>> couric: welcome to the program, i'm katie couru c filling in for carlie rose. topt for the our, a look at advances in cancer research today. we'll talk to scientists louise perkins, bill knellson and neil segal and tomorrow marsilje. >> i could here the one who did the colon os scope, your husband has colon cancer, we need to schedule emergency surgery so i went from the highest of highs to the lowest of lows. i was crying saying there are a few things that scare me in life but cancer is one of them. and it was june 4, 2012. i will never forget that date for the rest of my life. that is true of most cancer patients, they never forget the day they were diagnosed. >> couric: a discussion about

cancer for the hour next. >> funding for >> rose: funding for "charlie rose" has been provided by the following: >> and by bloomberg, a provider of multimedia news and information services worldwide. captioning sponsored by rose communications from our studios in new york city, this is charlie rose. >> couric: good evening. i'm filling in for charlie rose. in 2017 according to the american cancer society, nearly 1.7 million people will be diagnosed with cancer. and over 600,000 of them will die. that is over 1600 deaths from cancer every single day.

it's a matter that became deeply personal for me when my husband jay died of colon cancer in 1998 at the age of 42. but that was 19 years ago and today there have been a number of advances in medicine that have taken us a long way in the fight against cancer. there are promising new breakthroughs that are giving patients and their families a reason to hope. in 2015 president jimmy carter suffered from late stage melanoma, a cancer once thought to be a death sentence. but after undergoing a new immunotherapy treatment his tumors disappeared and today is cancerfree. but how close are we, really to finding a cure for cancer. to help answer that question we're joined tonight by dr. bill nelson, is he the director of the sydney kimmel sprensive cancer center at johns hopkins, dr. louise perk inns is chief science officer at the melanoma research alliance. dr. neil segal is the clin kalt director of the immunoaz therapeutics grown and

gastrointestinal oncologist at sloan ketterring. and tom marsilje is a patient advocate who was diagnosed with colon cancer at the age of 40. welcome to all of you. thank you for being here. tom, i want to start with you and your story. you are an oncology researcher working on lung cancer, primarily. when in 2012 you had the highest of highs and the lowest of lows. tell us what happened. >> yeah, to start the story i have always wanted to go on oncology discovery since high school because i had a lot of cancer in my family. i planned on that for many years. and i started industrial drug discovery in 2003. and i was very passionate about it because i was also end of life caregiver for my sister who died of pan cree attic cancer at a young age. so i took it very personally and very seriously, drug discovery for oncology. and will is definitely a lot of hard work, but also some luck in

drug discovery. and i was a part of a project team for lung cancer, about ten years ago now. where i was a coinventor of a drug that eventually became fda approved, and it is a dream come true for oncology scientists to have anything fda approved it is so hard. and so there is a conference in june or may, it was presented by our clinical team, clinical researchers at the clinical trial sites and an amazing response rate and i felt like it would help my mom, in hindsight, my family members so many patients. i got to know patients so well it was really kind of my one aty having success. and so by chance on the same day i had a colon os scoppee scheduled for about noon. so i went for the colonoscopy. they knocked me out. on one to ten, i for anesthesia put it to 11, so i started

waking up. and i couldn't open my eyes yet but i could hear. and i could hear the gastro ent roll guest who did the test tell my wife next to me your husband has coloncancer. we need to schedule emergency surge rao. so within a six hour period i went from the highest of highs to really the lowest of lows. i mean later that day i was crying with my wife. i said there are few things that scare me in life but cancer is one of them. and it was june 4, 2012, and i will never forget that date for the rest of my life. that is true of most cancer parybts. they never forget the day they were diagnosed. based on my pathology, i had i would say about a 30% curate. which isn't great. but st a lot better than zero. >> couric: i thought stage three had a higher than 30 percent cure rate with therapy and surgery. >> stage three c, hi a lot of limb-of-knoweds, invasion into my neurological system. and so i had a lot of things against me. but stage three overall is much

higher. but that was the worst case stage three patient. as well as things as a scientist i can look up these statistics myself. >> couric: they say you shouldn't google anything when are you diagnosed. >> you probably shouldn't but i did it immediately. >> couric: i'm sure as a scientist. >> extra warning signs were, from pathology. but i was very upset and scared. but really clinging to that 30% hope because 30% is not tbreat but that's real hope. and so i went through chem therapy for six months. i had a clean ct scan, at the end of chemotherapy and my life just turned around it was really, i reprioritized my life in a lot of ways. i felt like i had dodged a bullet. i started, i was always relatively active. i became a long distance runner. and then eight months later i had my next pt scan and there were enlarged lymph knoweds.

