A rich reward

A rich reward

Mike Ritchey is healthy, happy and cancer-free thanks to an innovative clinical trial at Providence Cancer Institute combining immunotherapy and radiation therapy for patients with head and neck cancer.

“What about immunotherapy?”

Those three words changed Mike Ritchey’s life.

Ritchey had been diagnosed with head and neck squamous cell carcinoma, commonly referred to as head and neck cancer. The 75-year-old saw his primary care doctor about a small bump on his neck. “It was just a tiny knot,” said Ritchey. But after an ultrasound revealed it was cancer, Ritchey found himself in the office of Allen Cheng, M.D., D.D.S., FACS, a head and neck surgeon affiliated with Providence Cancer Institute. With his wife Susan at his side, Ritchey learned his outlook was promising. The cancer was detected very early, before it had spread. Dr. Cheng reviewed the standard treatment: surgery to remove the cancer, followed by a long course of chemotherapy and radiation therapy. “Dr. Cheng gave me the gruesome details of what was going to be my immediate future,” said Ritchey. “And it sounded awfully rugged, and he told me it was. He didn’t pull any punches.” They scheduled the surgery.

Then, just as they were leaving, Ritchey remembered those forward-thinking, progressive treatments he’d read about. A retired newspaper publisher and journalist, he’d always been interested in medical advances. “What about immunotherapy?” he asked.

Dr. Cheng stopped in his tracks. He shares a clinical practice with Bryan Bell, M.D., D.D.S., FACS, associate member and medical director, Providence Head and Neck Cancer Program and Clinic. Dr. Bell and his colleagues at Providence Cancer Institute are leaders in immunotherapy for head and neck cancer.

“I know of a clinical trial about to get started,” said Dr. Cheng. “They’re looking for participants.”

IN THE NAME OF SCIENCE

The illustration on the postcard showed a medical attendant wheeling in a gurney to the surprise of a healthy, living patient. The caption read, “You the guy who donated your body to science?”

It was from Mike Ritchey, with a personal inscription: “Hello, Dr. Leidner. Colorado misses you. See you 11 a.m. July 18.”

“Mike is the first patient to send me a card that he is excited to see me in cancer clinic,” said Rom Leidner, M.D., assistant member and co-director, Providence Head and Neck Cancer Program.

Ritchey’s enthusiasm is well-founded. Dr. Leidner and colleagues saved his life. Ritchey, who lives part of the year in Portland and the rest in Gunnison, Colorado, was due for his postsurgical checkup. “It was really a stroke of luck how it happened,” Ritchey said.

With a referral from Dr. Cheng, Ritchey was the first patient to enroll in a new clinical trial at Providence Cancer Institute for patients with head and neck cancer. “The next thing I know I’m in this clinical trial, meeting Dr. Leidner and Dr. Marka Crittenden. The surgery was the same, except for the beforehand treatments. I only had five light doses of radiation, and 10 immunotherapy treatments – about 15 minutes per treatment.”

Mike Ritchey meets with medical oncologist Rom Leidner, M.D., and oncology research nurse George Morris, RN, for his postsurgical checkup.

A BETTER THERAPY

Marka Crittenden, M.D., Ph.D., associate member and director, Translational Radiation Research, along with Dr. Leidner, Dr. Bell and Kristina Young, M.D., Ph.D., assistant member, Tumor Microenvironment Lab, had long believed a better therapy was needed for patients with head and neck cancer.

Although patients with early stages of this disease benefit from high survival rates, many suffer from lifelong, debilitating side effects. The standard course of treatment – surgery, chemotherapy and radiation – is known to cause dental decay, tooth loss and dry mouth, among other problems affecting quality of life. Many patients find they are unable to continue with everyday social events, like sharing a meal with friends or coworkers.

“We sought to design a trial that offers these patients the same survival outcomes as standard therapy while sparing them from the harmful side effects,” said Dr. Leidner. Together with Drs. Crittenden, Bell and Young, he devised a clinical trial combining immunotherapy and radiation therapy as a means of down-staging cancer before surgery. Dr. Crittenden and colleagues at Providence were among the first to demonstrate a synergy between immunotherapy and radiation therapy in patients with melanoma.

The phase I study, known as NIRT: Neoadjuvant Immuno-RadioTherapy in Head and Neck Cancer, is the first study worldwide to evaluate the safety and effectiveness of radiation therapy and nivolumab, an anti-PD-1 immune checkpoint inhibitor approved for several cancers, given to patients with head and neck cancer before surgery. And, if needed, standard-of-care chemotherapy and radiation would be given following surgery to eliminate any residual microscopic disease.

FROM LEFT: Rom Leidner, M.D., assistant member and co-director, Providence Head and Neck Cancer Program; Marka Crittenden, M.D., Ph.D., associate member, Integrated Therapies Lab, and director, Translational Radiation Research; Bryan Bell, M.D., D.D.S., FACS, associate member and medical director, Providence Head and Neck Cancer Program and Clinic; and Kristina Young, M.D., Ph.D., assistant member, Tumor Microenvironment Lab. Dr. Leidner is principal investigator of the phase I study known as NIRT: Neoadjuvant Immuno-RadioTherapy for Head and Neck Cancer. Drs. Crittenden, Bell and Young serve as co-investigators.

