Despite having his prostate surgically removed ten years ago, Michael Auth hasn’t been able to put prostate cancer behind him. When his PSA — which is checked to screen for prostate cancer—rose or tumors formed, he required further treatment. From the beginning, the Westford resident turned to Emerson and received thoughtful care, including in 2019 when he joined a clinical trial studying an investigative drug. Good news: he had a great response to that clinical trial, and it is keeping his prostate cancer in check.
Mr. Auth’s cancer appeared to be confined to his prostate. At the time of his diagnosis, the best treatment for him was determined to be surgery, which was performed by Paul LaFontaine, MD, an Emerson urologist. “Everything was fine for a few years, until my PSA started to rise,” Mr. Auth recalls.
He then had a course of radiation at the Mass General Cancer Center at Emerson Hospital - Bethke that was successful — at least for a while. “When my PSA went up again, Dr. McGrath introduced me to Dr. DuBois,” says Mr. Auth. John McGrath, MD, medical director of radiation oncology, knew that Jon DuBois, MD, medical director for the cancer center, would determine the next step.
“It was clear that Mike had an aggressive variety of prostate cancer,” says Dr. DuBois. “When I met him, his PSA was rising, and CT scans revealed swollen lymph nodes in his pelvis. His prostate cancer was spreading.”
Dr. DuBois prescribed androgen deprivation therapy, which blocks testosterone and is known to slow cancer progression. “That worked for a while,” says Mr. Auth, an accountant who established his own firm after many years in corporate finance. “It seemed as though the pattern was being established.”
At that point, Dr. DuBois selected docetaxel, a well-known chemotherapy agent, as the best option for Mr. Auth. But nine months later, Dr. DuBois was again needing to consider options. Specifically, he hoped that a blood test would reveal a molecular target and pave the way to a different kind of treatment.
Targeted therapy — and a strong response
“I told Mike I didn’t want to put him through more chemotherapy and the associated toxicity if we could identify a cutting-edge, novel approach,” says Dr. DuBois. He previously had sent a sample of Mr. Auth’s blood to Xin Gao, MD, a colleague from the Mass General Cancer Center’s main campus in Boston, who specializes in prostate, bladder, kidney and urinary cancer. The two oncologists thought Mr. Auth would be a candidate for a clinical trial of a targeted therapy, but with the first blood sample, that was not the case.
“Then in January 2019, I gave it another try and sent a new blood sample to Dr. Gao, who is testing a group of inhibitors that target certain cancer cells,” says Dr. DuBois. This time, Dr. Gao found what he was looking for: a mutation in the BRCA gene. It meant that Mr. Auth was eligible for the clinical trial testing Niraparib to treat advanced prostate cancer.
“We’re starting to understand that 15-20 percent of men with treatment-resistant prostate cancer have one of a handful of genetic profiles that respond to these inhibitors, including Niraparib,” Dr. Gao explains. “In addition to prostate cancer, the BRCA gene mutations predispose individuals to female and male breast, ovarian and pancreatic cancer, among others.”
Why was the BRCA gene not found in the first blood sample that Dr. DuBois sent? “Cancer changes over time,” says Dr. Gao. “It can evolve on its own or in response to the various treatments a patient receives.”
Mr. Auth soon met with Dr. Gao. “He explained that the drug is safe and FDA approved for women with ovarian cancer,” says Mr. Auth. “I was very impressed with the advances being made in the treatment of cancer and wanted to participate, if at all possible.”
Mr. Auth began taking three pills daily, had his dosage adjusted when he became anemic — the only side effect — and soon felt better. It didn’t take long to see that he responded to the medication. “My PSA, which was 370 at the start of the trial, was down to 90 and has continued to drop to around 30,” says Mr. Auth. “The tumors they saw on my scans have shrunk by 55 percent.”
Dr. Gao has seen similar responses in other men whose prostate cancer tests positive for the BRCA mutation. “It opens a whole other door for treatment,” he notes. “This is what clinical trials do: they help us advance cancer medication and provide new, effective treatments for our patients.”
