Patient beats back AML with novel therapy after unusual recurrence

November 26, 2018 | by Malcolm Bedell

“When I came out of remission, it blew the oncologist’s mind,” recalled Donald Brust, 79.
“At that time, I don’t think they’d ever had a stem cell transplant patient be in remission that long and then have the same type of cancer recur. There’s this old baloney that if you’re cancer-free for five years … well, it’s not true.”
Fourteen years after “beating” acute myeloid leukemia, Brust and his longtime oncologist, City of Hope’s Vinod A. Pullarkat, M.D., were startled to learn through routine bloodwork in 2016 that his cancer was back. Acute myeloid leukemia (AML) is an aggressive cancer that quickly moves from the bone marrow to the bloodstream and into other organs. A checkup had revealed abnormally low blood cell counts. Brust’s platelet level was at 41,000, a far cry from the 150,000-400,000 platelets expected for someone of his age and normal health.

'I Was Running Out of Breath'

Raised on an Idaho cattle ranch, Brust has filled every moment of his life with activity. His San Diego veterinary practice, where Brust was an early pioneer in the field of multipulse laser-assisted surgery, was a fixture in the community for 38 years. He and his wife of 55 years, Ina, also raised guide dogs for the blind.
In spite of his busy professional life, Brust also found time to serve his other lifelong passion, officiating track and field, ultimately serving as one of 200 track and field officials for the 1984 Los Angeles Olympic Games, as well as the Olympic trials in New Orleans in 1992.
Brust’s wonderfully well-rounded professional and social life changed course dramatically in 2002. Shortness of breath, a tendency to bruise easily and general malaise were the first signs that something might be wrong.
“At the time, I was the caretaker of a 20-acre avocado grove,” Brust said. “I noticed I was having a hard time doing my job, including the irrigation. I was just running out of breath.”
Brust was treated at City of Hope that year by Pullarkat, currently clinical professor of the Department of Hematology & Hematopoietic Cell Transplantation and an expert on acute leukemias and bone marrow transplantation with chemotherapy and a stem cell transplant. Finding a donor was difficult, and the process laborious.
“I was adopted at 4 years of age, so I didn’t have much family history to go on. There was a battery of tests to find a match,” Brust said. Eventually, City of Hope unknowingly located Brust’s younger biological brother, with whom he had previously had no contact, through the National Marrow Donor Program, and he agreed to provide the donor stem cells. (Ever since, they have reunited at City of Hope’s annual Bone Marrow Transplant Reunion and refer to each other as “cell-mates.”)

As Normal As Possible

Brust’s prognosis was good following the transplant. Though complications due to infection and chemotherapy-induced neuropathy left him with pain that radiated down his arms and into the back of his hands “like hot irons,” the medication prescribed by City of Hope allowed him to resume his life cancer-free.
Of the five hospitals that I’ve spent time in, City of Hope has given me the greatest level of care and expertise, particularly when it comes to managing pain,” he said.
Things were back to as normal as possible until that day in 2016 when Brust received the devastating news that his AML had returned.
“You don’t realize the mental gymnastics that a person goes through when he’s told he has cancer for the second time,” Brust said. “You’re running on such a high for 14 years, and everything is hunky-dory. Then? Not so. It’s a real downer, I’ll tell you. You just hope that your immune system is strong enough to carry you through for that second time.”
Once again, Brust put his life in the hands of Pullarkat.

A New Journey Begins

“[Brust’s] recurrence is unusual, in that it occurred many years after transplant. Most AML remissions after transplant occur in the first couple of years,” Pullarkat said. “He is on a novel therapy, which is a combination of a hypomethylating agent [a type of chemotherapy] and an oral drug called venetoclax that causes leukemia cells to self-destruct. We are one of the cancer centers pioneering this treatment.”
At nearly 80 years old, Brust’s cancer is currently in remission. According to Pullarkat, his condition is considered “guarded,” because his treatment represents “a new regimen. There’s not enough experience with this drug combination yet to know if it can cure, but it is a very new and exciting therapy that has the potential to be a major advance in treating AML, particularly in the elderly.
Brust continues his recovery with daily pain medication and oral leukemia therapy, which have taken their toll. “At this age, there’s sometimes just no energy left in this body,” he said.
In spite of the side effects, Brust is in remarkably high spirits, and he will be evaluated for the potential cessation of treatment later this year. He gives much of the credit for his positive state of mind to City of Hope. “From day one, your pain control is their first priority,” he explained. “It’s not just the doctors and nurses. It’s a beautifully coordinated team effort, and there’s a willingness to try new technologies that eventually become the standard elsewhere. It’s just plain modern medicine, and it’s that modern medicine that’s put me where I am today.”

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