Me, My Cancer and the Vaccine Against My Cancer

Get an exotic cancer and see the world!

It may not be the best slogan for a travel agency, but in my case it turned out to be eerily accurate. I am, as English puts it far more elegantly than Serbian, a cancer survivor. I survived cancer. Melanoma, to be exact: a malignant disease that is simultaneously one of the most treatable cancers when caught early, and one of the fastest and more aggressive when it is not – when you give it the chance to extend its tentacles and metastasize. And that is precisely what happened to me.

I caught a lucky break in dark times, with crucial help first and foremost from my father and my mother, and from some truly, truly exceptional and courageous doctors. I made it through.

But for years afterward, I travelled from America to Nepal and Tibet, and to many places in between, carrying an ever-thicker and increasingly battered medical file. Inside a cheap, flimsy red folder with plastic sleeves for individual documents, were countless diagnoses, pathology reports, specialist evaluations, test results and follow-up records. More than once, I thought I had lost that damned folder. But even if I burned it, there is one place where it would always remain.

Because once you’ve had cancer, even when the disease itself is gone, you carry around an invisible part of it for a long time, a part so miniscule that no scan can detect it: the lingering question of whether it will come back.

Days can pass, months, even years, without you thinking about it at all. You work, travel, chase deadlines, fall in love, make plans, get annoyed about the things that all healthy people presumably get annoyed about. Or at least you become very good at pretending.

Then comes a follow-up appointment. A new mole appears. Something starts aching out of nowhere. Or, as happened to me now, you read one very specific piece of medical news, and it all comes rushing back.

All of it.

This is literally the first time I have written about this publicly, and I am doing it with a real knot in my stomach and no small amount of anxiety. As if putting it into words might summon it, wake it up, provoke it… bring it back.

Actually… fuck it.

Reading Can Be Dangerous

With cancer, the word “cured” rarely refers to some cinematic moment when the doctor tells you it is all over, the score swells and the credits roll with “and he lived happily ever after.”

Far more often, it is a gradual process in which you slowly learn to trust that the disease might truly be behind you, while living with the uneasy truth that nobody is ever going to sign an absolute guarantee.

And then, on August 19, I read the announcement from Moderna and Merck about the first positive Phase III result for an mRNA cancer therapy.

Not prostate cancer. Not lung cancer. Not pancreatic cancer.

Melanoma.

More specifically, it involved patients whose melanoma had already been surgically removed. Patients who may no longer have any visible disease, who feel healthy, and whose surgeon has told them the best thing a surgeon can say at that point: we got it all.

And yet the exact same shadow I know all too well still hangs over them: the possibility that some tiny cluster of cells has hidden somewhere unseen, and that in one, two or five years, those cells will start dividing again and trigger a recurrence or metastasis.

This new therapy, in other words, is not trying to destroy a large tumour you can point to on a scan. It is trying to train the immune system to hunt down and destroy the remnants of something everyone hopes is already gone.

Once you have had that particular cancer yourself, it is difficult to read news like this as just another headline in the science section.

Wall Street, of course, reacted much less sentimentally. After Merck and Moderna made the announcement, Moderna shares at one point surged by around 160 percent.

Not sixteen. One hundred and sixty.

That is a staggering jump for a company of that size, and reason enough for the story to break out of specialized medical journals and into the world’s news and financial pages.

But the stock market, as history has shown us time and time again, is prone to hysteria.

Tumours cannot.

They couldn’t care less what investors expect from the next quarter, which is why it is much more important to look at what was actually announced in the few concise sentences contained in the companies’ official press releases.

Novels in Two Paragraphs

The large INTerpath-001 clinical trial enrolled 1,137 patients with high-risk melanoma that had previously been completely removed by surgery.

Two-thirds received the already established immunotherapy drug pembrolizumab, better known as Keytruda — the flagship drug of the immunotherapy revolution that, over the past fifteen years or so, has transformed the way we treat melanoma and a whole range of other cancers.

Alongside Keytruda, those patients also received the experimental therapy now known as intismeran autogene, which in recent years we had come to know under the equally unpoetic labels mRNA-4157 and V940. The control group received Keytruda alone.

The combination achieved a statistically significant improvement in recurrence-free survival and distant metastasis-free survival.

That sounds important, but the next sentence carries far greater historical weight: no mRNA cancer therapy had ever before produced a positive result in a Phase III clinical trial.

That, however, is not the same as the headlines we have inevitably seen over the past few days, for the umpteenth time: “Cancer Vaccine Found,” “Cancer Finally Defeated,” or some other variation on the same universal urge to compress complex science into five-word clickbait titles.

We have not developed a vaccine that healthy children will one day receive so that they never develop melanoma.

Nor have we developed a single universal vial that will work for every cancer patient.

In fact, perhaps the strangest thing about this “vaccine” is that your dose essentially does not exist until you become sick.

