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Episode #20 - Genetic Testing Results

Steve Abbott:

Hello everybody, and welcome back to Episode 20 of CCAs Medical Minute Podcast. I am back to written notes-


Jill Hunt:

Good, good.


Steve Abbott:

Even though I liked flying without a net a couple of times, we got a lot to talk about today. I want to make sure we get through it on time.


Jill Hunt:

I prefer the net.


Steve Abbott:

All right. We've always got something to be excited about. So, this week is two things. One, I have a new sports coat.


Jill Hunt:

Nice.


Steve Abbott:

It allows me to bring this gold tie back out, which I'm excited about. And then we have new greenery. So, Chris has got this place all boogied up at this point with feels a little bit like Between Two Friends. Did you ever see Zach Galifianakis the Between Two Friends?


Jill Hunt:

I really need to know. This is a point of contention here at CCA.


Steve Abbott:

I like it, though. I like it. I like it too.


Jill Hunt:

We've got everybody who loves the greenery, and I feel a little encroached.


Steve Abbott:

It is a little-


Jill Hunt:

But Chris swears to me that it looks amazing on the screen.


Steve Abbott:

It's very green.


Jill Hunt:

I'm potentially being brought over to the green side, I guess.


Steve Abbott:

It's so green. It almost doesn't even look real.


Jill Hunt:

Almost.


Steve Abbott:

Yeah, that's amazing. Okay. Another thing we're excited about. So we discovered recently in the last couple of days none of us knows what it means, but we are now getting popup ads on our podcast episodes.


Steve Abbott:

There was a Seinfeld episode and it was the Sponge Worthy episode. Did you ever see that? No. Where Elaine's contraceptive sponges were pulled off the market. She thought she had a limited supply that had a last for the rest of her life. Any guy that she was going to use one with, had to be sponge worthy. So we are now Ad Worthy,


Jill Hunt:

We are Ad Worthy.


Steve Abbott:

That's right. Again, we don't know what it means, but that's good. I think I don't know. We got 345 subscribers now.


Jill Hunt:

Look at us go.


Steve Abbott:

Yes, exactly. All right. So we are finally who can finally do these genetic testing results. Then we're going to talk about that today, and I thought I would briefly walk people back through because there's been quite a lot of stuff going on.


Jill Hunt:

Do a little rehash?


Steve Abbott:

A little rehash. To recap what has happened, we'll do this quickly starting in mid-September. So my PSA was 3.5 in mid-September. It quadruple to 13.7 in mid-December, and that was the point where we kind of knew something was going on. As you'll recall, we did the Guardant360, which is the blood draw. Did that on December 23rd, that found evidence of shed cancer cells basically in the bloodstream. From that, we were able to identify a TP53 V216L variant.


Jill Hunt:

Correct.


Steve Abbott:

So remind us again, what does that mean?


Jill Hunt:

TP53 is just one of those mutations or alterations that can be found in multiple different types of cancer, prostate being one of them. That was so relevant for you because the previous Guardants that we had looked at had no detected mutations. This was correlating with the fact that we saw a progression of the PSA, and now we're seeing a measurable tumor mutation on the Guardant360.


Steve Abbott:

Got it. Okay. At that point, we had a high PSA. We had a positive finding in the Guardant results. Then we immediately scheduled a PSMA PET scan.


Jill Hunt:

Road trip to Michigan.


Steve Abbott:

Ann Arbor once again.


Jill Hunt:

Go bucks.


Steve Abbott:

I had that on January 27th and that found that identified cancer in two new spots left lung and left super clavicular node.


Jill Hunt:

Strong work.


Steve Abbott:

All right. All right. On January 26th a biopsy is done. That biopsy found in those two was well done in the neck area, but that was the super Clavicular.


Jill Hunt:

Super clavicular.


Steve Abbott:

Yeah. But it found that it was the same cancer, the existing prostate cancer, not new cancer, so that was good.


Jill Hunt:

Correct.


Steve Abbott:

On February 9th, I get another PSA result. 13.7 jumps to 19.3 on February 11th. I started on a new drug called Oxybutynin, which is helping with my hot flashes.


Jill Hunt:

Good, good. We have made it through a couple of episodes without the beats of sweat hopping up on the forehead.


Steve Abbott:

It's been nice. On February 13th started on another new drug called Casodex, which is probably one of the oldest, if not the oldest, hormone blockade drugs.