at that point we weren't sure it was cancer. they can get enlarged for illness for various reasons. so i was in this weird perking tore where i didn't know was i stage four or was i stage three, and my cancer was very, very slow growing. and so we actually watched a pt scan for almost one year where the knowed was get a little bigger, a bad news scan, a little smaller, there would be a good news scan, so a yo-yo affect. >> couric: so were you getting no chemotherapy. >> no treatment, just monitoring. because we didn't know if i had cancer or not. i didn't know, my doctors didn't know. so psychologically it was a very challenging time. as i said, it was almost like pergatory. i few if i had stage four disease i would become a fighter and do everything i could to combat it. if i was cured, i kind of wanted to move on in my life. and it was kind of stuck in the middle. but after about a year of monitoring, we had a couple

scans and saw enlargement in the limb-of-knoweds and spots in my month so i was restaged at stage four. >> couric: and what kind of cheem thrpee, you then went back on chemotherapy. >> once you are stage four, there is a lot of-- it depends a lot on the patient and doctor, we can use a lot of leeway, because i was not surgeically-- i like to use the phrase currently incurable because i look at things like melanoma where people were incurable tenniers ago and now are doing fantastically. i was currently incurable at that point. and since i had such a slow growing disease i said well i'm having a really good life right here. why don't i put off chemotherapy for awhile and monitor it. and my doctor is a fantastic oncologist and he agreed with that plan. so i went for a year without chemotherapy, continued monitoring and eventually want on once we kind of made a judgement call and had to weigh the quality of life with

treatment. and i went back on chemotherapy. >> couric: you have been an extraordinary inspiration to so many people, tom. i know you have started a blog or been writing a blog called adventures in living terminally optimistic. you have helped many patients sort of navigate the clinical trial system which can be quite confusing. why have you done all that? what has that given you? >> so for different reasons. i started with a personal blog, adventures living terminally optimistic. and that started because when i was first diagnosed, the first thing i did almost was go to google and find a blog. and it really gave me a lot of comfort. and the blog i went to, i loved it because it was both realistic, it talked about cancer, in harsh terms, very realistic terms. it always had hope, involved in it. and it br comfort that originally started a blog when i was diagnosed with

stage four because i wanted to keep my family updated on medical things but i didn't want to bombard people if with emails if they don't want it but they could choose to be a blog. originally it was going to be a private blog and at the last second i decided to make it public. for this reason. i imagined a new patient being diagnosed, going to google and needing comfort. and i wanted to pay it forward. i got help from someone else's blog y not pay it forward to the next person. so it became public. and i wrote my first blog piece. and although it planned to be a medical update for my family, turned into to so much more. i realized within the basically the first post that i had a unique view point. i am a scientist so i knew really up to date information on science, because i approaching clinical trials am i knew a lot about clinical trial data that is coming out. >> couric: so you could basically translate it, because when you are thrust into this world of cancer, unless you're trained like the three of you,

and like you, tom, it's like suddenly learning a foreign language. >> exactly. and one of those things where i knew this information. and i wanted to help other patients. and i decided well, can i write about this in layperson terms. so then it became a real mixture of a blog where i alternate. i go back from personal stories which are my own cancer journey. and once again harshly realistic terms. i talk about chemotherapy, vomiting in the chair, all the emotional things, of family, i have three young kids. but then i alternate with posts that are scientific posts in layperson terms. really it was meant to really share with my fellow patient population the things that i knew. cuz why would it be fair for me to know these things and not share it with my good friends. because i'm friends with these people. and i think the few things played off each other very nicely. it is almost by design but it definitely took off more than expected.

where there are other places to get trial information or science information in layperson terms. but when a fellow patient reads about it, from someone who knows what they are going through, and see it through their eyes, who has skin in the game, it just makes it so much more powerful. and so my little blog started taking off and i now have tense of thousands of hits per post. i have i am in 140 country, i'm in six languages. actually my biggest readership is actually in china, in chinese. where everything is translated by a group of scientists where i work. we're a chinese owned immigrants. and i get so many messages from people, it has been so rewarding. and that was really just the start. i then realized there is limits to what i a personal blog could do. i started working with a couple organizations to fight colorectal cancer, and became the currently incurable scientist and fight for them and work with them and am really educating parybts in layperson

terms through their network, basically, which is much more than a personal blog can do. and we may want to talk about it later because it's a pretty big topic but then i started working with an organization called colon town and the colon town clinic which is basically a private community where we talk about colorectal cancer trials 24 hours a day, 7 days a week, 365 days a year, in conversational tone. and i recruited fellow scientists that have a personal connection to crc, colorectal cancer. and basically we give information of trials that are opening up. because it is hard to find the information normally. and the real purpose is to then explain the trials in layperson terms so we have more than one professor of immunology to talk about immunotherapies in this private setting and it is facebooked stage so it is conversational, a two way street. the patients can go to their medical oncologist with a couple of trials that they have been made aware of, which is very hard to find without some help.

