One Step Ahead

Peggy Watson Alexander and Duke care team
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“WE DID IT !” Peggy Alexander's husband Lovest admires her medal, which she earned at the end of the 2018 Susan G. Komen three-day, 60-mile Walk for the Cure in Atlanta to raise money and awareness for breast cancer. She was one of the top 25 individual fundraisers. “It was important to me that while being grounded in gratitude in celebrating my 70th Birthday, I was participating in a cause that has a positive impact on the lives of so many people,” Peggy says. The avid walker never imagined that three years later she would be facing down cancer herself — a very aggressive blood cancer.

Peggy AlexanderPeggy Watson Alexander, 73, is an early riser.

“Listen, five or six o'clock, sometimes four o'clock, it's like, “Okay, what are we going to do this morning,” she laughed. “My husband Lovest is not a morning person. I don't even know how we've stayed together all these years, because he definitely does not like getting up early in the morning, but I do, I enjoy it.”

It's Peggy's nature to always be on the move.

Years ago, when she worked at North Carolina Central University (NCCU), she and a colleague would go to work extra early in the morning just so that they could walk around campus before they started their day.

“We did that for many, many years,” recalls Peggy. “You’re not only walking to heal the body, but the world is at peace early in the morning… And it helped me to be at peace with myself.”

Peggy served for 25 years in many roles at NCCU, including as director of Student Leadership Training and Development, International Student Advisor, director of University Career Services, and dean of Student Learning. During that period, she also briefly served on the Durham City Council (1987-1991).

When she retired in 2013, she got into a routine of working out almost daily at the Duke Center for Living fitness center (she’d been going there on a semi-regular basis since 1998) and filling the rest of her day with volunteer work and walking. Lots of walking.

Nestled in the woods of Duke Forest, the fitness center became a starting point for many of her walks, mostly into nearby northern Durham or downtown Durham.

“There’s freedom when you walk,” she notes. “There aren’t any limits.”

In 2018, Peggy stretched those limits when she embarked on a three-day, 60-mile Susan G. Komen Walk for the Cure to celebrate her birthday and raise money and awareness for breast cancer. She was one of the Top 25 Individual Fundraisers.

“It was important to me that while being grounded in gratitude in celebrating my 70th Birthday, I was participating in a cause that has a positive impact on the lives of so many people,” Peggy says.

Catch Her if You Can

Duke University
Duke University (source: Duke University)

In 2019, the year Peggy turned 71, she accomplished another personal goal; this time close to home. She walked from Duke University to UNC Chapel Hill via the main thoroughfare separating the two — the always crowded 15-501 highway.

She called the ambitious 11-mile trek “bridging the gap,” a reference to the friendly rivalry, yet close proximity of the two schools. It took her more than three hours to get there.

Peggy recounted it this way: “I shared with my daughter (Paula Borden, PhD, MA) who works at UNC Chapel Hill that I would love to walk from Durham to her office. How many times have I driven down 15-501? Well, that day finally came. It was overcast and I thought, ‘This is a great day to walk to UNC.' Shortly after beginning the walk to Chapel Hill, a woman pulled over in her truck and said, ‘Ma'am, I don't know where you're going. But if you need a ride, I'll help you.’ I responded, ‘No. I'm walking to UNC. I'm fine.’ I thought, 'I've got this all under control.' When I arrived at my daughter’s office, she turned beet red and said, ‘Please tell me you did not walk over here, you know cars zoom down 15-501. You could have been hit.’”

UNC Chapel Hill
UNC Chapel Hill main quad (source: Wikipedia)

Paula explained her reaction: "When she shared her mode of transportation with me, my emotions went from happiness, to concern, to fear."

“Like any parent, I understood her anxiety, however it was a major accomplishment for me and I was proud," Peggy said. "Just knowing that I could do it was exhilarating.”

An Epoch Journey

This spring, Peggy set her sights on completing a half-marathon. On Friday, April 23, 2021, she walked 10 miles without incident then went home to put her feet up. On Sunday (April 25), unexpectedly, her leg began to swell and hurt. Her husband took her to Duke urgent care, which diverted the couple to the Duke Regional Hospital Emergency Department.

“I thought maybe I walked too far. I de-compensated before my very eyes. My right leg became immobilized; suddenly I couldn’t walk,” Peggy recalled, adding that upon arriving at the hospital, she needed a wheelchair right away. “I gained 20 pounds (of fluid). Even sitting in a wheelchair, it was excruciating as my husband pushed me.”

She soon learned she had a type of non-Hodgkin lymphoma called "diffuse large B cell lymphoma" or DLBCL. At the time of diagnosis, it was present in several areas of her body, including the lymph nodes in her chest, abdomen, and pelvis. Blood cancers are often found throughout the body at diagnosis and Peggy's case was no different. However, it was also in her stomach and the lining of her heart, her spinal fluid, as well as the leg where she had the pain that first brought her to the hospital.