Jill Hunt:

Pretty sure.


Steve Abbott:

Okay. All right. That's a bridge drug until we figure out what we're doing. On February 15th, the first tissue sample comes back from Caris Life Sciences.


Jill Hunt:

QNS.


Steve Abbott:

Yeah. QNS. Nothing of any value, so we redo that on February 22nd. I have an MRI of my brain. They did find one and it looked okay. It-


Jill Hunt:

It speaks to the structure, not to the-


Steve Abbott:

Well okay. Fair point. Okay. Then that brings us to February 28th, when the Caris results come back that do have something that's that we can talk about. Do you want to explain what those things are?


Jill Hunt:

Okay. The Caris result came back, and it showed an AR-V7 variant. This is important because it's a result that indicates hormone resistance, which again, it matches, it matches the picture that we're seeing. You've been on hormone therapy, and now your PSA is increasing. We're starting to see disease pop up in the soft tissue outside of the pelvis. This all matches what we are finding in all of the tests that are being run.


Steve Abbott:

Okay.


Jill Hunt:

The other thing that we found was we were looking for that BRCA1 and BRCA2 mutation because obviously there is a treatment-related or a treatment option related to that mutation.


Jill Hunt:

However, you were not positive for BRCA1 or BRCA2. Beyond those two points, there really wasn't anything else that was found, but it definitely pointed us in a direction that we needed to decide what treatment options are going to be best.


Steve Abbott:

And the BRCA1 and BRCA2 negative results. What that took off the table was the use of PARP inhibitors. That would've been what? Alaparib and rucaparib.


Jill Hunt:

Easy for you to say.


Steve Abbott:

But basically, Lynparza.


Jill Hunt:

Correct.


Steve Abbott:

That would have been a possibility, but that's no longer a possibility. So, so on March 2nd, I met with my medical oncologist.


Jill Hunt:

Quarterback?

Steve Abbott:


Yeah. PSA up once again, 19.3 to 21.9. Obviously, we ruled out any further use of hormone therapy and we discussed three potential treatment options that I'm looking at right now. There's a possibility of a clinical trial at the National Institutes of Health in Bethesda, Maryland. One in Ann Arbor. Of course.


Jill Hunt:

Go bucks.


Steve Abbott:

And then we can follow what would be the basic standard of care that would involve chemo.


Jill Hunt:

Correct.


Steve Abbott:

Okay. That's where we are at the moment. Tomorrow I have a video meeting with the principal investigator at the national institutes of health. What should I expect from that phone call?


Jill Hunt:

When you are being evaluated for a potential clinical trial, all of your initial paperwork and previous test results, all of your pathologies, all of your records have already been sent up there and they've done a brief once over on, do they think that you're going to be eligible for their trial? Now tomorrow, what will happen is they're going to go into a lot more detail. They're going to us the ins and outs of the trials that they have available. They also are going to make sure that all of the nitty-gritty of the exclusion criteria is all met to make sure that you qualify for their specific trial and that there aren't any red flags or any things that would exclude you from being a can. That will be the gist of that call.


Steve Abbott:

Okay. This trial, in this particular trial, the NIH it's a combo. I guess it's a phase one and phase two trial.


Jill Hunt:

Correct.


Steve Abbott:

There are four drugs and all of which are investigational correct. in nature. Can you explain what an investigational drug is?


Jill Hunt:

An investigational drug is a drug that has not been FDA approved, and they are looking to see if it's going to be effective in specific disease types. It's something that hasn't... There will be some clinical trials that will look at an already known approved drug plus or minus an investigational drug.


Jill Hunt:

You've got one that is already gone through all of the rigorous FDA regulations to be approved and then the investigational that's starting that process. In this case, you have four investigational drugs.


Steve Abbott:

But other than that.


Jill Hunt:

But other than that.


Steve Abbott:

Okay, so the phase one, so two of these drugs would be phase one. We talked about that, Tim Schroeder, but so correct me if I'm wrong. But this is a first in mankind of a situation, so correct. It's been tested on animals and then, so it goes into a man for the first time. The idea here is to kind of increase the dose until to find out what the maximum tolerable dose is?


Jill Hunt:

Correct.


Steve Abbott:

Okay. So that sounds like a lot of fun, but it is what it is, I guess. The other option for me is this trial on Ann Arbor, which has a different approach. I guess you'd say that it relies on two already previously approved FDA drugs.