and they have a basic understanding in layperson terms. and we also supply pdf's for background literature for the oncologist to read. it's been amazing. >> couric: you're amazing for doing all this and help sog many people while you're going through your own cancer ordeal. and i want to talk about a couple of the things that tom, you raised, with the folks assembled here. and one is you're 40 years old when you were diagnosed with stage three c colon cancer. and there was a study out recently lead by the american cancer society scientists bill, that showed that the incidents for colorectal cancer, colon and rectal cancer is going up among people under the age of 50. and of course 50 is the recommended age for screening. nlings you're symptomatic as you were. so tell us a little more, bill,

about this study and what your reaction was to it. >> well, this is a report from the people without keep score of who et goes cancer in the country, how old are they, where do they live, are there differences between men and women, are there differences between different race and ethnic groups. there was a lot of good news in the study. what we are finding is that colorectal cancer mortality broadly has been declining particularly in folks above the age of 50 who get screened. not all of them on live television but the people who get colonos coppy, there is clearly a benefit so overall it's getting better. >> screening rates are going up, survival rates are improving. the worrisome thing though in the same report card, is that there is an increase in colorectal cancer incidents, people getting the cancer, and deaths from the cancer in this younger age group that are not, we were talking about this earlier, they are not the people typically getting screened because they are younger than age 50. i don't think anyone knows for sure what the reason is.

but some of the things that we know contribute to colorectdal cancer, obesity, some die tear habits and the like. maybe this millenial generation has a little bit more of those risk factors, so they are getting them at slightly younger age and that's woreisome. we need to figure a way to help. >> couric: according to the study, compared to those born in 1950, those born in 1990 have double the risk of colon cancer and four times the risk of rectal cancer. and the press release that came with this study said our finding that colo recognizal cancer risk for millenials has escalated back to the level back to those born in the late 1800st, it is very sob aring. educational campaigns are needed to alert clinicians and the general public about this increase to help delay delay diagnose soo but to encourage healthier eating and more active lifestyles to try to reverse this trend. neil, one of the things that came out of this study was a

discussion about the screening recommendations. right now the american cancer society and other organizations i guess recommend screening start at age 50, some organizations, 45 for african-americans 6789 who have slightly higher risk. do you think the screening age needs to come down for colon cancer screening and rectal cancer for that matter? >> well, katie, i think that studies like this are exceptionally important to focus our attention on the increased incidence in various age groups. and this is the type of data that the folk that guide the recommendation for age of screening will use to make a recommendation. studies like this will start the conversation. they will take it one step further deciding what the screening age will be and that is the one that we will follow. of course there are certain populations with higher risk features that should have screening at lower ages, particularly family history, for

example, symptoms as was mentioned earlier. those are specific types of indications but overall it will depend on analysis of the data. >> couric: and what do you think is behind this increase among younger people. >> that's a very good question. i don't think we know just yet, that article made a point of healthy lifestyle, is important, diet, may be important, exercise may be important. but there are potentially other factors that are changing the incidents of colon cancer and rectal cancer in a younger age group. but us knowing that this is becoming a problem will prompt discovery into what is the underlying cause. so we are just at the very beginning of answering that question at this point. >> couric: not to be too graphic but one of the things that i have discussed with dock ares to-- doctors about this study is the importance of digital rectal exams and that many doctors and patients don't want to get those done because they're uncomfortable or whatever. but that's critically important, isn't it, when it comes to diagnosing rectal cancer in

particular? >> yeah, rectal cancer you are talking to somebody who is a prostate cancer doctor, so digital rectal examinations is something we use frequently to look at that space. but i think the key is going to be if there is going to be more cancer in this generation, heralded by more cancer at a younger age. we need to get on top of this, just as neil was saying. we need to figure out what are these risk factors. can we deploy public health maneuvers to make them better. and can we, i think we're didding to develop new screening tools. if we can find dna on a hair followic el at the crime scene, can we find cancer dna in the circulation, in the stool or something like that-- . >> couric: or blood test where it is not nearly as invasive as a colono scope. >> and i think those things are on the horizon, i don't think they are this year or next year, i think they're coming. >> couric: i always worry to talk about that, neil, because i am afraid that will discourage people from getting screened with the tools available today because they are waiting for something on the horizon.

