Promising New Treatments for Melanoma

Desiree Ratner, MD
Director, Comprehensive Skin Cancer Program
Mount Sinai Beth Israel
Director, Dermatologic Surgery
Mount Sinai Beth Israel, Mount Sinai St. Luke's, and Mount Sinai Roosevelt


Promising New Treatments for Melanoma

It can be frightening to learn you have melanoma, the least common but most dangerous form of skin cancer. When caught in its early stages, melanoma is almost always curable with surgery, but when it metastasizes -- that is, spreads to other areas of your body -- it is notoriously difficult to treat.

In the past, patients diagnosed with the most advanced stages of melanoma usually had only a few months to live. However, metastatic melanoma is no longer the automatic death sentence that it once was. Chemotherapy, once the standard (but largely ineffective) treatment for advanced melanoma, is giving way to new, more successful therapies that are prolonging survival and improving patients' quality of life.

The promising new drugs approved by the U.S. Food and Drug Administration (FDA) in just the last few years fall into two classes: targeted molecular therapy and immunotherapy. The side effects of both tend to be much more tolerable than those of chemotherapy.

Targeted Molecular Therapy

About half of patients with metastatic melanoma have tumors whose cells contain a genetic mutation, most commonly in a gene called BRAF. As its name suggests, targeted therapy attacks and kills those particular mutated cells.

A recent study of one of the newest targeted drugs, nivolumab, found that 32 percent of patients responded to it and, in a third of those patients, the effects lasted six months or longer. This is good news, considering chemotherapy's traditional response rate of only 5 to 20 percent. In fact, the results represented such a significant improvement over previously available drugs that the FDA approved nivolumab three months ahead of schedule, in December 2014.

When targeted drugs work, the tumors shrink for a time, allowing patients to live normally for a while, rather than feeling continuously ill. Unfortunately, this type of drug eventually stops working for many patients as their genes undergo further mutations. To address this issue, researchers are investigating combinations of targeted therapies.

The New England Journal of Medicine, for example, recently published promising results of a study in which patients were treated with a combination of two targeted drugs. Those who received the double therapy survived for a median of 11.4 months without progression of the disease, versus 7.3 months for patients taking one drug alone.

The bottom line is that even though patients who respond to targeted drugs may still die of melanoma, they are surviving longer and with a better quality of life than ever before.

Immunotherapy

Immunotherapy strengthens the immune system by supporting activation of the body's cancer-fighting T-cells. For example, the FDA-approved drug Yervoy (ipilimumab) blocks a molecule called CTLA-4, which normally keeps immune cells in check. Blocking CTLA-4 "takes the brakes off" of your immune system, allowing T-cells to proliferate and launch a stronger attack on the harmful melanoma cells.

A 2013 analysis of data from 1,861 patients treated with Yervoy revealed exciting news: the patients' median overall survival was 11.4 months; 22 percent of them survived at least three years; and 17 percent were still alive after seven years, with no deaths due to melanoma after that. Such long-lasting responses to anti-cancer drugs in people with metastatic melanoma were previously unheard of.

Individual Factors

Despite these recent breakthroughs, there is no "one size fits all" treatment for patients with metastatic melanoma. Your medical oncologist (a doctor who specializes in treating cancer with medications) should consider the individual factors of your case to determine which drugs make the most sense for you. And that's the exciting part: these new therapies are giving real options to a set of patients who previously had none.

Even so, nobody wants to get metastatic melanoma. Checking your skin regularly for new or changing growths is crucial because, when caught early enough, melanoma can be stopped in its tracks. To learn what to look for, see the American Academy of Dermatology's online reference for identifying the "ABCDE" warning signs of melanoma, and this guide to melanoma from the American Cancer Society.

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The Emotional Weight of Social Media

We've heard it time and again; our culture is obsessed with social media. It's true; screens are our lifeblood. We are relentlessly tweeting, messaging, poking, liking and engaging with each other online. We have access to information that we've never had before, and let's face it, who doesn't love a good selfie of Ellen DeGeneres at the Oscars or an ice bucket challenge or two? But the truth is that beyond becoming a habitual part of our daily lives; social media has begun to define how we feel. We create personal profiles online but we often forget that our social media presence and behavior doesn't always show who we really are, or who others are for that matter. Social media has become an important factor in our own emotional weight.

