Tailored Treatment Brings Physician’s Leukemia into Remission
During a regular day off in December 2010, Anjuli Nayak, MD, received a phone call from her secretary informing her that results on Nayak's blood test came back flagged with a high value. The white blood count measured 22,000 -- more than twice the upper limit of normal.
"I felt shocked and bewildered," said Nayak, an allergist/immunologist with a practice in Bloomington-Normal, Ill. "I wasn’t sick and I didn’t have any symptoms, but I knew I had leukemia."
By that evening, she and her family huddled together in their Bloomington home to discuss options and treatment plans. Nayak’s husband, Nicholas, is a retired emergency medicine physician now engaged full time in research. At the time, their oldest son, David, was an internal medicine resident. Their middle son, Zachary, was in medical school and their youngest son, Luke, then a high school senior, was applying to six-year medical school programs.
"My husband and sons generated many medical papers from the Internet and searched the country for the best leukemia program," Nayak said. The family was considering going to Texas when Zachary called one of his medical school mentors for advice. She suggested his mother talk to Wendy Stock, MD, a hematologist/oncologist at the University of Chicago Medicine and a nationally known authority on leukemia.
Stock spent 90 minutes on the phone with Nayak, who had many questions. "I am a doctor, but I had never been on an oncology unit," Nayak said. "Dr. Stock described what the University of Chicago Medicine had to offer but said I should go wherever I felt comfortable. My church held a prayer service for me and when I got up from my knees, the answer was the University of Chicago. I called Dr. Stock and said ‘I’ll be there tomorrow.’"
Groundbreaking Research, Clinical Trial and Targeted Therapy Contribute to Patient’s Positive Outcome
A team of specialists working with Stock conducted a series of studies to identify the exact type of leukemia and to determine if any genetic abnormalities were present. Nayak was diagnosed with acute lymphoblastic leukemia (ALL), an aggressive type of cancer of the blood and bone marrow that can quickly spread to the fluid that bathes the brain and the spinal cord. Genetic analysis showed the leukemia tested positive for the Philadelphia chromosome, a mutation that results when breaks occur in each of two chromosomes and genetic material switches places to create a "fusion" gene. This new gene codes for a protein that causes leukemia.
In the 1970s, University of Chicago geneticist, Janet Rowley, MD, showed that these "chromosomal translocations" were a trigger for development of leukemia and other cancers. This pivotal discovery laid the groundwork for better diagnostic techniques and, more recently, for treatment protocols targeted to specific cancers.
"At the University of Chicago Medicine, we have always been focused on the underlying biology of leukemia," Stock said.
Drawing on scientific knowledge and extensive clinical experience, Stock’s leukemia team designed the best possible treatment plan for Nayak. "They told me the therapy was going to be rough and that I would be quite sick for awhile," Nayak recalled. When her sons asked her what she wanted to do, she responded, "I want to live for my husband and for my children. I don’t want cancer to snatch my life away from you."
The frontline treatment for patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) involves chemotherapy (to bring the cancer into remission) and stem cell transplant (to completely eradicate the leukemia).
The initial therapy tailored for Nayak included a combination of traditional chemotherapy as well as dasatinib (Sprycel ®), a pill that specifically targets Ph+ ALL. Dasatinib inhibits the abnormal protein (produced from the Philadelphia chromosome) that activates the growth and spread of the disease. According to Stock, dasatinib has improved remission rates and survival for patients with Ph+ ALL. Drugs of this class have been available since the late 1990s when imatinib (Gleevec®) was first approved to treat chronic myeloid leukemia (CML), another Philadelphia chromosome-positive leukemia. Dasatinib, a second generation of imatinib, was introduced in 2006. The University of Chicago Medicine was among the first centers in the country to test both of these highly effective medications.
The medical team felt that the best chance for cure was to proceed with a transplant after remission and to continue dasatinib following transplant. Because a fully-matched donor was not available for her transplant, Nayak was offered an opportunity to enroll in a unique clinical trial: a National Cancer Institute-sponsored research study involving transplantation of stem cells from both a half-match donor and from donated umbilical cord stem cells.
"This approach allows us to make transplant available to patients who do not have complete immunological matches," Stock explained. "The half-matched (haploidentical) stem cells engraft quickly and produce blood cells for a limited time. They provide the bridge needed to allow the umbilical cord cells to take hold for the long term. During the trial, we saw a seamless transition of haploidentical to cord engraftment." In December 2011, Stock and other University of Chicago Medicine investigators published a paper on the first 45 patients in the U.S. to undergo this type of transplantation. In addition to quick engraftment, study results showed low risk of graft vs. host disease (GVHD) and lasting remissions in many high-risk patients. Nayak, who received her half-match cells from Zachary, was among the initial group of patients in the trial.
After Cancer: Recovering, Rebuilding and Restoring
Nayak restarted dasatinib treatment in August of 2011 and has no measurable evidence of lingering leukemia. She continues to take the dasatinib pill daily and tolerates it very well. Using highly sensitive and sophisticated diagnostics, the medical team now checks her blood monthly to be sure no cancer cells are detected. As her immune system recovers and rebuilds, Nayak focuses on restoring her health through exercise and nutrition. She regularly speaks at churches and women’s retreats about her medical journey and tells her audiences that while her life is dramatically different, it has never been so good.
"I thank the Lord, as he opened the doors at the University of Chicago, for saving my life," she said. "I am so grateful to the leukemia transplant team for the care, compassion and courage received from the doctors and nurses. They have given me a rebirth, for which I am eternally grateful."