>> well, i think the topic of screening tests is a very emotionally charged topic. there is a lot of implications of what is the right age to be screened at. nobody wants to not get screened at the age that they should be. but we have to recognize how likely the screening test is to identify the cancer and what are the downsides of screening in a lower risk population. what could the false positive rates be, what could the financial costs be, what could the cost of additional testing be. >> couric: let's talk about younger patients and melanoma as well. because it is really increasing among younger women in particular. what can you tell us about that sth. >> so melanoma like most cancers is a cancer of aging it tends to happen in people in their 50s and 60s and so on. but melanoma is unique in that it is the most common cancer among young women ages 25-29. now why is that the case?

perhaps it's excessive exposure to ultraviolet light. we know that if you look at the dna sequence of melanoma that in-- from sun exposed sites, that is ultraviolet light exposed sights that you can see the footprint of dna damage in those mel snoam-- mela cells. so it stands to reason that ultraviolet light played a role in causing those melanomas. so why if you are a young woman would you jump into a tanning bed where they are going to bombard you with ultraviolet light. and it may well bb, although i don't think will is any data to support it, that high exposure tou v light is playing a role in this high prevalence in these younger women of melas. that said, i think another factor that could potentially play in is that nobody expects somebody in that age group to have a melanoma. and i suspect that is some of these folks are yupped diagnosed before it becomes a terribly aggressive situation.

>> that is something that is true in colorectal cancer as well. we talked about screening already. another thing i am glad of, for getting sun exposure, from that study, is that i was lucky. i have symptoms and so i went to a gastro ent roll guest who immediately ored a colono scope when i got to that part. but unfortunately there are a lot of doctors that are undereducated that it is possible to get colorecognizal cancer if you are under 50. and a lot of people-- . couric: isn't there something like 11,000 cases a ye, by the way. >> so i know many people that had symptoms an had them for one to two years that went to their pcp and their doctor and were really not taken seriously, and even after colon os scoppees and were not given them. i think because of an under education that it is possible. >> couric: i'm sure you heard story after story of people who had blood in their stools who

were basically told they had hemorrhoids. >> i hear those stories every day. and what i think really is kind of the worst aspect of that, is that younger people that are diagnosed with cancer, colorectal for sure, correct me if i'm wrong, they tend to be diagnosed at later stages because it is not diagnosed, if they are not taking this seriously, the symptoms. so for younger colorectal cancer patients they are often diagnosed with stage three or stage four. >> couric: in my husband's case it was stage four. he it mehta az static colon cancer and was all over his liver by the time it he was diagnosed. >> it which ties to survive ability rates and all those statistics that are feeding into that study. >> couric: what can we tell people waffing this at home who may have cancer or a loved one with cancer and are desperate for information about clinical trials and they just can't find them, they don't understand necessarily when they're eligible. >> the key to understanding

clinical trials is ongoing communication. and that communication should be had between patients and their physicians on an ongoing basis and the question could be as simple as what clinical trials open at the center, what could be happening, which are the ones i should be following. the types of clinical trials are phase one clip kal trials, face two and three. a face one trial is an early trial where we are trying to determine the dose of a drug, what the side effects of the drug are. a face two clinical trial is once you know the dose, we're trying to see how well the drug works or that could be part of the face one, sometimes the dis2eu7bgs is not that clear. a face three clinical trial is comparing a potential new therapy against a standard of care. so let's talk about phase one clinical trialsk face two clinical trials. these are usually small clinical trials, maybe 20, to 40, that is the general size. they may be open for a few months.

they may open at certain times, for example, three patients maybe enrolled and then a period of time in which the trial is not enrolling. so it is a very potential cum ber some process trying to understand what trials are available. so at memorial, the ability to put patients on to clinical trials is of tenant mount importance to us, it is very important to our patients. what we attempt to do is if a patient is looking for a clinical trial, then we will attempt to match up each of our patients with available slots on clinical trials so we can get as many patients on to the most appropriate clinical trial for them. >> couric: how do you know, though, if you want to get sort of the standard treatment, the first line treatment, i think, in probably your case, tom, it was-- which has been around since the '50s which is really maddening to me. or you want to do a more experimental drug. i mean bill thark say hard decision, right, because go with

something that is proven to be potentially effective to something that they don't even know the dosage you should get. so how do you wrestle with that? >> i think one of the things to take a step back that is getting much better about making that decision, and it's a hard decision. you want to be educated and empowered for how that treatment of standard of care will work and what the prospects are in a clinical trial like a blog and stuff that tom is going to be helpful to people. but if you look back 20 and 30 years ago, we were discovering anticancer drugs by screening things. these were drugs that what kill cancer cells on a dish indiscriminately. the more we put cancer cells on the dish the more we could kill. the clinical exercise that neil talked about was how much could we give somebody. could we give somebody enough without hurting him so much that it could kill cancer cells in their body. and this was horrendously inhe me to find the dose well.a long had no idea what cancer would

work with all these other trials and this largest one is it better than the best we got or if it we add it, is if an improvement. tom, both sides of this equation worked on these, think about how differently the clinical trial pathway was designed. they had an idea of what drug they wanted to use for a very specific kind of cancer, with a good idea that it might work. and that was the clinical trial that they did much faster, much smaller, much more rational. so again you go back and look at the early phase drug trials, 20 and 30 years ago. i think it's probably four or five pefers everyone who participated benefited and no more than that. now it's totally different. you want to participate in these clinical trials of new drugs as targeted therapy because the clans for them to benefit are so much higher. >> couric: i know, neil, this is one of the major goals of the moon shotd program that vice president bied enwas so critical in launching, to make clinical trials more accessible and to

