Dr. Julie Graff and Army veteran David Atkinson discuss how genomic (biomarker) testing identified a rare tumor mutation that led to a more effective, targeted treatment after an unsuccessful clinical trial. They explain the difference between inherited genetic testing and tumor genomic testing, emphasizing how biomarker testing can personalize treatment decisions. Together, they encourage patients to ask about genomic testing, explore their treatment options, and advocate for themselves throughout their cancer journey.
Dr. Julie Graff:
My name is Julie Graff. I'm a medical oncologist at the VA Portland, and at Oregon Health, and Science University. I design, and conduct clinical trials at the VA. I have a special interest in what we call precision oncology, meaning matching the right patient to the right trial. Some prostate cancer tumors have changes in their DNA that make them vulnerable to certain medications we have, and we try to match those mutations to the right medications. I'm going to introduce one of my favorite people in the world, David, who is a patient of mine from the VA Portland, used to be a patient of mine at OHSU, and he's had a long journey with prostate cancer, and is going to tell us a little bit about himself.
David Atkinson:
Hi there. My name is David Atkinson. I am an army veteran. I served in the 80s, and 90s, and came off of active duty in 1993. I spent most of my time in Europe initially, and then in Desert Storm. I have been a patient of Dr. Graff's for about seven years now. I have stage four metastatic prostate cancer that I was diagnosed with in December of 2018. And my initial care was at another clinic. Then at the urging of many people, I went to Oregon Health Sciences University, OHSU, a private hospital here in Portland, Oregon, and met Dr. Graff. I've been under her care since about September of 2019. And it has been amazing the quality of care I have received with her, and her staff here at the VA hospital in Portland.
Dr. Julie Graff:
You touched on a little bit on your prostate cancer journey. I did meet David as he said at Oregon Health, and Science University, and the treatments David was receiving for his prostate cancer at that point just weren't working. David, when you were diagnosed, we knew that we couldn't cure the cancer because it had already spread to the bone. And so we were working on treatments to help keep your quality of life good, and help you live as long as possible. We put you on a trial there that unfortunately didn't really work out, but interestingly, it turned out that the reason it wasn't working is that you were getting the placebo, meaning non-active treatment. And we got you over to the VA to get active treatment, and your cancer responded very, very well.
So, we hit a turning point at OHSU when that trial wasn't working, and that's when we did a special test called genomic testing, or next gen sequencing, or science people say genetic testing on the tumor itself to see if there were any changes in the tumor that we could target with some of our medication. And before we got the results of that, David, what were you thinking when I said the clinical trial wasn't working, and we needed to find something new, and we had a nice conversation with you, and your wife, Trish. What was going on in your mind at that time?
David Atkinson:
When you told me the trial wasn't working, I think we pretty much knew that because of the fact that I wasn't doing very well at all. And then you had the discussion with me, and my wife about doing genetic testing to see if we could figure out what would be a better course of treatment. The interesting part of the genetic testing after you did it was the fact that it came back, and said that the medication that I was on with the trial is the one that should work.
Dr. Julie Graff:
Yeah.
David Atkinson:
So, you, and I deduced at that moment that there's a really good chance I'm on a placebo, and not actual medication because you were convinced after doing your genetic testing that this should work for me. And that's the moment where we decided, you decided we decided to take me off of the trial, and put me directly onto the medication.
And that's when through our discussions, you looked at me, and you said, "You're a veteran, go next door." And now the Portland VA Hospital is next door to OHSU You said, "Go next door, get enrolled, and we'll treat you over there," which is what I ended up doing. So, in December of 2020, we started on this medication that I have now been on for six, and a half years, and has had very good results for me.
Dr. Julie Graff:
Awesome. I mean, one thing I think is confusing for providers, and patients is we're talking about these genetic tests, and looking for mutations, and I'll just say there's different types of genetic, and genomic tests. So, DNA in our whole bodies, and then there's DNA in the tumor. There's always more mutations in the tumor DNA because cancer is a problem with mutations. It starts growing. One cell grows over, and over, and over when it shouldn't be, and forms a tumor.
So, let's just clarify genetic testing is when you look for genes that could have come from your parents, and could be passed on to your kids. If you have a mutation that's genetic, it's present in all your cells versus genomic is just changes in the tumor itself.