Jill Hunt:

Correct.


Steve Abbott:

What's different about this one is one of them is Enzalutamide, which is a drug called XTANDI, which I've already been on and failed; if you want to call it failing, I guess. The other I'm going to try to, I'm going to try to pronounce this one too. Pembrolizumab.


Jill Hunt:

Very good.


Steve Abbott:

All right. Thank you.


Jill Hunt:

We call it Pembro for short to keep it simple.


Steve Abbott:

That's a good call, people.


Jill Hunt:

Pembro.


Steve Abbott:

So, that's Keytruda. Everybody's seeing lots and lots of commercials about Keytruda this day, but that's an FDA-approved immunotherapy drug.


Jill Hunt:

Correct, [crosstalk 00:11:07] inhibitor. Okay. The first drug that I mentioned, Xtandi, is an FDA-approved hormone blockade drug.


Steve Abbott:

Correct.


Jill Hunt:

Okay. Which is second-line hormone therapy?


Steve Abbott:

Yes.


Jill Hunt:

Okay. Then there's this other - there is one investigational drug called Zen-3694.


Steve Abbott:

Ooh, Zen.


Jill Hunt:

I feel more relaxed already, which blocks the expression.


Jill Hunt:

Do you have to do this when you're getting it?


Steve Abbott:

I may, who knows why I may end up doing that one, but that one blocks the expression of the MYC gene, which is believed to spur the growth of tumor cells. The idea here is, and I think I'd like you to explain that we're still on the bleeding edge of getting immunotherapy to work with prostate cancer, correct?


Jill Hunt:

Correct.


Steve Abbott:

Okay. In this case, the trial would be to take something that may be in the past hasn't been that effective against prostate cancer, but they're hopeful about it, but combine it with another drug that is effective against prostate cancer.


Jill Hunt:

Yes. Then an investigational drug and hoping that the right recipe will make the perfect pie.


Steve Abbott:

Okay. That leaves us with the other possibility. And that's one last thing I wanted to talk to you about because I've got a lot of stuff to think through in the next week. Then there's the potential for just chemotherapy, which is the current standard of care that seems to come later in the prostate cancer journey. But I think that's a past paradigm. Sometimes it does come earlier.


Jill Hunt:

Well, and the thing of it is that with chemotherapy, we know it's going to work. We know that it will shrink the tumors back. We know that it will offer a response, but it has a pretty significant physical impact, and the durability is unclear. Definitely, you want to hold that card for when you need it the most. Okay. We, tend to pull that trigger when, when the patient's in trouble, if there are any other treatment options, especially with someone like you, that are healthy and isn't symptomatic of what we're on paper. Then if there are other clinical trial options, that's the time to use that because once you get to the point where you're showing symptoms of cancer, you may or may not be eligible for those clinical trials.


Steve Abbott:

That's a good point. I hadn't thought about that.


Jill Hunt:

Yeah. The thing that's crazy about clinical trials is that they want healthy people with cancer, so it's like-


Steve Abbott:

This goes to what we talked to Tim about: there is a little bit of a misconception that's like, oh, I'm at the end of my rope because I have to go and do a clinical trial.


Jill Hunt:

No.


Steve Abbott:

Okay. All right. Good. Okay. We'll have a future episode where we'll we'll talk about whatever it was. I ended up choosing and how that's going.


Jill Hunt:

Well, glad you chose.


Steve Abbott:

Well, in the meantime-


Jill Hunt:

It's like The Bachelor.


Steve Abbott:

... But worse.


Jill Hunt:

I know, right? The Roast Ceremony is not nearly as much fun.


Steve Abbott:

Okay. Anyway, we'll do that. And then, everyone, if you can, we're super excited about the growth and subscribership for our podcast series. If you would, I wouldn't mind keeping that going for us. I'm writing a blog now to talk about some of this stuff because a lot of it's what we've talked about on these podcasts. I think it's important to give a real-life account of that, so that would be cool. And then March is Colorectal Awareness month, and we're going to have an upcoming episode on that.


Steve Abbott:

We'll do that next week, right, Chris? Yeah. Next week. That should be good. And everybody, if you can join us back here again next Wednesday at noon, that would be great. Maybe we'll have some more news on whatever it was that I'm going to do next. Anyway, thanks to everyone, and we'll see you next week.


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