educate people about-- and get more people to enroll. >> getting people to enroll in clinical trials, getting communication between the physicians running the clinical trials, between the basic researchers that are doing the work in the lab, that are allowing us to identify which trials should take to the clinic, and i think it's very important for us to recognize the tremendous investment that is needed in basic research so that we can understand which clinical trials we should take forward. and the moon shot program is an idea that is really going to enhance that type of communication. one step further is in the not too distant future and already starting now we are being to decide on clinical trials based on markers. ideally we can identify a patient who has the potential to respond to a drug. >> couric: so more personalized clinical trials. >> personalized clinical trials. this this is understanding a very complex endeavor but this

is what we are strifing to do. ideally we will put a patient on a trial with the potential for them to benefit based on a dna mutation, a change in the genetic sequence that may predispose them to respond to a drug or immunotherapy clinical trial, ideally we'll understand how their immune system may be made stronger and focus on that particular aspect of their immune system or why their immune system is not attacking the tumor, can we sir cum vent that and make the immune system attack it. that kind of identification requires a lot of communication yz that say good segue to what is on the horizon. >> what is very important, we are talking about access to clinical trials where people need to ask questions and they gain information as you did. one of the access problems is magnified for clinical trials are some of the health des parities, underrepresented minorities, people with lower incomes, lower, more difficult for them to get back and forth to the treatment center very often.

and we can't allow that to happen. we have to be, this clinical trial enterprise available to everybody with cancer who might benefit from participating in the trial that is going to take a lot of work. >> couric: and it's interesting, tom, your experience, i'm sure if you were searching for clinical trials and finding that the resources available were soarly lacking in terms of giving people information they could truly understand. >> exactly. an before we move on to the next topic, i am so glad you brought up the 3 to 5 percent statistic because i don't think clinical trials are necessarily appropriate for 100% of cancer patients. but in my view point is that 100% of parybts that are currently incurable should have a discussion with a medical oncologist about a clinical trial. i think the 3 to 5 percent current statistic is a tra vestee because there are inherent limitations to what standard of care can do. especially in the maij age of immunotherapies where the response rates may be low for some types of cancer still, in the age of immunotherapies i

think it is absolutely ethical tra vestee that the system is not better-- more easily accessed, and for all patient groups. to get way beyond that 3 to 5% marker. >> couric: this is a good segue because you are throwing around a lot of terms that people might be scratching their heads about at home. and that is sort of the new-- the new cancer reterch that is really providing a lot of hope for cancer patients. and that is perhaps taking us further to finding a cure, at least managing some of these cancers like a chronic illness. and one is immunotherapy. and we're going to do sort of cancer 101 for people watching at home. and immunotherapeutic approach is basically bolstering the body's immune system so it can kill the cancer, correct? and there are three, i think bill explained this to me very well earlier. so three different sort of types of immunotherapies, so you can explain those in layman's terms,

bill. >> first the immune system is remarkable. it is the system in your body that can recognize a virus when it comes, even if it affects one of your cells, a bacteria in infection and fight it off. it can recognize your cells if they are in my body if i had a kidney translant and re-- reject it. and also we know it can see the differences in cancer cells versus your normal cells. so the challenge historically had been if the immune system can see those differences why did the cancer grow to threaten your life in the first place. and can we goose the immune response in such a way as to get it to eliminate cancer the way it eliminates-- . >> couric: like turbo charge it. and that is one of the meds being used. actually i guess that is is consistent across all approaches when it comes to immunotherapy, correct. >> that's right, one of them is to take the brakes off the immune system that it needs when it fights off an infection. after the infection is gone it wants to slow down and stop so

it doesn't harm normal tissues. you take the brakes off for some cancers, talking to you, the one where the immune system mountedded a response, traveled right to the cancer, many cells are ready to destroy the cancer and we dot have adolescence girls so it's the talk to the hand 1307bs. >> couric: the cancer says huh-uh, you're not coming to get me. >> when you that wart the response, the immune system is unleashed and can eradicate it. >> couric: that is called. >> immune checkpoint inhibbitier therapy. >> glor: jim all be so i. >> he worked on one of them, we were talking before we came on about the prolive raise of these types of treatments and they're working their way into clinical trials. >> couric: so is that bolstering the immune system and getting rid of the cancer's ability to stop the immune system from doing its job. >> that is one the tricks. the cancer is nev arious, you get rid of that, and the immune system can destroy it kz what are other approaches. >> another one is to take immune

