Our copay program is open again.  If you think you may need help - apply. Do not feel bad about taking advantage of this program. Going through the brain tumor journey is stressful enough. Taking a little off of the expenses may help reduce stress and you will do better! 

 Roon is a new social media site dedicated to patients and families  dealing with high grade brain tumors.     We are considering partnering with them to run our online support groups.. so join it, test it out and let me know what you think of it!

 The GBM Agile trial is a new style clinical trial that screens multiple treatments against each other at the same time, minimizing the number of patients needed for a control group as each of the arms acts like a control to the other arms.    It does personalize by one biomarker - MGMT methylation status.  Currently, some arms only accept unmethylated patients, but most accept any methylation status.  It uses an algorithm to assign a patient randomly to any arm that patient is qualified for, but it is weighted to assign more patients to the trials doing the best and less to the trials not doing as well.   It quickly can tell if a treatment is worthy of graduating to the next level or not. If not, it is dropped from the rotation and another treatment added.    

Unfortunately for Kazia Therapeutics, it's drug, Paxalisib, which was tested by itself did not do well enough to graduate on, and was dropped from the trial.   This does not mean the end of the drug - it just did not perform well enough by itself in the specified circumstance of newly diagnosed Glioblastoma with unmethylated MGMT and recurrent GBM.  

As I have always been saying, I doubt if the cure is going to be a single magic bullet where a drug will work good enough by itself to cure brain cancer.  Instead, I think a rational combination of drugs will be needed and we need access to these drugs which is impossible (or difficult) under the current regulatory system.  This drug, Paxalisib,  is a PI3K inhibitor.  The PI3K pathway is one of the most important regulators of most cancers.  Unfortunately, targeting this pathway by itself is futile. The cancers that are driven by this pathway just mutate around it and use a different pathway when this is blocked.  However the cancers that were driven by this pathway are weakened when they can't use this pathway, giving other treatments a better chance of working.  There were two presentations about this drug being used in pediatric brain cancers, in combinations.     This was mostly in animal models but they presented two DIPG patients who used the combination of Onc-201 and Paxalisib under compassionate use and both demonstrated dramatic reductions in tumor volume (which is very hard to do with DIPG) and complete resolution of symptoms, with extended overall survival.   The combination is now being tested in a clinical trial.

 I love the concept of the GBM Agile trial, but I do not think we are at the stage where we have effective enough treatments to test.  I think what is needed is our "A Patient-Centric Platform Trial for Precision Oncology" to think up and try combinations that are personalized to each patient.  Our team of experts figures out a list of the best possible treatment options. The patient and their doctor decides which one to try. We try to help get access to it. Then we follow up on each patient to see how it works.  It is like a screening trial of combinations.  When we find a combination that works for a specific scenario, that combination should then be validated ina trial like GBM Agile - they would work together symbiotically.

 Two articles came out about this viral therapy that is approved in Japan for Glioblastoma.

The first is a phase 2 study reporting very promising results:   the 1 year survival rate for recurrent Glioblastoma was 84.2%. 16 of 10 patients were alive at the one year mark. This treatment is injected directly into the tumor up to 6 times.   As a result of this study, the treatment was approved in Japan with the name: DELYTACT .   I have been trying to get it for patients here in the USA with no luck but will keep trying!

The second article is the phase 1/2 dose finding study which had less impressive results: the 1 year survival rate was 38% but they did have 2 long term survivors.

 This press release talks about an article in the journal Science, which is behind a paywall so I can't get the details.   The press release says a team of researchers improved upon Temozolomide in such a way that the usual resistance mechanism won't work.   It sounds interesting.

  It appears that they did not take into account the reason why some people continued taking Temozolomide past 12 months - could it be they were in better shape so they continued? Or the opposite - Temozolomide stopped working so they stopped taking it.  This question can only be answered by a randomized blinded trial - I doubt that will ever happen because Temozolomide is generic and such a trial is expensive - and I doubt anyone would volunteer for such a trial.

 This study showed moderate activity in pretreated high grade gliomas.  May be worth considering regorafenib - especially if combined with something.  This drug is approved for other types of cancer but can be used off label for brain - although cost may be an issue.   No treatments really "work" well in this scenario, so it is impressive that this drug showed the results it did. Of course it is not good enough - which is why I say it needs to be combined with something.

 I recently wrote about the exciting results of the expanded access program for this therapeutic vaccine (Sitoiganap - which used to be known as Gliovac or ERC1671). Now the USA FDA granted them Fast Track Designation, which speeds up the USA process for approval!

 This video talks about a new way to reformat the DICOM images from an MRI scan.  The new views show the difference between treatment effects (Pseudo-progression) and tumor growth much better than standard MRIs. They also can show the best spot to do a biopsy, and tell much earlier if a treatment is working or not.   Sometimes these can be applied to the scans you already did (if they happened to do the correct techniques which they commonly do!). 

This is an update from a webinar we had on this topic last year! Well worth watching!

I love research like this. First they figure out how cytotoxic T lymphocytes kill tumor cells. Then they figured out how the tumor cells defended themselves against the T cells.  Then they figured out a way to suppress the defense mechanism, and made the T cells work dramatically better.   The problem is the defense mechanism is also used by normal dividing cells so in this case it might be difficult to create a drug to this vulnerability.  But they are working on it and think they can ultimately solve the problem! I wish them luck.

 Sorry - I did not notice the date on the article!  That was old news!   At least I know people read this newsletter as a few people pointed out the error!

