The elevator doors open on the fifth floor at Johns Hopkins Hospital, and Peggy Murphy tentatively steps out, as if crossing a threshold in the struggle to stay ahead of her breast cancer. Last fall, she had been accepted into Dr. Leisha Emens' clinical trial testing an experimental breast cancer vaccine, one designed to teach her immune system to attack the tumors that had spread to her right hip.
She had been euphoric, given at least a chance to help her live-in grandchildren find the right path in life. But by spring, even after receiving four rounds of the vaccine, Murphy's bone scans were lighting up with cancer: in her left hip, her back, her skull.
So on this early July morning, the 57-year-old must leave behind her bold hopes for a cure. She is reverting to a more conventional therapy, one that she knows won't heal her but might give her a little more time. Doctors have recommended intravenous chemotherapy three weeks out of every four, a pattern of treatment that, if she is one of the lucky ones, could go on for years. Today she will have surgery to install a port under the skin in her chest to make it easier for nurses to give her that medicine.
"I'm having a hard time with this one," she says, slumping into a seat in the waiting room. Her clear blue eyes are red from the tears she shed on the ride from near Lancaster, Pa. "It represents the vaccine not working.
"It symbolizes being closer to the end."
She entered the trial certain the vaccine would make her better. Before she signed up, by happenstance she had met two women who were doing so well on the vaccine that their scans didn't detect cancer anymore. No one promised Murphy a cure - the lengthy consent form stated: "It is unlikely that you will be cured of your cancer if you join this study." But when she sees how well some of the others have done, she can't help but feel cheated.
Why didn't it work for her?
Emens has no answers to give Murphy, or any of the other women participating in her trial. Her experiment is not done. At the same time, Emens must keep an eye on a more distant horizon the women may never see: the day when their daughters may get a vaccine to prevent a disease that still kills 40,000 American women each year.
Emens believes she can train the body's immune system to recognize cancer and destroy it. But at this point, her research can only look at whether the vaccine is safe, whether it elicits an immune response and what doses of chemotherapy should be given to rev up the immune system to attack. Emens knew there would be failures on the way there - even in mice, under ideal conditions, only 30 percent were cured of their cancer.
Murphy knows she is one of those failures.
Why didn't it work for her?
Does the vaccine work better in women with certain types of breast cancer? In those whose cancer has spread to their organs but not to their bones? In those who have not had extensive chemotherapy in the past? Did it matter how much chemo they get before and after the vaccine? The women received varying doses. Through the first trial, which the last woman completed this summer, Emens has learned that more chemo isn't always better. Too much, it turns out, may be killing off just what the vaccine is trying to enhance.
As Emens solves some of those mysteries, and each vial of blood taken could yield additional clues, she hopes she is moving closer to developing a vaccine that works better than this one.
For the present, though, Murphy considers herself a casualty. "Tomorrow, I'll be a fighter," she says, her accent revealing a childhood spent on Long Island. "Today, I don't feel like it. Today I'm angry."
A hard life
Murphy has rarely had it easy. An early divorce left her a single mother of two. There have been times when she had to do that all over again, taking in her two grandchildren, ages 6 and 7, when her daughter Tracy Ramirez, now 26, hit some rough patches.
All four of them live together in the two habitable bedrooms of Murphy's split-level duplex. Her daughter is on track for the moment. The family lives off Murphy's Social Security and Ramirez's food stamps. The children are finally learning how to read, now that they aren't switching schools all the time.
Murphy doesn't like to think about what will happen when she is gone.
"Life isn't about waiting for the storm to pass," reads a framed picture on the living room wall. "It's about learning to dance in the rain."
Murphy has spent most of her life in jobs like waitressing, jobs that didn't hold much room for advancement. She considers herself almost lucky that she got sick in the years after she became a postal clerk. The job came with health insurance.
Five years ago, Murphy felt a lump. She says she tried to get a doctor to pay attention to it, but he ignored her. It took nearly nine months before breast cancer was diagnosed. She had a mastectomy and chemotherapy, and was sent on her way with a clean bill of health. The treatment was difficult, but it was over. She didn't know the cancer could come back.
But after months of complaining of pain in her hip, again to doctors who dismissed the aches as arthritis, she was told in February 2007 that the breast cancer was now in her bones. This time, she learned, would be different. Her cancer was no longer curable. She decided she didn't want chemotherapy again, because for women with metastatic disease, it is not a cure. It might not even extend her life. There was a chance Emens could. It took eight months of fighting with her insurance company for approval before Murphy finally got her first vaccine last October. But soon after she got her last shot this spring, it was clear chemo was becoming her only option.
Crying for everyone
There is so much on her mind six days after her July surgery. She is scheduled for chemotherapy the next morning. In a rare moment of quiet time, she decides to sit down and write about her feelings.
"I feel horrid about starting the treatment tomorrow," she writes. "What is the pay off? I'm not sure there is one. I am crying for myself and for everyone else who has to go through this knowing it is not a cure but a surrender to the idea that nothing else is, and the end is inevitable. ... And tonight I am having strong thoughts of what is the use of putting myself through this. A big part of me wants to cancel this and hope for the best."
Lately, Murphy has felt alone. The other women she knows in the trials are doing so well. Why didn't it work for her?
Of course, she doesn't know all of the women. She knows just a handful and has heard about a few more, hardly a statistically significant collection. She has no real data. Emens didn't introduce the other study volunteers. That sort of thing is frowned upon in clinical trials. But some of the women have spotted one another in the phlebotomy lab, in the infusion center, in the waiting room, and struck up conversations. Some have become friends. They talk on the phone. They send e-mails. Once, a group even went to dinner in Fells Point.
But more recently, Murphy has started to learn she isn't the only one who's failing. Just the other day she saw one woman from the trial - who was once doing so well - barely able to get around and looking as though she was ready to die.
Disappointing test results
She also learned about Annie Siple, a waitress from the Orlando, Fla., area, who had been certain the vaccine was working, only to learn that it was not.
As summer arrived and Siple began to take those vacations she had long put off, to live the summer as if it would be her last, she got back some scary blood test results. Tumor markers in her blood, signs of proteins given off by some cancers, were on the rise. In the 10 days after her May appointment in Baltimore with Emens, they went up nearly 400 points. By the end of June, they had gone up 1,000 points, double what they had been the last time she saw the doctor.
The numbers shook Siple, who had sworn she would never have chemotherapy, who above all else wanted to remain in the vaccine trial. She hurried back to Baltimore for more tests in July, which confirmed that her liver tumors were still growing and that, in six weeks, a new one had appeared. Now she was throwing out the names of different chemotherapy drugs, asking Emens her opinion. Emens seemed to endorse her intention to at least consider a more proven therapy this time around.
Siple is a whirlwind that afternoon at Hopkins. Her tests and doctor appointments run late, so she has just minutes to see Emens before catching a plane. She isn't going home to Florida. She wants to fly to Seattle to consult a cancer doctor who uses alternative therapies. And she hopes to go to Chicago soon, to see another doctor who uses chemotherapy with a twist, and to anywhere else she can find someone to save her.
"I'll do what it takes," Siple says as she races out the door to a waiting car. "I want to live."
MORE ON THE SERIES
Coming tomorrow in The Baltimore Sun: Getting the experimental breast cancer vaccine isn't as simple as getting a tetanus shot - it's more like having a part-time job with an uncertain payoff.
Online at baltimoresun.com/vaccine: Watch a video of Peggy Murphy discussing her recurrence of breast cancer and find more photos, videos and previous installments of the series.