cells out of the body, change them in such a way that they are now empowered to go destroy cancer cells. it is a funny name they called car t cells or adoptive immunotherapy, a lot of jar gone, are you taking immune cells out of the body, in the se way you try to instruct it to prevent the flu, meesels and mumps. >> so the change that we have-- challenge that we have for the next set of clinical trials which are already starting to happen is a combination immune therapy. we need to allow the immune system to get in, but perhaps we need to make the immune system stronger with a drug that rid-- the white blood cells, so they are stronger on the way in or once they are in, they are going to do their job and attack the tumor 6789 combination therapies, combination immunotherapies or chemotherapy. >> if i could jump in, this is

the reason we need so much more research. because we really need to understand the mechanism that are used by tumors to resits immune system's attack. and when we talk, you sort of envision like this one tumor and one place and that's the foe you are fighting. in fact if you have met tallic cancer, many tumors where they are all related, probably, they all a little different from each other and a little different because of where they are located. >> do they have different mechanisms that may prevent the immunotherapy from workingor do they all share similar characteristics. >> the answer is yes, they all have similar characteristics but they also have differences. >> cancer is the worst thing because it is s evil. >> nev arious is absolutely the right word. we're funding a body work that is being done at johns hopkins to study the tumors in melanoma patients at autopsy. so people who were progressing

on their mune therapy and unfortunately died but were willing to donate their bodies to the study, in a very fast time, to be able to understand what are all of the differences among these different tumors, across all of the different sites in these individuals, and through this kind of work, hopefully we'll be able to get a large enough quantity of tissue to be able to tease apart what is going wrong. >> this is an interesting phenomenon. we have people particularly people who participated in clinical trials who unfortunately some of them succumb from their cancer and they are asking us to do autopsies, not to figure out why they died. we know why they died but to figure out why did it escape the treatment and how can this help the next people. so we have people asking us to do autopsies when they pass away, it is remarkable. >> so immunotherapy i guess is the most promising new approach to cancer, is that-- is that a fair statement? >> well, i think immune therapy

needs to be put in the context of the entire-- that we have to fight cancer. so there is a very real benefit and role for continued cheem thrpee, there is radiation therapy, there is surgery for tumors and then immune therapies are one of the tools that we have. so the aim right now for most kinds of cancers is not to replace chemotherapy with immune therapy but to use immune therapy in conjunction, either at the same time there are many clinical trials now especially lung cancer combining immune therapy with chemotherapy because chemotherapy we think of as suppressing the immune system in fact, that's 23409 what it always does, it suppresses a part of the immune system that may fight bacteria but it can also make the immune system recognize the tumor because as the tumor dies, small pieces of the tumor that break off, it tells the immune system there is something going on there, a dying tumor, the immune system should go there, so we are doing clinical trials of combining

chemotherapy with immune therapy or sequence it, chemotherapy first, immune therapy afterwards. >> sequencing is a really exciting area of research. i know, when to give, what drug and in what order. and what about vaccines, louise. i mean melanoma, there was a lot of buzz about vaccines working in melanoma. i would love to know what drug was used on jimmy carter. which i guess was an immune therp-- immunotherapeutic drug. are vaccines as promising as they once were in melanoma. >> the one thing about melanoma it is the most immunoagainic of all cancers. it means a patient's immune system seemed poised to recognize most melanomas. most, that people develop. and we though that back from studies, that go back into the late 1800st where dr. koli at memorial sloan ketterring was administering a mixture of bacteria to people and revving

up their immune system. so we knew that stimulating the immune system could activate the cancer-killing. and in the case of vaccines, most people think of vaccines as you get a stick in your arm like you get your measle mumps rubella vaccine and don't get the disease ever. but here we're talking about something different. we're talking about giving somebody something in their arm, for example, as a vaccine and askk it to treat a large existing disease. and that's proven very, very challenging. however, recently there was an approval in melanoma of something called t-vec which is a modified cold virus that is actually injected into accessible tumors. and it appears to stimulate the immune system locally. and to improve the outcomes of those patients treated with this particular treatment. now is that really a vaccine? is it a local therapy?

where you can start to lies it pretty fine here. but i think there is still some ram for improvement with vaccines in melanoma and other cancers. and there are a number of trials going on that stimulate the immune system in various ways. st excited about as a cancerou scientist yourself. you know about all these different approaches, i'm sure, not just for colorectal cancer but i'm sure for a lot of different cancers because one of the most exciting things in my view is that there is some overlap, of approaches that used to be very organ specific or cancer specific. and now as i was talking to bill, you know, childhood brain tumors may be treated the same way as nonmelanoma skin cancers through the hedgehog pathway, i guess and through other methods that i learned about. but what are some of the things that you are excited about? >> okay, to begin with, as neil