According to Todd Leopold at CNN, studies have show that "social media can have effects on mental health... getting 'likes' for Facebook posts actually results in a release of dopamine, a brain chemical associated with pleasure. Moreover, sad or moving posts can promote release of oxytocin, the 'love hormone,' which makes us feel protected."

It makes sense, Facebook and Twitter have become platforms for us to curate and share our successes, accomplishments and changes in life. This can contribute to our own lives in wonderful ways but it also has its challenges.

The problem is two-fold: Being dependent on the satisfaction received online can be a slippery slope. And not getting that satisfaction, and the natural problems with social media (online bullying, exclusivity and fast access to potentially emotional harmful content) can put our real life, tangible feelings at stake. There are ways to use social media effectively and enjoy it without making us feel emotionally heavy or weighed down. Here are a few of my favorite ways to help you lighten the emotional weight of social media:

Express Gratitude Online: When you log in to your Facebook I'm sure your feed is speckled with those self-promotional or celebratory posts. The: "I'm so excited to announce that..." or "I can't believe I..." posts. You know what I'm talking about. It's awesome to share successes online, it allows the word to spread quickly and as Leopold told us, it can even make you happier. But it can also be frustrating. Have you ever been having an absolutely awful day, logged into Facebook and seen a post about someone else's' "fabulous" life and felt like you were going to snap? Those posts are great but are often not very helpful if you're feeling unhinged or having a hard time in your own real life.

So why don't we begin to turn it around and start to create posts that express gratitude. Why not thank someone you love for being there for you online? Send a message of appreciation or a quick hello to a family member? Write a post about the way an old teacher or mentor encouraged you. Expressing gratitude, simply saying thank you will lift your spirits while also supporting and celebrating someone else.

Take a Social Media Breather: When we depend on our phones to evade awkward situations, to curate our own life through selfies, to gain likes and pokes and comments, we lose sight of what truly is important; engaging with each other in person and enjoying our time in front of each other. Social media is important, it is relevant but I promise if you try unplugging you'll connect with your world in a deeper, long lasting way. Taking a breather also allows you to return to social media with a different perspective. You'll find more enjoyment in engaging with others digitally because you've taken the time to work on in-person relationships. You may even find that social media matters less and less to you the more time you spend focused on others in real life.

Recognize that Social Media is a Game: It isn't who we really are. People curate and choose photos and information to share that highlights exactly how they want to be seen. Adrienne Erin of Socialnomics says that, "We are all at war with one another for likes and favorites and we compete by posting pictures of our expensive dinners, vacations and social interactions." Remember those self-promoting posts I mentioned before? They are great but they aren't actually what the world looks like. Life isn't always a steady uphill climb of happy, exciting events. But people don't want to share the mundane online because it's not as exciting. That's why it's good to remind yourself that we are all in this together. Life is beautiful because it isn't always the same. Imagine how boring your successes would be if they happened every minute of every day like they do on social media? We are all human, we all go through hardships, we all wait in line at the grocery store, and we all don't always feel awesome. But every color of life is important and unique and we all go through them. Life is so much more than a like. Enjoy social media but remember to not take it too seriously!

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A Health Care System That Works

My husband and I got married last year in Bled, Slovenia. While it's not the most popular wedding destination (which it should be), it's one of the most enchanting places I have ever seen. It was also convenient that he grew up in a town nearby and his family still lived there.

Two days before the event when we went to pick up some friends at the airport, I realized that I had severe pain in my lower abdomen. It had slowly crept up on me. That night after dinner, we decided to head to the emergency room in a nearby town called Jesenice.

We explained the situation to a physician and soon she ushered me into a small room for examination. After a few minutes, she stepped outside and had a long conversation with my husband in Slovene. His facial cues did not help my anxiety.

When they were finally done, he looked at me, took a deep breath and said "Looks like you have a cyst and it may require surgical intervention".