First, your tumour is removed. It is then genetically sequenced to pinpoint mutations that are absent from your healthy cells. You, your, yours, your own — it all sounds a bit narcissistic, doesn’t it?

From this molecular “crime scene”, researchers pick out the tumour features most likely to trigger an immune response, then manufacture an mRNA construct carrying instructions for as many as 34 such neoantigens.

That means the person sitting next to you in the waiting room with the exact same diagnosis may receive a completely different vaccine.

Their melanoma has different mutations, so their treatment will be different.

In that sense, this study of 1,137 patients did not test one vaccine in the way we usually think of vaccines, but potentially hundreds of individual versions.

One patient. One tumour. One mutational fingerprint. One tailor-made medicine.

As a pharmacist, I find this almost as fascinating as the trial results themselves, because a massive part of the history of pharmacy has been an attempt to produce a drug that is identical every single time it leaves the factory floor — in every batch, in every pill — and that can be dispensed to millions of people.

We are now seriously entering an era where manufacturing facilities are expected to reliably and rapidly produce a sophisticated pharmaceutical whose entire target population might consist of… one person.

Why is this even necessary?

Because cancer is not some foreign invader that has breached our borders, leaving us to merely teach the immune system what the enemy uniform looks like.

Tumour cells are our own cells.

That is the gist of the problem.

They have mutated enough to become dangerous, but not always enough for our defence system to readily recognise them as threats.

To put it visually: intismeran does not hand the immune system a photograph of a “typical criminal.” It assembles a police mugshot lineup of suspects taken specifically from your own tumour. Up to 34 photographs — or neoantigens — that T cells are supposed to learn to look for.

And that is where Keytruda comes in.

Over the course of their evolution, tumours have learned to hijack the immune system’s natural brakes, effectively signalling it to stand down. Pembrolizumab blocks one of those checkpoints, PD-1, allowing T cells to resume the attack.

Put very plainly: Keytruda lets the police out of the station; the personalised vaccine hands them the wanted posters.

What makes all of this even more compelling is that it happens at a stage when the patient no longer has a visible tumour.

At first glance, that seems paradoxical. Why vaccinate someone against cancer right after the cancer has been removed?

Yet that may be one of the profound lessons from several decades of mostly frustrating attempts to develop therapeutic cancer vaccines.

It is much harder to get the immune system t overcome a large, heterogeneous tumour mass that has already built its own microenvironment, erected defences and begun metastasizing, than it is to send the cells on a targeted hun after a surgeon has whittled the enemy down to just a few possible surviving cells.

This is the concept of minimal residual disease: every scan might come back clean, but oncology has learned too often that “we can’t see it” and “it isn’t there” are not always the same thing.

The new vaccine is trying to bridge precisely that gap.

The Best Way to Spoil Our Own Good News

At this point, however, we need to burst our own bubble.

Moderna and Merck have not published the complete Phase III results.

For now, all we have is what the industry calls a topline result: we know that the trial met its prespecified endpoints, but we have not yet seen all the numbers, the survival curves or the absolute margins between the two groups.

And the study is continuing, in part because of what is probably the most important question for any patient:

Will this therapy actually help people live longer?

So no, we did not suddenly get “the cure for cancer”, and I would not go popping the champagne in an oncology clinic just yet.

But perhaps we can already put the bottle on ice, because this is not the first encouraging signal that we’ve got.

In an earlier Phase IIb trial, after five years of follow-up data, the same combination cut the risk of recurrence or death by 49 percent, and reduced the risk of distant metastasis or death by 59 percent compared to Keytruda alone.

Now that concept has passed a much bigger test for the first time.

Which brings us to perhaps the greatest historical irony in this entire story.

Most of the world first encountered the term mRNA in 2020 and naturally came to associate it – permanently – with Covid. As a result, there is now a widespread assumption that we first developed mRNA vaccines to fight the coronavirus, and only later did someone wonder if perhaps the same technology might also work against cancer.

The truth is far more compelling, and practically the reverse.

Scientists had been developing mRNA as a platform for therapeutic cancer vaccines for years before anyone had heard of SARS-CoV-2. Personalised neoantigen vaccines and clinical oncology programmes existed before the pandemic.

Covid then gave that technology something no laboratory could have provided on its own: previously unimaginable funding, hyper-accelerated industrial scaling, massive global manufacturing capacity, and experience gained from billions of doses.

One of the more pleasing ironies of modern medicine is that early cancer-vaccine research helped prepare us for the pandemic, and all that experience gained during the pandemic may now be paying its debt back to oncology.

In other words, perhaps we simply mixed up the running order of the play.

Covid was not to be the climax of the mRNA revolution, nor its glamorous premiere.

It was only the dress rehearsal.

And then comes the more uncomfortable social irony, which is hard to ignore.

For years we listened to the claims that children should not be vaccinated, that Covid shots will “show their true consequences later,” that mRNA is a reckless experiment and that nobody knows what it will do to us in a few months, or a year, or two…

And now even the infamous five (5!) years have passed, and still no mass die-off from Covid vaccines.

