Jacob Flores, M.D., has met Mother Teresa.
He’s fond of quoting famous people: Thomas Paine, John F. Kennedy, Winston Churchill, among others.
And he makes house calls.
The 70-year-old son of Mexican immigrants is fiercely proud of his heritage: One grandfather served in the Mexican revolution.
Dr. Flores, a family physician, has a well-established practice in Oceanside, California, near San Diego. But on any given day you’re just as likely to find him in his tending to the elderly members of his community at senior and homeless centers, as well as in people's homes. He also serves as chief of staff at Los Angeles Downtown Medical Center, and once a week he looks after indigent and homeless patients at White Memorial Medical Center, in the shadow of Los Angeles’ skid row.
And that’s just a partial list. His CV portrays a man driven to help those less fortunate, a fact he freely admits.
“I have a passion to take care of the poor, the sick and the infirm,” he said.
That passion intersects with another deeply held belief: to never take the easy path. From his earliest youth he has challenged himself, excelling in athletics, especially martial arts, joining the Marines (“a rite of passage in my Latino community,” he explained), then later attending medical school while already married and the father of three “because,” he said, channeling President John F. Kennedy’s famous reason for going to the moon, “I knew it would be hard.”
As if handling the course load at UC San Diego School of Medicine weren’t hard enough, in his spare time Dr. Flores founded a clinic across the border in Tijuana, Mexico, where “everyone was poor, living in shanties.” That’s where Mother Teresa, on a church visit, gave Dr. Flores his guiding light. He’d asked her why she was drawn to the needy and vulnerable. “She told me, ‘Most people help the poor out of pity or disdain. But if you have respect for the poor, it’s easy to be compassionate.’”
Not always easy.
During the first difficult year of the COVID-19 pandemic, Dr. Flores, like so many physicians, found himself overworked, overwhelmed and overexposed to danger. (“These are the times that try men’s souls,” he said, invoking Paine.) Patients were pouring into the hospital. He would see as many as 70 desperately ill people each day — saving those he could, attending the final, lonely hours of those he could not. Working 100-hour weeks surrounded by the COVID-19 infection took its toll. He barely survived his own bout with the virus in 2021.
Plus, his oncologist believes, this may be where Dr. Flores’ cancer challenge began.
“He worked so hard during COVID. I think he ignored his pain,” said Murali Janakiram, M.D., M.S., associate professor in the Department of Hematology & Hematopoietic Cell Transplantation at City of Hope.
Arthritis-Like Pain Diagnosed as Myeloma
The pain felt like a bad case of arthritis, and it kept getting worse. He self-medicated with Tylenol and the like, but by mid-2022 he knew something was wrong. He headed to the emergency room. Doctors there diagnosed “metastatic cancer,” later clarified, after a pair of bone biopsies, to Stage 3 multiple myeloma.
Myeloma is a blood cancer that causes plasma cells to overproduce, collecting in the bone marrow and the outer layer of the bone. Stage 3 is considered “terminal”: five-year survival rates barely top 50%.
Doctors detected a pair of plasmacytomas — tumors made up of plasma cells — on Dr. Flores’ spine. They had to be surgically removed, but not before the second one caused paralysis, putting Dr. Flores in a wheelchair.
He received chemotherapy and radiation, but they failed to achieve remission.
He remembers thinking, “Do I have to put my affairs in order?”
He had a better idea.
“I decided to fight to the end,” he said, “because I still had much to contribute.”
To partner in his fight, Dr. Flores wanted the most knowledgeable and experienced team possible. He knew he might need a stem cell transplant to survive. So, he called City of Hope — pioneers and leaders in the procedure, with more than 19,000 transplants performed to date — and in short order he was speaking to Dr. Janakiram.
“Dr. Flores knew what he wanted,” said Dr. Janakiram. “He was concerned about his wheelchair. He didn’t want it to distract me, to prevent me from offering the most aggressive treatment, worried that he couldn’t handle it. He made it clear he was willing to take the risk.”
Turning to CAR T Cell Therapy
Dr. Janakiram, a renowned researcher constantly searching for new and better myeloma treatments, considered the transplant option, but felt Dr. Flores would do better with something even newer and potentially game-changing: CAR T cell treatment, approved by the Food and Drug Administration (FDA) for myeloma in 2021.
CAR T cell therapy involves harvesting the patient’s own immune cells, re-engineering them to recognize and attack cancer cells, then returning them to the patient’s system. City of Hope has been instrumental in developing this novel treatment, from early clinical trials to today’s landscape: Six FDA-approved CAR T products are presently available for various blood cancers.
And every day, the process gets better.
It can take two months for a lab to re-engineer a patient’s immune cells, but that is changing. Dr. Janakiram says today’s process is much simpler, “like big LEGO blocks a 2-year-old plays with.” Refinement is coming. Creating CAR T cells may soon take as little as 48 hours. Even better, work is underway to develop an injection that will trigger the CAR T process inside the patient — no lab needed at all.
But that’s the future. For now, Dr. Janakiram felt that even today’s “slower” process would be more effective for Dr. Flores than a transplant. “It potentially could provide a stronger response for a longer period,” he said.
The wheelchair-bound Dr. Flores spent weeks at City of Hope, first prepping for the CAR T cell procedure, then recovering from it. He underwent chemotherapy before the infusion to reduce the number of T cells in his body, giving the re-engineered T cells a better chance of working. He received the new turbo-charged T cells in November 2023, in a process that resembles a blood transfusion and typically takes 60 to 90 minutes. Would it work?
It did, but a few problems cropped up.
Dealing With Cytokine Release Syndrome
Dr. Flores developed a case of Bell’s palsy — partial paralysis of the facial muscles, an occasional byproduct of CAR T cell therapy. Many such cases resolve on their own, while others respond to corticosteroids like prednisone.
More seriously, Dr. Flores endured a significant bout with cytokine release syndrome. CRS means the body’s immune system overreacts to the unfamiliar, newly introduced cells. Untreated, CRS can be very dangerous, just as it was during the pandemic when some infected patients suffered severe symptoms when their immune systems kicked in a little too well to battle the novel coronavirus.
Dr. Janakiram was not surprised. And he was prepared.
“I was expecting CRS,” he said. Dr. Flores’ “PET scan showed more disease in his bones than I’d anticipated. And the more disease the person has, the more CAR T cells will attack and cause inflammation.”
Dr. Janakiram deployed an anti-cytokine drug called tocilizumab, a monoclonal antibody first approved in 2011 for treating arthritis, then green-lighted for CRS in 2017. It effectively knocked down Dr. Flores’ symptoms and, 21 days after receiving his CAR T cells, he was able to go home.
More than a year later, there is no sign of multiple myeloma in his system.
“I feel stronger,” he said. “Getting better all the time. And I’m walking!”
Nearly all multiple myeloma patients eventually relapse. The median timeframe is a little over two years, though some patients can go 20 years or longer. Dr. Flores knows the statistics. He’s optimistic that better treatments, perhaps even a cure, may come.
Dr. Janakiram is proud of his patient.
“I’m pleased that he had such a good experience,” he said. “This is what makes our day and gives us our greatest happiness.”
For his part, Dr. Flores feels “extremely fortunate” that he found a team of experts who saved his life and “treated me with compassion and respect.” Whatever comes next, this tough Marine plans to maintain his “never give up” attitude, summed up by another favorite quote (naturally) from Churchill:
“Fear is a reaction. Courage is a decision.”
Main image: Dr. Flores examines a patient as part of his mobile outreach practice.