Mr. Auth had heard of the BRCA gene in the context of female cancers. “I wondered if I was getting the benefit of all the successful research that has been performed on breast and ovarian cancer,” he says. According to Dr. Gao, the answer is yes. That research led to ongoing work on this group of inhibitors and the realization that a medication like Niraparib has a role to play in certain men with treatment-resistant prostate cancer.
“They’re on your side all the way”
The close collaboration between oncology staff on-site at Emerson and their colleagues at Mass General Cancer Center in Boston, who sub-specialize and perform clinical trials, benefits patients on a regular basis. “Our mission is to leverage the expertise at our home base in Boston and provide more sophisticated care in the community as a result,” says Dr. DuBois.
At Emerson’s cancer center, oncologists subspecialize in breast, gastrointestinal, genitourinary and thoracic, as well as benign and malignant hematological conditions. Emerson’s skilled and experienced general surgeons perform a full range of cancer surgical procedures.
Having access to important clinical trials, as Mr. Auth experienced, can change everything. Dr. DuBois emphasizes that there is impressive progress in cancer treatment underway. “Mike benefited from research on targeted therapies, where we test tumors for mutations that are critical to the cancer cycle,” he says. “This allows us to engineer new drugs.”
Immunotherapies that direct the patient’s immune system to treat cancer are becoming increasingly sophisticated. “Checkpoint inhibitors — agents designed to block proteins that keep immune responses in check — are one example,” says Dr. DuBois. “They have been game-changers and are now being further developed to make various cancers more responsive. Then there is CAR-T technology, which revs up a patient’s immune cells to attack cancer cells.
“Also, we are seeing the benefit of using stereotactic radiation to treat cancer cells that remain after treatment,” he adds. Emerson established a stereotactic body radiation program earlier this year to provide highly precise treatment.
Mr. Auth, who will continue on the clinical trial as long as it is effective, experienced the benefits of Emerson’s close, productive collaboration with the Mass General Cancer Center in Boston. His care was personalized throughout his experience, and collaboration with all members of his team was evident.
“One night, early in the clinical trial, I received a call informing me that the results of my blood test showed that I needed a transfusion,” he recalls. “I was asked how I felt and if I wanted to have the transfusion that night or wait until the morning.
“Before long, the phone rang, and it was Dr. DuBois calling to reassure me that, as long as I felt okay, there was no hurry,” says Mr. Auth. “That’s pretty good service. At Emerson, you definitely feel like they’re on your side all the way.”
Cancer surgeons use the most current techniques with the goal of avoiding opioid medication
Emerson’s four general surgeons have cancer surgery pretty well covered: they perform surgery for breast, colon, rectal, thyroid and skin cancer. Other Emerson surgeons provide gynecological, bladder, kidney and prostate cancer surgery. Atif Khan, MD, (pictured at right) chief of general and vascular surgery, emphasizes that they use the most current minimally-invasive techniques to make surgery as easy as possible on the patient, something that leads to a shorter hospital stay.
“The average hospital stay for our patients who have colon or rectal surgery is two or three days,” says Dr. Khan. “I’ve seen people go home the day after their colon surgery.”
Today many individuals are able to have surgery performed laparoscopically — through small incisions. “This is very different from when I was in surgical training, and patients had traditional surgery performed through a large incision, typically followed by a week in the hospital,” Dr. Khan recalls.
A new approach, Enhanced Recovery After Surgery (ERAS), benefits those having cancer surgery. Emerson’s general surgeons follow the protocol to minimize the stress of surgery by keeping patients as “normal” as possible. It is proven to reduce complications and hospital stays, as well as speed recovery. Emerson’s gynecological surgeons have adapted the ERAS protocol, and other surgeons are doing the same.
The ERAS approach pays close attention to pain control — specifically, the avoidance of opiate medications. “We begin managing the patient’s pain before surgery with a non-narcotic medication, then often use a nerve block, in addition to general anesthesia, to provide localized pain control,” Dr. Khan explains. “After surgery, many patients take Toradol, an anti-inflammatory medication.”
Today many patients ask about pain medication in the office, he notes. “It’s an important topic for people who are having surgery, including for cancer. Patients often ask me to not prescribe an opioid medication. Now, because of how we manage their surgery, we have effective options.”