the results have been the same, no long term remission.  I have poor genetic markers, which limits the effectiveness of some of the ‘approved’ treatments.  I have had autoimmune issues with my AIHA.  In 50% of the cases, the AIHA comes back in patients, and is almost guaranteed to return if you use the wrong treatment.  So this limits my choices, and a trial is maybe my best shot.

I feel that the only way we are going to make real headway on curing or stabilizing this disease is to have people enter into trials.  Remember, you can’t get trials just anywhere.  They are usually provided only at teaching and research hospitals, like UCSD, Ohio State, MD Anderson, Mayo, Sloan Kettering and Fred Hutchison.  So you can’t go to your local hematologist and say ‘give me trial 123’.  You can’t even get the same trial at two different hospitals.  They are tightly controlled by the drug companies and the FDA.  Now there is a match made in heaven.  The trial I was on before had less than 50 people in the WORLD enrolled.  One of the most promising ones (that I am looking at) has only 400 people that have taken this drug, and it has been out of the lab for less than 3 years. There are a lot of accusations about the teaching hospitals using people as Lab Rats.  I don’t feel that way.  This is MY choice.  I can do it or not.

Dr. Kipps gave me 4 informational packets on trials that MIGHT be appropriate for me.  We will then have to wait until after the tests to see where I really am.  THEN, I have to be ACCEPTED by the drug company.  This sounds like I am applying for college, or a job.  I won’t get into the details of these trials right now because none of them might pan out and we might have to go to plan B, whatever that is.

I am not as anxious as I was before the last trial.  In general, I know what to expect (although every treatment has its own personality).  I know there will be a lot of paperwork, a lot of tests and drugs. Once again I am trusting Dr. Kipps and God to lead me in the correct direction.  

Life goes on.  Our youngest son Matt and his wife Randi have announced they are expecting.  My oldest son Jeff has announced he is engaged to his long time girl friend Kristen.  Wyatt continues to be a great baby and Aimee and Bryan are great parents.  Sarah is now a licensed CNA and is continuing her education in Acute Care.  My golf index is at its lowest since I began playing (that’s a good thing for you non-golfers).  So for now, I’m not going to worry about any of this, and Donna and I are going to relax in Hawaii.  ALOHA.

Terry