The good news was that the cyst was very benign and removing it was a minor procedure. The bad news was that we had a wedding happening in less than 48 hours.

They gave me a prescription for antibiotics and painkillers. I was asked to return to the hospital immediately if the condition worsens. I was also informed that if I were to get the surgery, I had to refrain from eating or drinking for at least six hours prior to the procedure.

As we headed outside, we stopped at the reception to pay for the services rendered. It is quite unusual for them to have a foreigner get treatment at their hospitals, so it took a while for them to process the fees.

A lady behind the counter finally emerged and with a rather regretful voice said "I am not going to lie, this visit is going to cost you. It's going to be €7.92 (approximately $10), but you don't have to pay it now. Pay it next time."

Despite everything this made me chuckle. We insisted on paying the bill and headed to the pharmacy. The cost for all my medication was €17.94 (approximately $24).

Back at the hotel, we contemplated on canceling the wedding but decided to play it by ear. Next day, after breakfast, I diligently took my medication. However as time passed, the pain soon became excruciating and the pills were no match to the pure agony.

It also didn't help that I had not eaten anything since breakfast. Around 4 p.m., I made the grave mistake of unwittingly taking a bite out of an apple. The problem is when you're under anesthesia, all the normal reactions, like swallowing becomes impossible and since you can't control your gag reflex, your stomach contents could regurgitate into your airways and can potentially be fatal.

What that meant was that I had to wait for another six hours before I could get the surgery. It also meant I had to use ER services again because of the late night hours. We finally got to the hospital close to midnight. While they did some tests to confirm my condition, I tried to convince the surgeon to postpone the procedure until after the wedding. My efforts however failed miserably when mid-sentence I realized that I was about to pass out.

Next thing I knew, I was getting wheeled into a surgery room. They asked me to count as the anesthesia was flowing through my veins. After counting to six I lost consciousness and when I opened my eyes I was in a different room. The surgeon came by to explain that the procedure was successful and I should stay in the hospital overnight. My husband stayed there with me.

Next morning after the checkups, I was discharged around 6 a.m. Given that we were getting married at 4 p.m. that afternoon, they didn't want to hold us up with any paperwork or payment processing. They also needed additional time to figure out the cost since Slovenia has universal healthcare and their citizens don't pay for these services. Despite all the drama, the wedding ceremony went better than even originally planned (topic for another article).

We went back to hospital after a couple of days. The bill for the surgery, medication and stay overnight for both of us was €657.26 (approximately $887). In stark contrast, years ago, my husband went to an emergency room in the U.S. for a cat bite. There was no surgery, no stitches and the wound was relatively superficial. Yet his co-pay was around $1500 and the total was over $8000. Obviously his insurance was not great but still that service does not warrant a bill that high.

The beautiful thing about Slovenia, like so many other developed countries, is when you are a citizen and need medical care, you don't think about whether your insurance is good enough and what you can and cannot afford; you just get treated. It's extremely affordable even for non-citizens like me.

Not to mention I did more paperwork in the U.S. to get reimbursed from my insurance provider compared to one or two forms that I signed to get a surgery in Slovenia. Yes, U.S. is "the best country on Earth"! Hooray! But a tiny and young country like Slovenia has a much better health care system than U.S., and that's just sad!

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5 Phrases That Send Me Spinning

The room is dark and hazy. Pedals whir. Bright eyeballs and shiny teeth glow in the eerie blue light. I smile and say hello to everyone even though I recognize no one. I wonder if I've gone through the looking glass along the wall and stepped into an alternate world where the beat is heavy, the energy frenetic... and the language completely mysterious.



Before I know it, I join the one two rhythm and begin the grueling energizing ascent up an imaginary hill. The words I hear seem to have no meaning, and I wonder if all this activity is causing some kind of aphasic episode. Luckily my brain is smarter than I am. It refuses to acknowledge it doesn't understand the enigmatic instructions, and by the time we reach down for the next quarter turn (um... what?) it is already decoding the cryptic phrases that only make sense right here right now:

Gimme a quarter turn. This does not mean with your body, your head, or any part of your anatomy. Whatever you do, please do not actually turn one quarter clockwise, counter-clockwise or any wise. It's impossible to do that anyway since you are, hopefully, perched on your bike pedaling like crazy. One two one two one two.

