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Richard: Melanoma Survivor

Dedicated to making a difference

Richard: Melanoma Survivor

 

For the past 16 years, Dick Metz has experienced the ups and downs of a cancer diagnosis. He has had clean scans and bad scans, and has experienced joys and disappointments of therapy results, but he has never faltered.

Mr. Metz’s journey illustrates the incredible strides that have been made in treating melanoma, a cancer that just ten years ago had a much more frightening prognosis. Making matters worse for Mr. Metz was his cancer’s tendency to spread to the brain, and the fact that historically patients with brain metastases were completely excluded from clinical trials. Although older therapies resulted in responses in up to 15% of patients, the use of contemporary immunotherapy -- using the body’s own immune system to fight the disease -- has changed the way oncologists now treat melanoma, using a new generation of drugs that specifically activate immune cells called T cells. Progress that has taken the best minds of scientists and doctors working together to beat an extremely aggressive cancer.

Mr. Metz’s chronicle began in 2003 when his dermatologist biopsied a mole on his back and discovered Stage II Melanoma. Mr. Metz was referred to Yale Cancer Center and Dr. Stephan Ariyan, where he underwent wide excision, which removes the tumor along with area margin of healthy-looking tissue around it. In addition, nearby lymph nodes were checked and a biopsy was taken of the sentinel lymph node, the lymph node closest to the tumor. For Mr. Metz, all lymph nodes were found to be clear and he could exhale. He was then referred to Dr. Harriet Kluger to be monitored.

“I felt like I had dodged the bullet,” recalled Mr. Metz. “The doctors had me check in with them each year to make sure nothing had spread to other organs in my body. All was fine until a few years later when I started waking up in the middle of the night soaking wet with night sweats.”

Mr. Metz’s primary doctor sent him for an ultrasound, which revealed an 11-centimeter (4 inch) tumor on his liver, a metastasis from the melanoma on his back.

“I was shocked and surprised that the melanoma cells had escaped into the bloodstream and gone from my back to my liver,” Mr. Metz said. “I had had the initial surgery, had been checked annually for four years after that, and felt that I was cancer free.”

“My oncologist, Dr. Harriet Kluger explained that if we did not do anything, I only had a matter of months to live. This news sent me into a tailspin. I came out of it in what I call my fight mode. I wanted to become an expert in my disease. I immediately went on the internet to find out any information I could. I wanted to really understand the treatment options and what possible cures could beat this disease.”

The choices of treatment for Stage IV melanoma in 2008 were very limited, either chemotherapy—which had limited efficacy, or an early form of immune therapy, high-dose interleukin-2, which required two five-day hospital stays, with one week off in between, followed by scans to see the results of the treatment.

Mr. Metz chose to proceed with the interleukin-2, but after completing the standard of care, his scans did not show any changes in the tumor.

Dr. Kluger recommended Mr. Metz visit the National Cancer Institute (NCI) in Bethesda, Maryland for an investigational treatment where he would be considered for a trial for tumor infiltrating lymphocyte therapy (TIL), which activates immune cells to recognize and attack cancer cells. This modality was not available at the time at Yale, but it is now.

Unfortunately, Mr. Metz’s blood test revealed high liver enzyme levels from the tumor in his liver which indicated he was not a candidate for the TIL investigational trial. Instead, the doctors at NCI recommended surgery to remove as much of the tumor on his liver as possible. They also explained that there was a small chance (15-20%) he would not survive the surgery. Considering his chances of survival without surgery were 2-3 months, it was an easy decision.

“The liver is one organ that can actually grow back,” explained Mr. Metz. “The doctors thought that taking out the tumor would allow the liver to recover, and with normal liver enzyme levels, I might be able to get into the TIL study.”

Following the surgery, Mr. Metz continued to return to Bethesda periodically for the next three years for scans and checkups.

