Skin pathologist fights own skin cancer with immunotherapy

Everything seemed to be going Nicole Dominiak’s way. After four challenging years of medical school, she was finally about to graduate. And to make things even better, her wedding was just three weeks away.

But something was off. Or, more accurately, on - as in, something was on the back of her right shoulder. It was a small, raised spot. “I was on rotation with a dermatologist and asked her to take a quick look,” Dominiak said. 

That led to a life-changing test. The young doctor-to-be found herself on the other side of the examination room as a patient. She had melanoma, the most serious form of skin cancer, and it was stage three. “Within 18 hours of that test, I was in surgery.”

The timing was terrible in many ways. The diagnosis cast a frightening shadow over the rest of school and her wedding preparations. But Dominiak said if she had to be diagnosed at all, her timing was good in one important way. Immunotherapy, which fights cancer by revving up the immune system, was showing real promise, beating back cancer in about 20 percent of cases.

Dominiak wanted to be one of those cases.

The disease didn’t run in her family and she wasn’t a sun worshipper, so the 26-year-old medical student had been blindsided by her diagnosis. But once she knew she had cancer, she was ready to fight.

Dominiak’s first operation showed the cancer had spread beyond the original tumor. Doctors removed the rest of the lesion on her back and found that the melanoma had spread to the lymph nodes under her right arm, so they removed them as well.

Dominiak somehow managed to finish school and get married.

“The middle of June I moved down here from Toledo to start my residency. It was a complete whirlwind,” Dominiak said.

With the help of melanoma specialists at MUSC Health, she started immunotherapy to try to keep the cancer from returning. Interferon, a protein that helps cells communicate and works with the immune system, occurs naturally in the body. Dominiak’s doctors thought if she had more of that protein, it might give her immune system an extra kick to help it keep her cancer from recurring.

“I did the subcutaneous injections as opposed to IV therapy because it would be easier to tolerate,” Dominiak said. “I did that for almost two years. I was very lucky in terms of side effects, but it was not easy.”

Interferon can cause flu-like symptoms, including fever, body aches and a headache. Dominiak had her treatments on Fridays so she could recover as much as possible over the weekend and go back to work on Mondays.

Immunotherapy helped keep her cancer at bay for those two years, but Dominiak’s fight wasn’t over. Melanoma is known for its ability to spread to other parts of the body, and in her case, it lived up to its reputation. In mid-2014, doctors found cancer on one of Dominiak’s lungs. She had surgery to remove it.

Two months later they spotted cancer in her brain. She started ipilimumab, another immunotherapy agent. “I progressed further, developing metastases to my liver, more lesions in my lungs and some lymph nodes.”

But the young doctor continued her residency with the support of her colleagues at MUSC. And then, something went Dominiak’s way.

In the time since her initial diagnosis, the Food and Drug Administration had approved the pembrolizumab for melanoma treatment. The drug is a checkpoint inhibitor; it tells the body that the “checkpoints” cancer uses to ward off the immune system should be ignored. Former President Jimmy Carter was treated with pembrolizumab for his melanoma, and about six months ago, said he was “cancer free.”

Dominiak was able to start using the new drug in November of 2014, and she’s still on it. So far, so good, she said. “As of my last PET scan, the lesions have completely regressed. We’re watching and waiting.”

She now sees her chosen area of medicine, dermatopathology or skin pathology, in a new light. As a patient, she’s optimistic. “Knock on wood, if pembro doesn’t work, there are other lanes we can take.”

As a doctor-scientist, she’s focused. “Even before I was diagnosed I knew I wanted to practice dermatopathology. There will forever be an interest in this area,” Dominiak said. “No, not just an interest. It’s a passion now.