Dec. 10: Emma Whitehead has been bounding around the house lately, practising somersaults and rugby-style tumbles that make her parents wince.
It is hard to believe, but last spring Emma, then 6, was near death from leukaemia. She had relapsed twice after chemotherapy, and doctors had run out of options.
Desperate to save her, her parents sought an experimental treatment at the Children’s Hospital of Philadelphia, one that had never before been tried in a child, or in anyone with the type of leukaemia Emma had. The experiment, in April, used a disabled form of the virus that causes AIDS to reprogramme Emma’s immune system genetically to kill cancer cells.
The treatment very nearly killed her. But she emerged from it cancer-free, and about seven months later is still in complete remission. She is the first child and one of the first humans ever in whom new techniques have achieved a long-sought goal — giving a patient’s own immune system the lasting ability to fight cancer.
Emma had been ill with acute lymphoblastic leukaemia since 2010, when she was 5, said her parents, Kari and Tom. She is their only child.
She is among just a dozen patients with advanced leukaemia to have received the experimental treatment, which was developed at the University of Pennsylvania. Similar approaches are being tried at other centres, including the National Cancer Institute and Memorial Sloan-Kettering Cancer Center in New York.
“Our goal is to have a cure, but we can’t say that word,” said Dr Carl June, who leads the research team at the University of Pennsylvania. He hopes the new treatment will eventually replace bone-marrow transplantation, an even more arduous, risky and expensive procedure that is now the last hope when other treatments fail in leukaemia and related diseases.
Three adults with chronic leukaemia treated at the University of Pennsylvania have also had complete remissions, with no signs of disease; two of them have been well for more than two years, said Dr David Porter. Four adults improved but did not have full remissions, and one was treated too recently to evaluate. A child improved and then relapsed. In two adults, the treatment did not work at all. The Pennsylvania researchers were presenting their results on Sunday and Monday in Atlanta at a meeting of the American Society of Hematology.
Despite the mixed results, cancer experts not involved with the research say it has tremendous promise, because even in this early phase of testing, it has worked in seemingly hopeless cases.
“I think this is a major breakthrough,” said Dr Ivan Borrello, a cancer expert and associate professor of medicine at the Johns Hopkins University School of Medicine.
Dr John Wagner, the director of paediatric blood and marrow transplantation at the University of Minnesota, called the Pennsylvania results “phenomenal” and said they were “what we’ve all been working and hoping for but not seeing to this extent”.
Drug company Novartis is betting on the Pennsylvania team and has committed $20 million to building a research centre on the university’s campus to bring the treatment to market.
Hervé Hoppenot, the president of Novartis Oncology, called the research “fantastic” and said it had the potential — if the early results held up — to revolutionise the treatment of leukaemia and related blood cancers.
Researchers say the same approach, reprogramming the patient’s immune system, may also eventually be used against tumours like breast and prostate cancer.
To perform the treatment, doctors remove millions of the patient’s T-cells — a type of white blood cell — and insert new genes that enable the T-cells to kill cancer cells. The technique employs a disabled form of HIV because it is very good at carrying genetic material into T-cells. The new genes programme the T-cells to attack B-cells, a normal part of the immune system that turn malignant in leukaemia.
The altered T-cells — called chimeric antigen receptor cells — are then dripped back into the patient’s veins. If all goes well, they multiply and start destroying the cancer.
The T-cells home in on a protein called CD-19 that is found on the surface of most B-cells, whether they are healthy or malignant.
A sign that the treatment is working is that the patient becomes terribly ill, with raging fevers and chills — a reaction that oncologists call “shake and bake”, Dr June said. Its medical name is cytokine-release syndrome, or cytokine storm, referring to the natural chemicals that pour out of cells in the immune system as they are being activated, causing fevers and other symptoms.
The storm can also flood the lungs and cause perilous drops in blood pressure — effects that nearly killed Emma.
Steroids sometimes ease the reaction, but they did not help Emma. Her temperature hit 105. She wound up on a ventilator, unconscious and swollen almost beyond recognition, surrounded by friends and family who had come to say goodbye.
But at the 11th hour, a battery of blood tests gave the researchers a clue as to what might help save Emma: her level of one of the cytokines, interleukin-6 or IL-6, had shot up a thousand-fold. Doctors had never seen such a spike before and thought it might be what was making her so sick.
Dr June knew that a drug could lower IL-6 — his daughter takes it for rheumatoid arthritis. It had never been used for a crisis like Emma’s but there was little to lose. Her oncologist, Dr Stephan A. Grupp, ordered the drug. The response, he said, was “amazing”.
Within hours, Emma began to stabilise. She woke up a week later, on May 2, the day she turned 7; the intensive-care staff sang “Happy Birthday”.
The research is still in its early stages, and many questions remain. The researchers are not entirely sure why the treatment works, or why it sometimes fails.
For the patients who had no response, the team suspects a flawed batch of T-cells. The child who had a temporary remission apparently relapsed because not all of her leukaemia cells had the marker that was targeted by the altered T-cells.
The cells do have a drawback: they destroy healthy B-cells as well as cancerous ones, leaving patients vulnerable to infections, so Emma and the other patients need regular treatments with immune globulins to prevent illness.
So far, her parents say, Emma seems to have taken it all in stride. She went back to school this year with her second-grade classmates, and though her grades are high and she reads about 50 books a month, she insists impishly that her favourite subjects are lunch and recess.
“It’s time for her to be a kid again and get her childhood back,” Tom Whitehead said.