"Gimme a quarter turn" is the foundation of a spin class. It means reach down, grab the red resistance knob, and turn it one quarter to the right to add resistance. And hope the instructor does not ask you to do it again. It's a futile hope. Every quarter turn adds more resistance until pretty soon you're pushing your bike up Mount Everest. Which is the point. It's worth it.

Tap backs. Yep, that's what he said. These sound elusive, confusing, and exciting: I'll tap your back if you tap mine?! Or something. I'm going to leave it there. Some moves are better left unexplained.

Go to the hover. Right, now I'm really in an alternate world. Complete with Marty McFly, hover boards and that must be the easiest way up this hill. Almost. Not quite. What it means is squeeze those abs (more on that later), summon every ounce of strength you may or probably do not have, and hover hummingbird-style above your bike. Don't stop pedaling! I promise, your thighs (and abs) will thank you one day. If they ever talk to you again!

Singles. I believe this is a shout-out to all the single people in the room. An invitation for them to do those awesome-looking push-ups and tap backs. Since I'm not one of them, I ignore this part. And pretend I don't hear him say, "Gimme a quarter turn."

Squeeze those abs. This is my favorite! The one I will never understand, no matter how loud the music. Because... how? How do you squeeze your abs? I've deduced that it does not mean grab the kangaroo-like pouch you will forever have after four pregnancies and give it a juicy squeeze with your hand. It has something to do with squeezing from the inside. The problem with this instruction is it assumes you have abs inside to squeeze. I don't. See aforementioned kangaroo pouch. So I can't. This is too much resistance.

I love this class. I love the loud music, the beat, and the tap backs. And also disco lights! I love the darkness (because the instructor can't see that I'm not giving him a quarter turn. Sneaky!), and I love the vibrant, motivating trainer telling me I can do it, especially when I feel like I can't. Which is almost every day. I believe him when he tells me. And then I do it.

Mostly, I love these quirky phrases that really only make sense in this world. Because where else would you hear anything as fabulous as, "Squeeze those abs!"

This post originally appeared on Red Boots. Follow Nicki Gilbert on Twitter and on her blog.

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4 Ways to Live an Amazing Life

An "amazing life" will have a different meaning for each of our lives. The one theme that everyone strives for in life is freedom. We long for freedom from financial stress and freedom to live and love. The freedom to wake up each day and spend our precious time on the things that are important to the kind of life we want to live.

For years, I was in survival mode. I was happy just to wake up and limp through each day. I had no hope or dreams and never gave a second thought to what I wanted from life. I was overweight, overworked and stressed beyond my limits in my marriage. My finances were a joke -- we were in serious debt. We spent money faster than we made it.

You may be going through some stressful situations in your life right now. Happiness feels like a fairy tale that only happens to characters in a movie. Here are four ways you can life a amazing life and experience real freedom.

1. Eat Healthy and Move More

I'm not a health expert, but there are enough books, websites, and courses that can teach you what it means to eat healthily. In the last year, I've lost 170 pounds through portion control meals and avoiding junk food. What you eat affects how you feel and it essential to living a long life.

Along with healthy eating is exercise. Again, what exercise you should be doing and how often will be different for each of us. Exercise provides you more energy, helps you keep the pounds off and gives you an excellent opportunity to relieve stress. It can be a time for you to plan, refresh and challenge yourself. That discipline will boil over into other areas of your life.

2. Grow Your Relationships

Stress in relationships -- romantic or not -- can affect your mood or worse. There will always be ups and downs in relationships, but the toxic ones can kill your happiness. Our relationships should lift us up and compliment our life. Communication is crucial and understanding that we won't always see things the same way as others will help. Deciding to love that person each day and keeping situations in the right perspective will help your relationship grow.

3. Do Work You Love

Most of us will spend 40 hours plus in some form of work. That time could be spent doing something you love or hate. To many of us spend a bulk of our week doing work we don't enjoy, and that doesn't fulfill us. With so much of our week spent miserable, that stress festers into other areas of our life.

