Fourth grade teacher Tricia Gallagher was 43 when she felt something like a scab — smaller than a sunflower seed — on her head. She didn’t think much of it.
“I thought it was a tick, because my boys and I hike,” said the energetic mother of two active teenagers.
Her doctor in Winston Salem, North Carolina, biopsied the tiny mass, and much to her shock, told her it was melanoma. She had one surgery to remove it then another surgery to take out 35 lymph nodes behind her ears. Six months later, a new spot — close to the old one but deep into her skull — emerged. Another surgery, then six weeks of radiation, followed, during which she lost her naturally curly blonde hair. The spot remained.
“At this point my doctors said, ‘We’ve done everything, we can’t help you anymore, so we’re sending you to Duke’,” recalled Gallagher, who secured an appointment after a couple weeks. “And that’s when I met Dr. Hanks, my dragon slayer.”
While more spots had developed in the interim behind her right ear and on her neck, Duke Cancer Institute’s melanoma team had a plan; an aggressive immunotherapy treatment called Interleukin-2 that because of its toxicity would require a hospital stay. She took the chance.
Gallagher endured two grueling rounds of treatment; one over summer break 2014 and one in October 2014.
The spot on her neck and behind her ear disappeared after the first round, but then spread to her lower back, left thigh, and lung. So, she went for the second round — treatment for a week, resting for a week, then back to teaching fourth grade.
“The side-effects are like the worst flu you ever had, fever, chills, everything hurts,” said Gallagher, who despite this, managed to keep her spirits up for her sons. “I wanted them to see that I was OK; see me cracking jokes and asking for Chick-Fil-A.”
At the same time, she said she "never tried to sugarcoat anything" with her boys, who were in middle school and high school when she was first diagnosed.
"If something happens to me I would have never wanted them to look back and think ‘Why didn’t she tell us? We weren’t prepared. We didn’t know,’” said Gallagher.
Chasing Her Tail
Some relief came in late 2014 when a PET scan revealed that the tumors on her head, lower back and left thigh were gone. The lung tumor, though shrinking, was still present.
At New Years, Gallagher, her sons and her best friend ran a 5K. She was feeling good. Then, her lung tumors stopped shrinking. Her oncologist Brent Hanks, MD, PhD, advised a newer immunotherapy, ipilimumab, approved by the Food and Drug Administration (FDA) in 2011. One day, every three weeks, for four months, she would come to Duke for infusions that made her nauseous, but happy when the tumor started shrinking again.
At that point, Hanks considered surgery, but after undergoing an MRI in February 2015, nearly two years since diagnosis, she learned the melanoma had spread to her brain.
“When Dr. Hanks called to say that it had moved to my brain I thought this is it, I need to start making final arrangements,” said Gallagher. “I felt like I was chasing my tail. We would have success, then the melanoma would move somewhere.”
According to the American Cancer Society, skin cancer is by far the most common of all cancers in America. While melanoma accounts for only about 1 percent of skin cancers, it’s the most deadly; causing a large majority of skin cancer deaths. Ten-year survival rates for melanoma patients range from 95 percent for stage 1A melanoma to between 10 and 15 percent for stage 4.
While the average age of patients at diagnosis is 63, it’s also one of the most common cancers in young adults, especially young women under 45.
Depending on the stage, treatment options may include surgery, chemotherapy, radiation, targeted therapy and/or immunotherapy. Early stage melanomas can often be treated with surgery alone, but more advanced cancers usually require a combination of treatments, as in Gallagher’s case.
Hanks, whose research lab focuses on identifying the causes of immunotherapy resistance in the tumor micro-environment, noted that melanoma treatment has come a long way; according to clinical trial data, the one year overall survival for Stage 4 melanoma increased from 25 percent of patients in 2010 to around 80 percent now.
