photograph courtesy of west cancer center
“I’ve been interviewed a couple times before and I’m not very good at it.” So says Dr. Michael G. Martin of the West Cancer Center and Research Institute, Mike to his friends and patients, by way of introduction. Yet any fears of being tongue-tied fade as he waxes enthusiastic about the great advances in oncology since he was a medical student some 20 years ago.
“I graduated from the University of Tennessee Health Science Center in 2003,” he says today, “and I learned at that time that lung cancer was either non-small-cell lung cancer or small-cell lung cancer. And that’s all that mattered. It was just A or B. In either situation, you’d use slightly different chemotherapy, and then have about a 7 to 8 percent improvement in survival. And the only person who could love a 7 to 8 percent chance of survival is a medical oncologist. Frankly, a patient who could really see what we were achieving in 2003 would say, ‘Oh, hell no! Give me a bottle of Jack Daniels and a trip to the Caribbean, and call me never.’”
He pauses a moment, taking stock of his field’s evolution. “That’s how it was when I graduated 21 years ago,” he says. “Now, we win more than we lose.”
Put simply, the twenty-first century has witnessed a sea change in a cancer patient’s odds. “Immunotherapy and targeted therapy have changed things dramatically,” says Martin. “We understand the difference between hot and cold tumors, which is driven by genetic diversity. We’ve even learned how to take breast cancers, that we thought weren’t sensitive to targeting, and make them sensitive to it.”
Targeting is a crucial aspect of immunotherapy, which trains a patient’s own immune system to hunt for certain characteristics in tumor cells. The more identifying characteristics a tumor cell has, the easier it is to target.
As Martin explains, the way immunotherapy works — and the way our immune systems work — is by recognizing proteins on the surface of a cell called neoantigens. If such a protein has never been seen before by the immune system, it can be recognized and killed. And the more genetically complex a tumor is, the easier it is to target. As Martin puts it, “their genetics are completely screwed up,” and thus more recognizable. These complex cancer cells are called hot tumors.
photograph courtesy of west cancer center
Dr. Michael G. Martin
On the other hand, says Martin, “you have genomically simple tumors which are not caused by carcinogens.” These are the cold tumors. “They’re random tumors that happen all across the world, like sarcomas. Because they’re just random events caused by a genomic error, they’re genetically simple, and your immune system can’t see them. There is no uniform way that they occur. And the more genomically simple a tumor is, the less likely you are to be able to use immunotherapy.”
For patients, the difference is profound, as Martin illustrates from his own experience with the hot variety of tumor. “I have a patient who presented with a melanoma, which is a complex disease because there’s a clear carcinogen — the sun. This gentleman had cancer in his brain, liver, esophagus, stomach, and lungs, and I only had a small biopsy of his lung to tell me what was going on. So I gave him immunotherapy, and eight days later we biopsied his liver and we only saw immune cells, no cancer cells. Eleven days later they opened his brain, trying to find the cancerous cells, and there was nothing left of the cancer. Four and a half years out now, and no cancer ever again.”
Martin reflects, “When I was in med school, he’d have been dead in two to three months. And today we obliterate the majority of cancers. Though from an oncology point of view, the thing that you always say is, ‘I can promise you nothing, you can die from this in the next month.’ But there is an enormous amount of hope.”
The cruel irony is that, while there is hope for many, Martin doesn’t reserve much for himself. That’s due to a diagnosis he received before we spoke. “I almost died four weeks ago,” he reveals quietly. “I got septic shock after a biopsy and that biopsy showed that I now have cancer.”
Moreover, without getting too specific, it’s a genetically derived cancer of the cold variety. Having witnessed the past two decades’ worth of immunotherapy advances, he still can’t avail himself of them. Rather, he’s confronting it with chemotherapy, an older and less effective approach. But that’s changing how he relates to those he treats.
“I thought I understood my patients,” he says. “Now I’m fist-bumping them, saying, ‘How’s your radiation going? Mine’s going pretty shitty. How’s yours?’” And his experience is deepening his understanding of what people go through after such a diagnosis.
Meanwhile, Martin feels lucky to be based at the West Cancer Center. “My clinic has completely rallied around me and taken care of me,” he says. “Despite me almost dying and missing weeks of work. We take care of our people.”
“From a cancer-patient point of view,” he says, “I did not appreciate the emotional part of this until I got diagnosed with it. There’s this word, asthenia. I actually published a paper on the concept over 20 years ago. But I didn’t understand it then. I just thought I did. It’s the feeling of being exhausted without doing anything. The feeling of knowing you’re going to die from it. I know that at my age, with my diagnosis, this is what’s going to kill me.”
The genetic nature of Martin’s particular cancer only increases his sense of a foregone conclusion. “There’s this whole thing called anticipation that happens in genetics,” Martin explains with a subtle quaver of emotion. “As the same genetic thing is passed down through generations, it happens earlier and earlier and earlier, which is called anticipation. So that’s why, at 47, I have a cancer that my father got diagnosed with at 55, and that his father got diagnosed with at 67. My kids have the exact gene that I have and there’s a chance that they are at risk for prostate, breast, pancreatic, and ovarian cancer as well.”
Aside from his own treatment, Martin’s reaction to the possibility of dying within a decade has been to increase his community engagement. Already recognized by Health Volunteers Overseas for a lifetime of service in international education — “I’ve taught in Brazil, Nicaragua, Nigeria, Uzbekistan, Nepal, Vietnam. And I just got invited to teach in Cambodia,” he says — he’s now focusing that energy closer to home, and closer to the asthenia he himself is feeling.
“I’m starting a counseling project to actually work on that,” Martin says, “that we have funded through Bellevue Baptist Church with my good friend Harry Smith, for counseling for people with cancer.”
Meanwhile, Martin feels lucky to be based at the West Cancer Center. “My clinic has completely rallied around me and taken care of me,” he says. “Despite me almost dying and missing weeks of work. We take care of our people. I have the means to be treated anywhere in the world, and I chose West. I could go anywhere in the world. I talked to five or six places and I ultimately chose my hometown.
“Most of us [at West] are like me. I came from Duke and Washington University in St. Louis. And others came from Penn, Stanford, Memorial Sloan Kettering. We’re not a bunch of slouches. We’re here for family and social reasons. We are here because we choose to be here.” His colleagues at West, he says, “are going to do as good a job as anyone. And the thing about them is, they were more honest with me than anyone else.”
And Martin is unflinchingly honest with himself. Even as ongoing research continues to make great strides in oncology every day, he’s trying to be philosophical about being on the other side of the stethoscope.
“There’s some weird way in which I’m thankful, because I was incredibly healthy until March 8th,” he says, taking a deep breath. “Now, I understand my lot in life.”