Yes, the economy is still recovering. Yes, finding a job you love seems like it's right up there with finding a unicorn, but these are just self-limiting beliefs. Every day people all over the world wake up and do work that they love. It's not easy to find a good job or start a business, but it is possible, and it can happen if you start today. With over 2.5 billion people on the Internet every day, a wealth of new opportunities have presented themselves. Don't let your work keep you from an amazing life.

4. Live Fully Present

Life is short and time is the one resource we can never recover. When you live life distracted, you waste that precious time. Learn to live each moment. Be there and tune out the distractions that will make you miss what's right in front of you. Listen, breath, and understand what that moment means. There will be plenty of time to check Facebook later.

Today my life is a different story--today I wake up each day amazed that anyone can live life this way. I lost the weight; I got financial freedom by paying off the debt entirely. We now invest and make our money work for us. I quit a job I hated with every fiber of my being to live my dream of being a writer. We moved our family to our dream destination of Maui, Hawaii. I have to pinch myself each morning.

Life may not be what you want it to be right now. You may be where I was and are struggling to believe life can be better--I'm here to tell you it can. You can wake up every day and experience true freedom in every area of your life. It's going to take time, sacrifice, and more determination than you think is possible, but it's possible for you, too.

It all starts with what you believe about yourself and your dream. If you don't think it's possible, you won't do anything about the kind of life you want to live--you won't take action. Don't listen to doubt, fear, or self-limiting people or beliefs. Dig deep and take control of your life. You can and will find your happy place. You will find what an amazing life means to you.

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Photo: Flickr/ IamNotUnique

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4 Ways to Make Your Period More Enjoyable and Restorative

This article was originally posted on HerAfter.com, a site for women learning to live fully after cancer and other physical and emotional battles.

It's time to end our war with our "time of the month."

For too long, women have been pretending our periods are some kind of hideous beast that arrives to ruin our lives every month. But it's time to stop treating it as an inconvenience. It's time to stop using it as an excuse for our inability to practice willpower, or as logic motivating our bad behavior, As with the debates in our culture on weight, on women in politics, on sexual prowess v. slut shaming, and so much more:

It's time to stop shaming our bodies. That includes its functions, its needs and all it's miraculous cycles -- including the "period."

Having a period isn't a burden, it's a blessing. It doesn't make us irrational or unbearable, it makes us human, beautifully human. It's an essential function that gives us the ability and choice to have children, a choice that is individual and personal and should be taken seriously.

Though this is not at all an article about women's reproductive rights (though if you're looking for one, Bri Seeley's article on the choice not to have kids is a great read), it is still important to realize how powerful it is to have reproductive rights, to have the political and biological the choice to be a mother. Because today, rather than be shoved in tents while we menstruate, or having our worth decided by our ability to bear heirs, we have the freedom to reproduce or not, to function in society while menstruating, and so much more that women before us fought hard and bravely for.

If you're looking for more about how your mother and grandmother fought for your ability to be self expressed, check out this recent article.

It's also a monthly reminder. With all the roles women take on today -- mother, boss, entrepreneur, role model, sister, friend, confidante, girlfriend, the list continues -- we could use a reminder to slow down, honor our bodies and offer a little rest, relaxation and reward.

Yes, the side effects are serious, and can often need medical support. The pain can be unbearable, the emotional roller coaster of it can be overwhelming. But the act, and the time, should be sacred.

This will sound crazy, but it shouldn't: I enjoy having my period. During my chemo, the doctors essentially "froze" my reproductive cycle, so as to protect it as much as possible from the therapy. It took full years after treatment in which I didn't have any cycle at all -- a dream to some girls, a nightmare to me, who was in a hurry to get my body back to normal. When it finally did return, it was happily welcomed with gratitude. To this day, 10 years later, I'm still happy to get it every month as a sign of my body's incredible ability to heal and renew.

Here are a few ways to turn your "week of hell" into a week of healing, of physical and emotional cleansing, and most importantly of self respect:

Be kind.