said there are so many different approaches that it is going to be a plethora of different ways that will help patients i believe in the future. and so i'm going to pick out two. but the first one is actually vaccines including a viral type vaccine like t-vec where i look at it like a two step process where you are first educating the immune system of what to look for t may not know what to look for as an efficient manner and then you take the breaks off orr ev it up with a two step combination therapy. melanoma is also the poster child for immunotherapies because it tends to have a lot of mutations. and what that means is a lot of things are kind of funny. >> so it's not a target. >> a lot of things that look different to the immune system. a lot of targets for the immune system to grab on to, it tends to have a lot of immune cells near it or preexisting to it. it is kind of a perfect storm to facilitate immunotherapy, that is why it is really a mono

therapy like a checkpoint inhibbitier. obviously there are a lot of different types of cancer out there. a lot of types of cancer including colorectal cancer, the main form that i have, like i said light stable, it does not have those character stkszs. does not have the large amount of mew taitionzs which you really can't impact t is something intrinsic to the cancer. but also it doesn't have a lot of immune cells near it for various reasons that are still being figured out and will probably take years to figure out more fully. and so earn vaccines, another compare it to how do you make a type of cancer other than melanoma look more like melanoma. you can't impact the genetics. but can you get it in such a fashion to get the immune system's attention to bring an immune cells, and then the immune system is very complicated. there can be immune cells that activate and attack the cancer. there are immune cells that tully suppress the immune

system. and that's where it comes down to a very cli keated problem of a lot of cotherapies. but with these types of cancer, really first the attention of the immune system is going to be key. then you get to where hopefully closer to where melanoma is and then bring in the combination therapies that are now really at the forefront of early phase clinical trials. >> and personalized medicine, being able to, i used to say cancer is millions of different diseases and millions of different biologies because my body may respond differently to cancer than louise's and toms, then neil's, then bills. but are we closer to saying well, this person has this specific mutation or this specific protein as part of the cancer cell. so we're going to give this person x therapy while we're going to give somebody else y. >> this is the standard of care in melanoma. in melanoma a routine test done

for all parybts is to look for a mutation in a gene called b-reft is brin add braf and about half of melanoma patients have a particular mutation that actually turns that protein on. and so it's actually known to be driving the cancer. an there are approved fda approved therapies that target that particular mutation, mew taited protein and things downstream of it. >> couric: right. >> so these work well for melanoma patients but unfortunately, resistance is quite common to these treatments in those patients. >> couric: but are you seeing this in other cancers as well, for example, i mean hercepton is a discovery if somebody is positive with breast cancer they are a candidate for that drug are we going to see those kinds of character statistics surface in other kinds of cancer so a specific treatment targeting that specific mutation can be employed? >> yeah, i think you are. and you are going to see them

cross different cancer types. so ovarian cancers, particularly those that arise in women with inherited syndromes, the brca type defects, they have a very specific problem that ends up giving them defective genes that leads to ovarian cancer. but that problem is the achilles heel for one particular kind of drug. and so when women with ovarian cancer have that defect this one particular kind of drug works incredibly well. turns out a small fraction, four or five percent of men with prostate cancer are from those kinds of families and have that same gene defect that they have inherited. what is really interesting is if a man goes all the way through with bad prostate cancer, gets all kinds of treatment and it is still getting worse, that ends up being about 15% of them or so may have that same defect and they will respond to the same treatment that women with ovarian cancer with that defect will have. so it is much more important what defek they had rather than

whether it was breast or ovarian cancer. >> couric: i feel like in the past you threw something against the wall, you saw what would stick, without really knowing an individual's particular characteristics or what their cancer may respond to. but that is starting to change. >> yeah. i think you're right on track with that thought because up until now we've identified markers that will in general not necessarily be the target of the therapy but will indicate whether or not there is sponges, for example in in colon cancer with a mutation, it tells us that a certain type of drug is unlikely to shrink the tumor. so these are markers but it's not the actual target. so what we want to do, when we identify new treatments for cancer is to identify the changes that we can specifically design a drug to go directly to that point. if that is going to be a change

in dna that will cause a change in a protein and if that protein causes cancer, we want to turn off that protein, this is the realm of targeted therapies. a lot of these therapeutic strategies are in clinical trials right now. so we can learn how to do that. and we can learn which change can be targeted is, for dna mutations, for immune therapy t is a whole different idea because we are not looking at mutations or changes in dna, we are trying to identify which immune cells are turning off these soldiers and these white blood cells that are trying to get into the humor. >> couric: i find it so frustrating that progress seems so slow. but cancer is so complicated. having said that, do you feel that we are at this critical point in cancer research with

deat and technology and new approaches and a new understanding of basic biology that we're going to see more progress made faster for patients like tom? >> i think the answer is yes. the first wave of oncologists, the difference in experience between men i took care of in the early 80see and 90s, is stunning, most of men we take care of, we look at men who died of prostate cancer had it for a very long time, had suffered near the end of life for a very short period of time. and that was absolutely not true before. so we have made more progress, i think sometimes than we credit ourselves with. and everyone around this table will tell you tomorrow it's going to be better than today. >> it really is starting to happen. >> it's incredible. going to to a cancer conference, i'm sure everyone here has been to acr.