 This edition of the Brain Tumor Guide For The Newly Diagnosed is a huge upgrade from prior version!   Only the electronic edition is available now. We will be sending the files to the printer to get a soft cover version in a few days!  Please let me know if you spot any problems in the guide! We have a few days to correct it before it goes to printer!   IF you order the printed version, we will be sending the old 11th edition of the guide until the new edition is available!

Sitoiganap is a therapeutic vaccine which used to be called Gliovac or ERC1671.  This paper presents the results of the expanded access program for the vaccine on patients with recurrent glioblastoma.  Expanded access programs are not as controlled as a traditional randomized controlled trial, in that they usually allow any patient to enter - whereas the traditional trials cherry pick those patients who would be expected to do well on the treatment. So these patients would be expected to do worse than the historical clinical trial statistics.  Although this is a small study, the results are very exciting. The vaccine more than doubled the median survival to 19.6 months. Other trials are reporting a median survival of about 8 months for recurrent glioblastoma.   The 2 year survival rate was 45% which is excellent. 

With this data, they asked the  European Medicines Agency (EMA) to approve the vaccine for the treatment of Glioblastoma.  Strangely the EMA refused and wants more data.  Seeing how there were minimal side effects and had very good results in a small group, I feel they should have received approval.  Probably the same thing would happen here with our FDA.  This is outrageous and we should fight to get the regulations changed. Our Promising Pathway Act is designed just for these types of treatments - it really is too early to tell how well it works, but with no side effects and early indication of success, how could a regulatory agency tell us that they will not allow us access to treatments like this.  As with all previously approved brain tumor treatments, we never really find out how they work until after approval and they are used in combinations and on average patients.

 This is one of the most important papers of the year.   They look at the mechanisms of action of Optune and come up with ideas to improve the effectiveness of Optune.  My favorite is where they talk about 5-ala.  5 ala is a dye, approved as Gleolan to be used during brain tumor surgery to help the surgeon tell the difference between tumor and normal brain. The dye accumulates in tumor only.   Optune increased the concentration of the dye in the tumor but not in the normal brain, so to start with - combining Optune and Gleolan for a surgery would seem helpful. However, there are new clinical trials going on now where 5-ala is used in a new way called sonodynamic therapy.  They give the 5-ala then wait for the tumor to take up the dye, then they treat the tumor noninvasively with focused ultrasound. The focused ultrasound excites the dye causing it to kill the tumor cells.    Too early to tell how good it is by itself but imagine the possibility of easily increasing it's effectiveness just by using Optune while waiting for the dye to be taken up by the tumor?  They also talk about Optune opening the blood brain barrier letting chemotherapies in that couldn't pass the blood brain barrier by themselves. This opens up a lot of possibilities.  They also talk about the immune effects - possibly adding a checkpoint inhibitor may help with that. They talk about the effect Optune has on migration and movement of cancer cells. It slows them down.  The problem we have with drugs like Avastin is they cut off the blood supply to the tumor, which causes the tumor cells to migrate towards a better oxygen supply.  Imagine if we add Optune - to stop that migration. Perhaps the combination (which is being tested now in trials) could be a home run by starving the tumor cells and stopping them from invading the normal brain.

The best part of all of this is that all of the components are FDA approved and could possibly be used off label. Our patient navigation program is probably the best way to screen all of the possibilities!

 This is early research but interesting.  If it is true, I doubt it is a major cause as then we would see a geographic distribution of brain tumors that mimics the distribution of Lyme disease cases which we do not see.  However, if there is a link, that may be the reason Doxycycline might help brain tumors.  Doxycycline is an old oral antibiotic - very safe - that is used in the treatment of Lyme disease which is caused by a bacteria.   It is also part of the Care Oncology Glioblastoma Protocol, which is a cocktail of repurposed drugs used to treat Glioblastoma - and which has reported some success!

 The NCCN is the most trusted source for treatment information about all types of cancers. They just published their recommendations for pediatric brain tumors.   They basically recommend clinical trials for all brain tumors.  In an ideal world, I would disagree and try for a cocktail approach with unapproved drugs, but that is impossible for most patients, so the best course of treatment now for pediatric brain tumors is clinical trials.   Even for those "curable" tumors - there are clinical trials going on that try to eliminate the long term side effects of treatments.

 This is another form of Sonodynamic Therapy - as I mentioned recently, this is one of the most promising new therapies for brain tumors.  It is noninvasive, and can be repeated if needed.  This trial is https://clinicaltrials.gov/ct2/show/NCT05362409 which is "Study to Evaluate 5-ALA Combined With CV01 Delivery of Ultrasound in Recurrent High Grade Glioma". Eligible patients have recurrent grade 3 or 4 brain tumors including Oligodendroglioma, anaplastic astrocytoma and Glioblastoma! this trial excludes DIPG but the other sonodynamic therapy trial I recently mentioned does allow DIPG.

 This article talks about using electric field delivery via implanted electrodes. Interesting to think about the best way to approach these therapies - implant electrodes and a battery, or noninvasively, with arrays.   Most patients have to make the decision about Optune early in their journey before they realize how serious their glioblastoma is and at first do not like the idea of shaving their heads and wearing arrays - some refuse to use it at first only to accept it when they realize that their lives are at stake but by then it is too late to even bother trying. Compare that to having electrodes implanted into the brain with possible short or long term complications. Hard decisions.