If your body is feeling overly-tired because of the cycle, pay attention. Allow extra time to rest and recuperate from the important work your body is doing internally. Getting enough sleep and time for the muscles to rebuild and restore is very important.

Honor your body.

Fit into your schedule restorative activities like gentle yoga (no inversions!) or long, hot baths or a massage. Don't punish your body for what it's doing, offer yourself chances to see how miraculous and beautiful your body is by honoring it like a temple.

Keep a journal.

If you're the type who's hormones go haywire during this week, sending you into tears at the site of just about anything (read: me), keep a journal. It will help you express the emotions that come up, identify your triggers, and give you a deeply personal and intense look at the power of your feminine capabilities. After all, isn't it incredible that our hearts can feel so much from our cycles? Isn't it incredible the way our body can affect our mind? Isn't the body magnificent?

Be conscious.

We like to pretend that it's our week to "be bad," and overeat. But products like dairy and sugar, as rewarding as they might seem, can make things worse. Be sure to drink plenty of water, eat well, and keep your relaxation time geared toward positive activities rather than passive ones (IE reading rather than hours in front of the TV). This will ensure you finish the week with a feeling of peace rather than bloat. That said, eat a little chocolate. And make sure its the good, expensive kind.

Rachael Yahne (@RachaelYahne) is a writer, blogger, and 10 year cancer survivor. You can read more of her articles about healing from life's big struggles on her website, HerAfter.com. Articles cover topics like beauty, well-being, purpose, and pretending to be 'normal' after treatment and recovery.

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Life -- Living With the Growing Pains

Henry Ford is quoted as saying: "Life is a series of experiences, each one of which makes us bigger, even though sometimes it is hard to realize this. For the world was built to develop character, and we must learn that setbacks and griefs which we endure help us in our marching onward."

Growing Pains

Growing, and especially rapid personal growth, is rarely a comfortable or easy experience (I'm speaking from lots of personal experience here!). However, if we persevere with our struggle (often largely with ourselves) and find a way to come out at the other end of the dark tunnel, we have learned what we were meant to and may find ourselves in a wonderful new place -- the tunnel led to a gorgeous, green valley, more beautiful than we could ever have imagined.

When there are struggles, challenges or issues in our lives; when things are not working out the way we would like; when obstacles arise; relationships falter or breakdown; disasters occur and all the other minor and major challenges that face us daily, in order to overcome them, to change our circumstances, we are forced to grow, to become "bigger," as Mr. Ford said.

Being Grateful

A mentor of mine gave me an interesting perspective once as I was dealing with yet another challenge (I must be a very big person by now). He suggested that I be very grateful to the person who was the source of my dilemma. "Why grateful," I ask, thinking about the lost sleep, soul searching, fear and hard work that was occurring.

He suggested that it was as if God had decided that I was capable of more, more joy, more satisfaction, more giving, more growth; it was time to offer me an opportunity to "be bigger," and that he had given me a gift to help me. And of course that gift was the person triggering the above lost sleep etc. In fact, my mentor said, "Think about the words 'the present.' A present is a gift. The present, what's happening to you right now, is a gift from this person (and/or God)."

Well, of course, this concept took some time to filter through my beliefs; I wondered if this was new age "woo woo" stuff; if it was just a cop out (NO -- there's too much hard work involved for it to be a cop out); and the idea of being grateful for pain took some work!

Live in the Present

However, it now makes sense to me. I like the idea that the present is a gift. Living in the present, no matter how challenging, is always more rewarding than wallowing in the past or being terrified of something in the future. And if we manage to conquer the challenge, inevitably we are presented with a "gift" of some sort -- a new relationship; new job; new opportunity; new life.

And then I thought that if I wasn't growing during my life (not just physically), I would probably be very bored in nanoseconds! Recall that old saying -- I forget who originally said it -- "if you're green, you grow, if you're ripe, you rot!" The day we think we know it all, we've done it all is the day we start to rot. We lose our zest for living.

Here is another quote that I think you will agree is relevant:

"The world is round, and the place which may seem like the end, may also be only the beginning." -- Ivy Baker Priest, a former U.S. treasurer who must have been a very wise woman.

Zooties!

Amanda Gore

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