Suzanne Kirby, MD, PhD
Suzanne Kirby, MD, PhD

Peggy's oncologist Suzanne Kirby, MD, PhD, a blood cancer specialist who practices at the Duke Blood Cancer Center at Duke University Hospital in Durham and at Duke Cancer Center Raleigh at Duke Raleigh Hospital, called Peggy's variant of the disease “very aggressive.” It would require intensive treatment.

According to the Leukemia & Lymphoma Society (LLS) and the American Cancer Society, approximately every three minutes one person in the U.S. is diagnosed with a blood cancer and approximately every nine minutes, someone dies. By the end of this year, in the U.S., new cases of leukemia, lymphoma and myeloma are expected to account for nearly 10% of the new cancer cases and 9.5% of cancer deaths. New lymphoma diagnoses will account for nearly half of new blood cancer cases.

Peggy never imagined she'd be at Duke as a cancer patient. Up to that point, she’d had an entirely different relationship with the University and Health System — both as an employee herself (a brief stint with Duke Human Resources) and as the wife, for the past 26 years, of Lovest Alexander, Jr., MHS, PA-C, the director of Diversity and Inclusion for the Duke Physician Assistant Program, and an associate professor of Family Medicine and Community Health with a 40-plus-year career history at Duke.

Even after viewing, with her husband and daughter, the PET scan image “all lit up” to show where the cancer was, Peggy refused to believe she had cancer. That she was training for a half marathon one day and two days later was facing down a diagnosis of lymphoma had come as a complete shock.

"Her shock was appropriate. Unfortunately, it is not shocking to those of us who treat this type of cancer; we have many patients with similar stories,” said Shelby Bettoney, PA-C, a physician assistant who works closely with Kirby at the Duke University Hospital Blood Cancer Center and has been treating Peggy since May.

Peggy Alexander (far right) and her husband Lovest and daughter Paula enjoy a day at the beach
DEVOTION At the heart of Peggy Alexander’s circle of love and support is Peggy’s husband Lovest Alexander, Jr., MHS, PA-C, and her daughter Paula Borden, PhD, MA who's followed Peggy's footsteps into higher education leadership. The three of them had a chance to relax on a recent family trip to Virginia Beach.

“Peggy is lucky to have the best family support I could hope for. I wish I could clone them for my other patients,” says Shelby Bettony, PA-C.

Explained Peggy, “I’ve taken fairly good care of myself over the years. As a result, my sense of denial was very strong. I was afraid. It was almost a month before I could say, ‘I have cancer.’ That was the most frightening thing in the world. I said to myself ‘Lord, I don't want that dreaded disease. I don't, it's not me, I can't have cancer.’”

“Denial is a common part of the grief response to learning about a cancer diagnosis," noted Bettoney.

It took Peggy's family and a care-team effort, Bettoney said, to help her adjust to her new cancer reality.

“Peggy has had the benefit of the support of dedicated nurses who chose this profession; some have worked here for decades. Joey Misuraca is our RN manager and she is very committed to the experience of patients. She hires incredible nurses and fosters an environment of healing, safety, and teamwork,” said Bettoney. “The nurses help set the expectation for the patients' new "normal," answer questions, and suggest solutions for side effects or problems. The service also has a social worker, several case managers, an incredible recreation therapist, physical therapists and occupational therapists, and nutritionists who support our patients. I know she has enjoyed the care she received from Dr. Lou Diehl, one of our attendings who has a gentle way of helping folks adjust.”

Kirby had started Peggy on “R-EPOCH” — a regimen that included several chemotherapies (cyclophosphamide, vincristine, doxorubicin and etoposide), the steroid prednisone, and an immunotherapy (rituximab) delivered intravenously in the hospital over the course of five days, every 21 days. Rituximab (brand: Rituxan) is a monoclonal antibody, a man-made drug that works by targeting the CD20 marker that’s found on the surface of all B-cells (a type of white blood cell) to slow or stop cancer growth.

With lymphoma cells in her spinal fluid, treatment was a challenge. Most systemic cancer drugs can't get past the blood-brain barrier into the protected space that houses the body’s vital command center — the brain and spinal cord. To mitigate this, Peggy had an Ommaya reservoir (a quarter-sized, soft, plastic, dome-shaped device) surgically placed under her scalp and attached to a catheter directed into that protected space. This allowed the cancer drugs to be delivered straight into her central nervous system.

Three months out from treatment, Peggy’s scans revealed “an excellent response to treatment.”

“I thought I was going to die. I really did. I felt, ‘Kid, you aren't going to make it.’ But I did make it. I can now walk and my gait is stronger. My body is stronger. And you know this is a second chance for me… sometimes I almost cry at how blessed I am,” shared Peggy, speaking via Facetime from her Duke University Hospital room early last month.

