Cancer treatment extended Jimmy Carter's life before his 100th birthday

Nine years ago, Jimmy Carter held a press conference at the Carter Center in Atlanta to discuss his cancer diagnosis and treatment.

Carter, then 91, explained that a severe cold last May led to a thorough examination that led to a diagnosis of melanoma, an extremely dangerous form of skin cancer, in early August 2015. He underwent liver surgery earlier this month and doctors identified four places where the cancer had spread to his brain.

If his diagnosis had been made a few years earlier, he would have had about six months to live.

Instead, the former president celebrates his 100th birthday on Tuesday.

Of course luck played a role. But there is no question, experts say, that he is still alive today thanks to the immunotherapy he received.

“It's a trite term, but in many ways it's kind of the poster child for immunotherapy,” said Dr. Stephen Hodi, who directs the Melanoma Center and the Immuno-Oncology Center at the Dana-Farber Brigham Cancer Center in Boston. “There were so many problems that he modeled as a patient.”

More:Jimmy Carter, America's longest-living president, celebrates his first year of hospice care

At the time, the treatment was a new addition to the cancer arsenal.

Just four years earlier, the Food and Drug Administration had approved the first so-called checkpoint inhibitor, the generic name ipilimumab. Carter received the second drug of its kind, pembrolizumab, which was only approved a year before he was given it.

These treatments and other cancer immunotherapies are now among the most important pillars of cancer treatment alongside surgery, chemotherapy and radiation – not only for melanoma, where this approach was first established, but also for dozens of other tumor types.

Like any other patient

Dr. David Lawson said he treated Carter with pembrolizumab because the former president is still incredibly healthy and resilient at 91.

In the Aug. 20 news conference, Carter said his only regret about his cancer treatment was that it might interfere with a planned trip to Nepal on behalf of the charity Habitat for Humanity.

Lawson, who works at Emory University's Winship Cancer Institute, said he believes he treated Carter the same way he would have treated anyone else.

“The best favor you can do for a famous patient is to forget that he is famous. Cancer doesn’t care,” he said. “I hope it didn't change the way we treated President Carter. We definitely tried not to let it happen, but you never know.”

Lawson said he stopped Carter's pembrolizumab after six months, even though he would normally give it for two years. The former president seemed to respond well and had been exposed to many people, so Lawson didn't want his immune system to be compromised.

Carter's treatment was “on the cusp” of when doctors first realized how effective the treatments could be, said Hodi, who conducted the first clinical trials of the drugs.

When Carter was treated in 2015, Hodi said it was still unclear whether patients whose cancer had spread to the brain would benefit. There were fears that the drugs would cause brain inflammation and worsen patients' conditions, while doing nothing to affect their tumors.

Research by Hodi and others has since shown that, like Carter, many patients with brain metastases from melanoma can benefit from checkpoint therapy. But today, Hodi said, he would give most patients both pembrolizumab and the previously approved drug called ipilimumab.

Lawson said he wanted to be aggressive in Carter's treatment, but not too aggressive.

“That’s why we stopped (the pembrolizumab),” Lawson said. “You never stop worrying, but at one point we thought, 'He's probably cured of this.'”

Never too old

Age is not a barrier to treatment with immunotherapies.

Dr. Antoni Ribas, a melanoma specialist who directs the tumor immunology program at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles, said he has given checkpoint inhibitors to patients as young as 96 or 97.

Although older people have weakened immune systems, the fact that the drugs can be effective at such an advanced age shows that the immune system remains active throughout life, he said.

“The fact that people in their 80s and 90s can get rid of metastatic melanoma shows us that the immune system is pretty remarkable,” Ribas said. “I wouldn’t underestimate the immune system of a 90-year-old.”

Still, doctors tend to be quicker to grant older patients “medication holidays” if they suffer side effects, he said. This term refers to patients taking a break from medications and can be used to assess how well a therapy might work, to alleviate side effects, and more.

Overall, only about 1 in 20 patients experience serious side effects from immunotherapies, with skin rashes and flu-like fatigue being the most common relatively minor factors.

The “C” word: healing

In addition to immunotherapy and liver surgery, Carter received radiation treatments for the four tiny tumors discovered in his brain. But Lawson, Hodi and Ribas agree that without pembrolizumab he wouldn't have lived much longer than six months.

“The life expectancy of a person with liver and brain metastases is months, even after radiation and surgery,” Ribas said. “Unleashing the immune system can lead to a normal life.”

Pembrolizumab and ipilimumab – nicknamed “Pembro” and “IPi” – are called checkpoint inhibitors because they remove the brake or checkpoint that cancer places on the immune system and allow the “soldiers” of immunity to latch onto the immune system To do work in the fight against cancer.

Other forms of immunotherapy, many of which are still in development, use the immune system in different ways. Some initially attract immune soldiers to the tumor site, while others target other immune tools.

About half of patients with this extremely dangerous type of skin cancer respond well to immunotherapy, according to a study published earlier this month in the New England Journal of Medicine. Of the patients who survived three years without cancer progression, the study showed that 96% were still alive seven years later if they had received both ipilimumab and a pembrolizumab-like drug called nivolumab; 97% were alive when given nivolumab alone and 88% were alive when given ipilimumab alone.

Without these immunotherapy drugs, perhaps one in 20 patients would have the chance to live longer than about six months, Ribas said.

Still, like other cancer doctors, Ribas doesn't want to create unrealistic expectations for his patients: “I think we need to start using the word 'cure.'

At this point, Ribas and others believe that whatever ultimately kills Carter will not be melanoma.

Looking ahead

Researchers are still trying to make immunotherapies effective for more melanoma patients and more people with other types of cancer.

Cancer treatment extended Jimmy Carter's life before his 100th birthday

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