Yet the moment we utter the words “cancer vaccine,” and the conversation across a large share of the public will probably shift dramatically.

It will no longer be “would I take it?” but “which one can I get?” American, Russian, maybe Chinese?

During the pandemic we already had our own little vaccine “buffet,” as the inimitable Vedrana Rudan put it, where choices were often made less on the basis of medical data and indications than according to political, ideological or geopolitical taste: I’ll take the Russian one; I only want the American one; I trust the Chinese one; I don’t trust the Western one…

As if we were buying a car or picking a football club, rather than assessing a medical treatment on its balance of benefits and risks.

And so I find it entirely plausible that one day we will see someone who once dismissed an mRNA virus vaccine as an unacceptable experiment begging to receive the same technological platform as quickly as possible when it offers an additional chance that their melanoma will not return.

That is not as hypocritical as it may seem at first.

The technology has not changed. What has changed is what we put on the other side of the scale.

It is one thing to imagine a possible vaccine risk when you feel perfectly healthy, and quite another to make that choice while, sitting right accross the desk in the doctor’s office, is the the disease that has already tried to kill you once, perched like a sinister imaginary friend, grinning at you.

Our relationship with vaccines has never been purely about science. Data, trust, identity, politics and, above all, fear have always been mixed together.

The only question is what we happen to fear more at any given moment.

If this therapeutic approach is confirmed by the full data and goes on to receive regulatory approval, the next challenge may no longer be whether we can do it, but whether we can do it for enough people.

How do you organise a system in which a tumour is taken, sequenced, its mutations computationally analysed, the best neoantigens selected, an individual mRNA product manufactured, quality control completed, and the treatment delivered to the patient quickly enough?

How does a regulatory agency oversee a drug that is, by definition, different for every patient?

And perhaps most importantly: how much will all of this cost?

“Personalised medicine” sounds like the realisation of one of medicine’s oldest dreams until we ask the uncomfortable question of whether it will truly be personalised for everyone, or only for those whose healthcare systems or private insurance can afford a factory making a medicine practically just for them.

This is why Merck and Moderna are not betting on melanoma alone.

They are testing the same principle in other cancers.

If the model proves transferable, the real revolution may not be a single new vaccine but the platform itself, the production pipeline that gets us there: remove the tumour, read its mutations, identify its weaknesses, draft the mRNA message and dispatch the instructions to the immune system.

Then repeat the process for the next patient, whose tumour is different.

And the next.

And the next.

That is a radical paradigm shift — moving away from a single drug designed for millions of people and towards the capability of making millions of different medicines for millions of different patients.

Somewhere in that shift may also lie the way to make the entire system, and the final product itself, affordble once the process becomes established across sufficiently large patient populations.

My Medical File Is Not Your Medical File

And in the end I come back to my battered medical file.

I dragged it across oceans, carried it through airports, in backpacks and in car trunks.

Always within arm’s reach.

Was it because I genuinely thought I might need it at any given moment, or because it gave me some primitive illustion of control over something that by definition resists control?

Today, I do not think about melanoma every day. Nobody could live like that.

But cancer permanently changes the weight of some very ordinary words.

A “check-up” is never quite just a check-up again, and “no abnormalities found” becomes one of the most beautiful phrases in the language.

In the same way, the term “recurrence-free survival” is not, for me, merely an endpoint in a clinical-trial protocol.

It is another birthday without cancer.

Another year in which the one cell you feared did not come back to unleash chaos and hell.

It isn’t just survival. It is life.

That is why I do not want to frame this news as a miracle.

Miracles are very dangerous currency in medicine.

If the full data eventually shows a more modest benefit than we currently suspect, that should be said so.

If the therapy does not improve overall survival, that must be stated too.

If it proves too expensive, too complex or suitable for only a small number of patients, that too is part of the story.

Science is not religion, and one of its greatest strengths is precisely that every fresh piece of evidence has the authority to ruin a beautiful conclusion.

Yet something monumental has indeed happened.

I will say it again: for the first time, an individualised mRNA cancer therapy has passed a large Phase III clinical trial with a positive result.

We do not yet know whether we will one day look back on this August announcement as a historic watershed moment or simply as an important step along a much longer journey.

But once you have lived through melanoma yourself, it is difficult not to marvel at the fact that a therapy made from the genetic signature of someone’s own tumour succeeded in lowering the odds that the tumour would return.

For a long time, medicine has worked by making a drug first and then looking for the patients it might suit.

Here, the order is turned on its head.

First, there has to be you.

Your cancer.

Your mutations.

Your unique molecular signature.

Only then does the medicine come into existence.

And perhaps one day we will be able to tell some future traveller setting off to the other side of the world with a heavy medical file in their bag somebody nobody could tell me back then.

Not that we have a vaccine against cancer.

That would still be too simple and, in fact, inaccurate.

Rather, that we have a vaccine against their cancer.