Pacing Herself

Peggy and Lovest Alexander
“Just my husband touching my shoulder sometimes makes me feel better. Or when he looks at me, it makes me confident that life is going to get better. I know sometimes he's tired. I realize that is a common characteristic of family members who are walking along the cancer journey with a loved one. He wants the best for me,” says Peggy Alexander. Here she is with her husband Lovest by her side during an outpatient infusion appointment on Oct. 13 at the Duke Blood Cancer Center, DCI. (photo by nurse manager Ashley S. Potter, MSN, RN, OCN, CNML)

Towards the end of September, Peggy’s scans showed a mixed response. Her treatment regimen was no longer working as everyone had hoped.

Some of the previously seen areas of cancer, including in some of the bones, had improved, but new areas of disease had appeared in the right axilla and abdomen suggesting new drugs were required to control the disease.

“This is not unusual for a patient with a ‘triple hit’ diffuse large b cell lymphoma (DLBCL),” explains Kirby. “A double hit or, in Peggy’s case, a triple hit, means that the patient’s lymphoma carries two (double) or three (triple) mutations — either of which signify a particularly aggressive variant of the disease that makes one’s cancer harder to get in and stay in remission.”

In consultation with Peggy and her family, Kirby quickly mapped out a new treatment plan in response, involving two cycles (eight weeks) of R2 — the immunotherapy Rituxan, this time delivered via outpatient infusion, plus Revlimid, a daily oral chemotherapy she could take at home. Peggy doesn’t need to be hospitalized with this regimen.

“Dr. Kirby is my physician, and I could not be more satisfied. I trust her. I believe what she says, I feel that she knows what's best for me, but she always involves me and my family in the treatment plan,” said Peggy. “I do not feel that it's solely her responsibility to help me reach remission. I have to join her in this partnership. Dr. Kirby, my family and I have to work together. The whole idea is for me to get better.”

For Peggy, doing her part includes taking advantage of supportive resources offered by Duke, exercising regularly, modifying her diet, and keeping a positive mindset grounded in her faith.

Kirby already has a contingency plan in mind in case R2 is unsuccessful — CAR T-cell therapy — an individualized gene therapy that transforms a patient’s own T-cells (another type of white blood cell) into CAR T-cells designed to recognize, attack and destroy the cancerous B cells (lymphocytes).

“CAR-T is an option that may be of benefit to patients with double or triple hit lymphomas, like Peggy,” explains Kirby.

Considered a breakthrough in hematologic cancer treatment, this high risk, potentially high reward type of immunotherapy was FDA-approved in Oct. 2017 under the brand name Yescarta to treat various types of non-Hodgkin’s lymphoma and the Duke Blood Cancer Center was one of the first authorized to administer CAR-T.

In early October, Peggy and her family met with DCI cellular therapy specialists Ahmed Galal, MD, FRACP, MSc (a professor of medicine in the Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy) and Krista Rowe-Nichols, MSN, RN (a hematologic oncology nurse) to discuss this possible next line of attack, should she require it. They explained how the CAR-T would work. First her blood would be pumped out through an IV tube into a machine that would remove her T-cells, which would then be frozen and shipped to a lab where the cells would undergo “an education” by the drug (Yescarta) on how to recognize and kill the cancer cells. (Although natural T cells are capable of killing cancer cells, they are often fooled by cancer’s disguises.) She would then undergo chemotherapy and her re-engineered T-cells would  be infused back into their body.

Peggy has had nearly six months to reflect on her experience with the uncertainty of cancer. She says it’s reaffirmed that she should “enjoy every single day, every single moment.”

She admits that in her “fast-paced world” before cancer she didn’t always “take the time to stop and look at the daisies.”

Now she’s all about pacing herself.

“On those good days, enjoy them, do as much as you want to do. Because there are some days in which you say, ‘You know what? I'm not getting off this sofa today.’ That's new for me. That's been a real learning experience.”

Peggy draws strength from the love and support of her family, her church community, her friends, and her care team at Duke — all of whom give her hope.

She calls cancer an illness that the whole community bears rather than “an isolating world that you gradually sink into and the light goes out and you’re gone.”

Before COVID-19 and her cancer diagnosis, Peggy would join her church in preparing and serving meals once a month for the homeless at Open Table Ministry downtown Durham. Volunteering with Open Table Ministry is particularly special to Peggy because she and Lovest would prepare the meals together. And every Monday she would help serve the meals.

“I believe life is all about service. You want to know that you've made a difference. We should all try to leave the world a better place than when we arrived,” said Peggy. “There are still things in the world that I want to do. I want to help people and be a blessing to others. I hope that doctors can learn from my experience (with this disease) and reduce the suffering that other people go through.”