Ninety-year-old former President Jimmy Carter announced Thursday morning that he’s being treated for melanoma, and the cancer has been found in his brain and liver.
My reaction: “Melanoma? Isn’t that supposed to start with weird spots on your skin?”
I turned to Dr. Elizabeth Buchbinder, melanoma expert at Dana-Farber Cancer Institute. Our conversation, lightly edited:
So is our popular conception of melanoma — odd, mole-like things on sun-hit skin — not consonant with reality?
So often, when people think of skin cancer, they think of the more traditional basal cell, squamous cell, where you go in to the dermatologist, they cut it off, maybe you need to get a little bit of liquid nitrogen, or something else, but really, once they’ve done that, the risk in terms of it affecting your survival or anything else is very low. They’re really very controllable cancers.
Melanoma is kind of the exact opposite of that. It’s the real bad actor among the skin cancers, because melanoma likes to get into the blood and spread. It likes to go anywhere it wants in the body. Some of the places it likes to particularly go are the liver and the brain. It can also go into the lungs and other areas of the body. It’s kind of the ‘bad boy’ of the skin cancers; it’s definitely a bad actor in terms of cancers in general, but then also in terms of skin cancers as a group.
And you can have melanoma without ever having seen a spot?
First of all, melanomas predominantly arise on the skin and are most commonly associated with sun or UV exposure. However, they can arise in areas of the skin that never see the sun. They can also arise on other membranes that are not visible; for example, the inside of the mouth or the inside of the intestine. They can also arise within the eye.
Although most of them arise on skin that are seen, some melanomas may arise on the skin and never necessarily be detected. We have a fair rate of what’s called ‘unknown primary,’ where we never find that skin spot, and one of the thoughts is that that skin spot either has been attacked by the person’s own immune system and kind of gotten rid of, or that something else has happened; it’s been scraped off or itched, or who knows? It just never was found. So there’s some rate of that.
And so what is the cutting-edge of melanoma research and treatment now?
Melanoma treatment is so exciting right now. The real, real cutting-edge is basically using the immune system to fight the cancer itself. What we’ve known for a long time is that the immune system has a relationship with cancer, and sometimes can keep it from growing or prevent new cancers from forming, but often the cancer kind of overcomes that somehow. And what’s happened with new treatments and with new research and understanding of how the immune system works is we’ve been able to use medications to make the immune system attack the cancer.
What’s so exciting about that is once the immune system starts attacking the cancer, it continues to do so. So just like as a kid when you’re vaccinated against mumps you’re not going to get mumps for the rest of your life, if you get that immunity going, there’s a chance that the cancer can be controlled not just for a brief amount of time, but for five years, 10 years, ongoing. And so what we’re seeing with some of these new immune therapies is what are called ‘durable responses,’ where people respond well to the treatment initially, but then continue responding without the cancer coming back. So very, very exciting.
So have you actually moved the dial on what could be called a cure rate?
In cancer, we’re always afraid to say cure, because we always think it could come back and then we really haven’t cured it.
But we definitely have. A lot of people ask about the prognosis in cases like former President Carter’s, and it’s very hard to say, because if he has a great response to immune therapy, there’s the potential that he could go on to live many, many more years. And so it’s really changed the landscape for melanoma, and we’re hoping, as these treatments are tested more and more, for cancer as a whole. Because they’re seeing success in other cancers, like lung cancer and bladder cancer, which is really exciting as well.
So melanoma is a little bit like the poster child for the new immune therapies?
It really is. I think it has the highest rates in terms of response. We’ve actually been doing immune therapy for many years in melanoma, even before these newer agents came along, partly because there weren’t a lot of other option in melanoma treatment.
So maybe that could also be an effect of Carter’s announcement, that it will bring even more attention to the very promising nature of these immune therapies. I know you can’t comment on his case directly, but we can assume he’s going to be getting them, right?
I think I read in one of the reports that he is getting something that is enhancing his immune system.
I think the other area of melanoma treatment that’s also very exciting — but these days is kind of falling to the second tier in a way — is the targeted therapies, where we actually look at genetic changes in the cancer itself and use drugs that attack those genetic changes. But the immune therapy, because of those long-term responses, is really what people tend to be starting as front-line. So it makes sense that that would be exactly where they start in terms of his treatment.