“All was well,” said Mr. Metz, “until a scan showed that the melanoma had metastasized to my brain. I was devastated because I had been thinking that if something happened, the TIL treatment would be my savior. And now, brain mets (metastases) would preclude me from getting that treatment.” The doctors at the NCI recommended Mr. Metz return to Yale for further treatment.

Mr. Metz called Dr. Kluger, who explained the available options and introduced him to Dr. Veronica Chiang, a neurosurgeon, in March 2011. After further consultation, Dr. Chiang recommended he come in for a gamma knife procedure.

The gamma knife treatment allows a team of radiation therapists and neurosurgeons to give high doses of radiation to a very small part of the brain. As an outpatient procedure, it gives radiation to a very precise area, only exposing the surrounding tissue to limited amounts of radiation. After his first procedure, Mr. Metz was able to return home the same day.

“After the treatment, my life pretty much went back to normal again.”

It was at this time that Mr. Metz wanted to make a difference. He decided to start The Brain Metastasis Fund to raise money and support Yale Cancer Center’s multidisciplinary research, helping to bridge the gap between basic research scientists and those doing clinical and translational research.

“My doctors had been great to me and I wanted to pay them back. I relied on my former experience working in the insurance and financial industries to begin this initiative. I invited 100 people to a party in my back yard. Seventy-five showed up and we started raising money. To date, we have raised over $700,000 from private donations,” said Mr. Metz.

In 2013, during one of Mr. Metz’s checkup scans, another small brain metastasis was identified.

“I had another gamma knife treatment,” recalled Mr. Metz. “And I understood that should another one pop up, this treatment could take care of me. Dr. Chiang told me she also could use microsurgery to treat small lesions. I just have to keep having scans to stay ahead of the cancer. “

”The brain mets kept popping up – in one month, I had eight treated by gamma knife.”

In fact, one of the major research initiatives resulting from The Brain Metastasis Fund was the ability to support trials that the pharmaceutical industry was not willing conduct themselves. The purpose was to provide access to promising drugs prior to their approval by the Food and Drug Administration. One such class of immune therapy, inhibitors of PD-1, was looking highly promising, but patients with brain metastases were excluded from those trials. The Yale team therefore initiated the first study of pembrolizumab, commercially known as Keytruda, for patients with brain metastases from melanoma or lung cancer. In 2014, Mr. Metz was accepted into this clinical trial.

After starting on Keytruda, which at the time was a much higher-strength version of the drug than what is offered today, no brain metastases developed. However, Mr. Metz could not tolerate the higher dosage and he was pulled off the trial and instead placed on the FDA-approved dosage of Keytruda, which allowed stabilization of the disease and Mr. Metz to recover functionally to how he is today.

“I have the highest regard for Dr. Kluger. She is incredibly smart and talented. And she’s never given up on me. She continues to find new ways to keep me going. Today, I’m still on Keytruda along with phenobarbital to lessen the side effects. If it wasn’t for her and her team, I would not be alive today.”

“I have served as co-chair of the patient advisory council at Yale New Haven Hospital for two years, and continue working with other volunteers as a member of the council to improve the patient-family experience at the hospital, making it a more welcoming environment. On a more personal level, I have given some of my healthy tissue and some cancer tissue to the NCI for its research work.”

“I also work with other patients who have melanoma. My feeling is that patients need to become experts on their disease. They need to know the right questions to ask in order to get the best answers. They need to know the options they have. They need to understand that they will have good days and bad days. Good scans and bad scans. And they need to surround themselves with friends and family, who can support them.”

Mr. Metz cherishes the encouragement and assistance that his wife of 45 years, his two sons, and his grandchildren have given him.

“They continue to be my greatest joy. I treasure the time I get to spend with my family. My cancer has changed my perspective and my life. I have looked at myself and set new priorities. I am fortunate to be surrounded by good doctors, a wonderful family and many friends. I know that there is a tremendous amount of work being done in the research field. That gives me hope that someday I will be totally healed.”