“Death is no longer a foregone conclusion of stage 4 melanoma,” he said. “We’re extending survival and turning melanoma into more of a chronic disease. There’s been several patients we’ve had that even stopped therapy because they’ve had complete responses and now they’re under surveillance; coming every three months for a few years.”
After the discovery of her brain metastases in February 2015, Gallagher underwent a series of stereotactic radiosurgery procedures for recurring brain tumors, then began treatment with a new immunotherapy drug FDA-approved for the treatment of advanced melanoma only in late 2014 — pembrolizumab — an anti-PD-1 immune checkpoint inhibitor.
“We do see improved progression-free survival and durable responses to the anti-PD-1 immune checkpoint inhibitors in melanoma; if you respond to treatment, the duration of response is very good,” Hanks said, cautioning that only around 35 percent of advanced melanoma patients respond to single-agent immunotherapies.
“If I’d have had this journey two to three years before it started, this treatment wouldn’t have been available for me,” Gallagher said, grateful that as of May 2017, there’s been no evidence of cancer in her brain for nearly 18 months and none in her body since her scans came back clear on Good Friday, 2016.
Now 47, she continues to take pembrolizumab, knowing there’s no long-term data on outcomes or protocol for how long to take it.
“I joke with the phenomenal nurses in the infusion suite that my pembro infusions are kind of like Linus’s blanket,” Gallagher, said, adding that she calls her infusion days every few weeks at Duke Cancer Center her “daycations.” “I really enjoy the alone time. I get a chance to ride in the car by myself, listen to whatever music I want, sing at the top of my lungs, and go and see my favorite doctor and my favorite nurses. Even the times I drove there and didn’t get good news, I always walked out of there feeling like it’s going to be ok.”
Gallagher doesn’t have a history of cancer in her family, let alone melanoma, and she said she’s “not much of a sun person.” However, she acknowledges that growing up in Louisiana she ran around outside without using sunscreen and the top of her head would get sunburned.
As people plan trips to the beach, pool, and backyard BBQs, Gallagher — ever the teacher — has an important message: “Check yourself, wear your sunscreen, protect your kids. It can happen to anybody.”
She gets up a little bit earlier than usual for school each morning in May — melanoma awareness month — to post related photos and facts on Facebook; reminding friends of the risk factors for melanoma, including having fair skin that burns easily, high lifetime exposure to natural or artificial sunlight, a history of blistering sunburns, many common moles, and/or a personal or family history of melanoma.
She also shows images from her personal experience with the disease. “I want to remind people that I’m ok today, but ‘look where I was before.’”
Make An Appointment: To make an appointment with Dr. Hanks or another Duke melanoma specialist, please call 888.275.3853 or 919.328.3947. For more information on skin cancer care at Duke Health, visit Melanoma and Skin Cancers: Basal Cell and Squamous Cell Cancers. For a list of clinical trials for melanoma and other skin cancers, click here.
Ongoing Melanoma Research at the Hanks Lab: Led by Brent Hanks, MD, PhD, the lab is currently working to develop a phase I clinical trial in collaboration with gastrointestinal oncologist John Strickler, MD — in both melanoma and colon cancer patients — to investigate pembrolizumab combined with an inhibitor of the Wnt-beta-catenin pathway, a pathway the lab recently identified to be important for suppressing the immune response to melanoma. Other upcoming Hanks Lab projects include; testing in mice, a promising new dendritic cell vaccine they’ve developed (an immunotherapy that could potentially target any kind of cancer) as well as a melanoma tissue immunotherapy biomarker study. And, Hanks has just been granted a pilot award (2017-2020) by The Melanoma Research Alliance for a research project on understanding the role of myeloid-derived suppressive cells in resistance to anti-PD-1 therapy.
Circle photo (top): Tricia Gallagher with her sons Ian,18 (left) and Patrick,16 (right). Her sons came with her to her doctor appointment and infusion on Good Friday, April 14, 2017. (photo by Jared Lazarus, Duke Photography)