15 years to today it is stunning the speed and excitement level among scientists. but as an example from my own personal story is that drug that was, i talked about at the very beginning on a project team for. >> the lung cancer drug. >> couric: that you developed. >> part of a team that developed, a big undertaking but it was a-- mutation, for the trial we enrolled patients that had that mutation and from the start of the phase one trial first patient, first dose to fda approval was 37 months which is blirsingly fast compared to how that was before general etic markets could be employed in that way it is a world of difference so from a patient point of view you want it faster but it is getting faster and i think it will get more fast in the future. >> i was going to mention this whole notion of convergeance

where suddenly engineers and sis fists and different mathematicians and data are all converging, if you will, and trying to work together to really unravel the mystery of various cancers. >> i think it is a golden age where we can bring together the insights from all of these different perspectives people working on new formlations, nano technology, new drugs. >> epigenetics, big data, taking all of the data, dna sequences that are being produced faster and faster every day, k450e7er an cheaper every day and bringing it all together it still takes time t still takes tremendous insights but the positive gains that have happened just embolden others to come in, and increase the excitement. so that is part of what the promise of immunotherapy has been. is to change the game to open up new fields. to be able to bring

astrophysicists together with biologists to look at what is going on. it is amazing what we can do right now. >> so what advice would you give to patients when it comes to finding out about clinical trials. what practical advice gaws it's hard to find out about these things quickly if you o are your loved one heres those horrible three years, you have cancer, take charge. ask your doctor, go to websites there are foundations for almost all the cancers, there are so many people who want to help, and ask, can i participate in a clinical trial, should i participate in one, and until you get the answer you want to hear, keep asking. >> and neil what would you tell patients. >> have a discussion with your doctor early on. ask them which clinical trials they should be looking at. ask their doctors to calm and ask them what is available should the patient go there to pursue a clinical trial what if the doctor says i don't know, you have to figure that out on your own.

>> then ask again because-- . >> couric: or go to another doctor. >> it is a good question, it deserves an answer. the answer is there. the answer may not be that there is a clinical trial but the answer may be there is one and you want to know you should ask the question. >> don't be fearful, you have to look at all the information that is available. don't be afraid to ask ask your doctor these questions. in you offend them you probably need another doctor, hopefully you won't offend them but keep asking those questions and do look for the disease specific foundations in whatever cancer you have been diagnosed with because there is a lot of information across different foundations, and across different sites at various blogs that can help point you in the right direction. be forceful is my advice. >> and tom as somebody who is in the middle of this, and who has learned so much along the way, what would you say? >> first of all, i think you said it beautifulfully, i agree with everything i heard. words out of my mouth. so i say most simply be pushy. don't take no for an answer. if you want to do a clinical trial, use resources, go see a

second doctor, secretary opinion if you need to. if you are able to, get to an nci designated major cancer center. don't take no for an answer. it is your life. >> we were saying it is a shame that hospitals that have nutritionists or psychologists or social workers and various people who can help deal with the family and help people through this disease and by the way critically important, but why not have an expert in clinical trials onsite to help people navigate this very confusing system. >> i agree compleatly. >> i think doctors, want to put the patients of clinical trials as oncologists we want to provide the best care to our patients and that includes conventional therapy and clifn kal trials t is important for doctors to have access to the resources where they can communicate. organizations that provide communication between doctors so that we can learn what there is. we want to provide this to our patients. >> again i think this is one of the goals of the moon shot program with joe biden's help,

people can navigate the system more easily. >> and recognize as a patient that if you are looking at a clinical trial, you may need to go to a different center. you may need 20 travel. that is just because not every friel is offered in every place. and i think that is uncomfortable for people who are not feeling well. but that is part of the way good clinical trials can get selected for individuals. >> and the doctor patient nurse relationship in the clinical trial setting is wonderfully collaborative. it is the reason we are in this game, because it is wonderful to work with people developing new therapies as their partner. >> couric: well, i have always said that cancer scientists are really the unsung heroes of our society. and i truly believe that. and i think that can be said for each and every one of you sitting around this table. thank you for what you do. thank you for what you do for patients. tom, thank you for being a patient and helping other patients it is quite remarkable. >> thank you for all do you for colorecognizal cancer, the whole

community thanks you. >> couric: well, we're working on it we are going to keep on pushing for you and other patients, tom. so dr. bill nelson, dr. neil segal, dr. louise per kins and dr., that's right dr. tom marsilje, thank you all so much for being here and helping us understand this mystery that is still plaguing us called cancer. i so appreciate it and thank you all so much for joining us. >> for more about this program and earlier episodes visit us online at pbs.org and charlie rose.com. captioning sponsored by rose communications captioned by media access group at wgbh access.wgbh.org

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