And David, in your case, you had a mutation, and we call it a mismatch repair deficiency where your DNA, and your tumor couldn't repair itself, and that's why you got the cancer. But we also did that test because we wanted to know if your beautiful granddaughter needed to worry to see if that mutation was present in all of your cells, and it was not, thankfully it was just in the tumor itself.
So, if you didn't have this change in the biomarker, or the mutation, and we gave you the drug you're getting now, it wouldn't work. It's because you have that mutation in the tumor that it works. So, what was it like when the results came back, and we talked about how there's another treatment option for you?
David Atkinson:
Are you talking now, or back then?
Dr. Julie Graff:
I'm talking, I still remember calling you in 2020 when we were looking at the results, and maybe it's a silly question, but maybe just for the audience, I didn't know the results yet like David, and I, and David, and his wife Trish, and I were talking, and during our conversation I looked at that part of the patient record where there's results, and it must have just come back, and it showed this mutation that's present in 3% of patients with prostate cancer, so incredibly unlikely. And I was like, "David, hold on a second. I have an idea for you." And that's the moment I think we both realized you must have been on the placebo arm.
David Atkinson:
Yes, I believe you're correct with that. And then from kind of that moment, because as we said earlier, up to this point while I was on the trial, you were adamant, you were insistent that this should work based on all the research that you had done. And so when we finally got the results, that's when we both looked at each other I think, and said, "Okay, time to go to plan B."
And I would say for anybody dealing with prostate cancer, or any other issues of cancer, always be discussing with your provider what your options are. You, and I have had to have the discussions over the years of, "Okay, we're going to try this, and now we're going to try that." And so far it's been extremely positive, and we're still here to talk about it. But yes, back in 2020 when we had to make that decision to take me off of the trial, and put me directly onto this drug, I think there was both a lot of relief from both your side, and my side because we finally had what we felt was a good path forward in trying to treat this.
Dr. Julie Graff:
So, it's like actually what's really important I think is even though it's super rare, it's super important to know if that mutation's present, and if patients kind of... Actually, I had someone who was not an oncologist talking to me once who said maybe testing for these mutations was a fad. I was like, "I really don't think so. I think this has the ability to really change someone's life."
David Atkinson:
One wonderful thing about you, Dr. Graff, is that you truly believe in research, and finding answers when problems present itself, which happens a lot in the cancer world. And so the fact that you were very adamant about making sure that we did the genetic testing, or biomarker, or whatever the technical term is, and you've always been doing that for me, probably me, and any other patients you deal with in the VA system, it's a very important part of this process, and I don't think that I would be sitting here today talking to you, and anybody else if it wasn't for the quality of research, and testing that you do over time.
And so you've been wonderful with doing that. And so I think that any kind of testing that the VA system can do for veterans, and any research that you, and your team get to do is extremely helpful to helping us veterans have a quality of life as we deal with the health issues that we have.
Dr. Julie Graff:
Thank you, David. One point that comes up as we're talking is I had a patient last week where I wanted to do genetic testing to see if there were any changes that could have come from his parents, and go down to his kids, and he was worried. He didn't want the testing done. Do you have any advice? I think people get worried because they may find out things they don't want to know, or they think that the insurance will kind of drop them, or that's going to be a sub big consequence. Do you have any advice for those people?
David Atkinson:
I would just highly recommend to always have the testing done as mildly painful as some of it can be from time to time, but you were very insistent adamant that I have the genetic testing mainly so that I could make sure that my children, I have two sons, and a daughter, but my two sons... I didn't have any genetic markers to pass along prostate cancer to any of my sons. And in the history of my family, both up my parents' side, and of course down, we've never had any history of cancer, but it was still important to you to make sure I got tested to make sure my children were safe.
So, I would always recommend to any veteran when your doctor recommends to have genetic testing, it's to keep you safe anybody in your family, any offspring, anything like that, just to make sure that they don't possibly have issues in the future.
Dr. Julie Graff:
Thank you, David. And thank you for being here today to talk to me about your experience, and the genetic genomic testing.
David Atkinson:
I appreciate being here today, and let's hope with all the amazing things that you, and your wonderful team at the VA is doing, that I get to do this again in a few more years because I'll still be here.
Dr. Julie Graff:
I love it.
David Atkinson:
Thank you.
Dr. Julie Graff:
Definitely. All right. Bye, David.
David Atkinson:
Bye-bye.
This interview was produced with the generous support of AstraZeneca Pharmaceuticals