“Instead of broadly radiating the neck and oral cavity – common procedure with standard care, we chose to focus the radiation to the precise location of the cancer,” said Dr. Crittenden. “Normal tissue is spared, such as healthy salivary glands needed to avoid tooth decay and dry mouth.”

Another benefit of radiation therapy is its immune-stimulating function. Radiation has potential to propagate an immune attack against cancer at the radiation treatment site and also against unknown microscopic disease located outside the treatment field.

When combined with a potent PD-1 inhibitor such as nivolumab, radiation is an effective treatment strategy for shrinking cancers before surgery.

OF PRIMARY IMPORTANCE

Eliminating cancer at the treatment site and priming an anticancer immune response against microscopic disease are essential to preventing cancer recurrence, particularly in patients whose primary sites of cancer are unknown. Such was the case for Mike Ritchey. His ultrasound showed a malignant mass in his right neck and three affected lymph nodes, but the origin of his cancer was unidentified. That was until Dr. Cheng performed surgery.

Ritchey had completed his short course of radiation therapy to his right neck and lymph nodes, and received several intravenous immunotherapy treatments. Another presurgical scan indicated the immuno-radiotherapy combination shrunk the cancer in his neck.

But when Dr. Cheng began surgery, what he found was remarkable: Ritchey’s cancer had vanished. The mass on his neck and all affected lymph nodes were cleared of disease. And his right tonsil – which was confirmed as the cancer’s origin – showed evidence of tumor regression despite having received no direct radiation. Ritchey was cancer-free, thanks to immunoradiotherapy, and he felt great. “I never experienced one single side effect, it was just lickety-split,” said Ritchey. “Even friends of mine are wide-eyed, in disbelief, that I’ve never felt bad.”

Through it all Susan was at his side. “We doubleteamed it. She went to every session with me – visits with Dr. Leidner, Dr. Cheng, Dr. Crittenden – taking notes and asking questions. Even though we’ve been married 46 years, our relationship prospered further by the experience.”

With his treatments behind him, they could return to activities they loved, like treks to Mount Tabor Park or strolling along Hawthorne Street, stopping at Powell’s Books. “We’ve always been outdoorsy and active,” recalled Ritchey. “We started coming to Portland because our daughter Marianna went to Lewis and Clark College. She graduated in the late ‘90s, but we just kept coming, because we love Portland so much.”

PERFECT 10

Ritchey is not the only patient to benefit from the innovative study. Ten patients with head and neck cancer were enrolled to the trial. All patients received radiation therapy and immunotherapy followed by surgical resection five weeks later. None experienced unplanned, treatment-related delays to surgery. At the time of surgery, nine patients were found to be cancerfree and one patient had less than 10 percent of cancer remaining, which was removed by surgery. None required chemotherapy or radiation after surgery.

“Our hope with this study was to deintensify treatment for better quality of life. The results have changed everything,” said Dr. Leidner. By changing both the treatment field and therapeutic modalities, Drs. Leidner, Crittenden, Bell and Young have introduced a potential alternative to standard care for patients with early-stage head and neck cancer, offering comparable survival and superior outcomes for tooth loss, dry mouth and other lifelong ailments.

There is no better place to run into cancer than Providence and its powerful squad of healers.

Investigators across the world are taking notice. Dr. Crittenden reported early results at a joint meeting of the American Society of Clinical Oncology and Society for Immunotherapy of Cancer, and Dr. Bell presented the study to the American Head and Neck Society. At the 2019 annual meeting of the American Association for Cancer Research, Dr. Leidner gave an oral presentation at the Clinical Trials Plenary Session. “This study represents a major paradigm shift in the approach to treating locally advanced HPV-positive head and neck cancer,” Dr. Leidner said.

HPV – human papillomavirus – is associated with several cancers, including head and neck cancer. A new study cohort was added to evaluate the treatment strategy in patients with HPV-negative head and neck cancer. HPV-negative patients have the worst survival outcomes for this disease.

AN UPSIDE TO CANCER

Following their brush with cancer, Mike and Susan Ritchey are enjoying all that life has to offer. When not in Oregon or Colorado, they can be found in Massachusetts and Hawaii. Their daughter Marianna teaches musicology at the University of Massachusetts in Amherst, and their son Buck works in construction in Maui.

“I’m just on cloud nine here, riding a big wave, instead of something that could have been entirely different,” said Ritchey. “And don’t think for a minute I don’t realize it.” Ritchey returns to Providence Cancer Institute regularly for checkups with Drs. Leidner and Crittenden.

“I can’t honestly recommend it, but cancer can have an upside,” Ritchey said. “The opportunity to meet the doctors, nurses and staff – had I not gone through this fire, I would have been poorer for it. There is no better place to run into cancer than Providence and its powerful squad of healers. I am indebted to the entire system.”