MENTAL HEALTH OCTOBER/NOVEMBER 2013 BY SUSANNAH GORA Actress Valerie Harper on Living with Brain Cancer Harper discusses her diagnosis, keeping a positive a}itude, and her acting career. "For more than 40 years," says Valerie Harper, with warmth and gratitude, "people have embraced me as their own. They have treated Rhoda like family." Indeed, week after week, we welcomed Harper into our homes as the lovable, wisecracking Rhoda Morgenstern on The Mary Tyler Moore Show, and later on her own spinoff, Rhoda. We laughed with her, cried with her, and rooted for her. Fifty-two million of us even tuned in to watch her get married. Maybe that's why it felt as if a member of our own family was sharing some difficult news when Harper revealed in March of 2013 that she has leptomeningeal carcinomatosis (LC), a rare and incurable form of brain cancer. Then again, as the four-time Emmy winner wisely points out, "All of us are terminal. Nobody is promised the next day, or the next moment. So live every moment, in the moment." Although there is no cure for LC, Harper has responded well to treatment and her positive attitude knows no bounds. "I have to walk slower," she says, "but after [this interview], I'm going to get out there and take a walk and breathe the beautiful air. It's a pretty day here. Seize the day!" Valerie Harper in 1974 in the Telling the Truth TV role for which she is best January of 2013 was an exciting time for Harper. While known. Photofest getting ready to take her show Looped on the road (for which she'd received a Tony nomination for her portrayal of screen siren Tallulah Bankhead), she was also preparing to promote her autobiography, I, Rhoda (Gallery Books/Simon & Schuster). The book ends on a high note: Harper's victory over lung cancer, which the lifelong non-smoker had been treated for in 2009. "It was gone," says Harper of the disease, "and I felt it was gone, and I was getting screened regularly." But one day, while rehearsing Looped in New York, Harper began feeling strange sensations. "I started having numbness in my jaw," she recalls. Harper was eventually diagnosed with LC, which occurs when cancer cells invade the spinal fluid inside the meninges (the membranes covering the brain and spinal cord). "The brain, spine, and nerve roots are all bathed in spinal fluid, and so LC can affect any of those," explains Jeremy Rudnick, M.D., a neuro-oncologist on the faculty of neurology and neurosurgery at Cedars Sinai Medical Center in Los Angeles, CA, and a member of the American Academy of Neurology (AAN), who treats Harper. Unlike more traditional cancers, in which there is often a solid "chunk" of tumor, the cancer cells in LC are diffused throughout the liquid of the spinal fluid. This makes the condition extremely difficult to diagnose and treat—and impossible to cure. "As you are treating the cancer cells," says Lynne Taylor, M.D., neuro-oncologist, director of Palliative Care at Tufts Medical Center, and Fellow of the AAN, "they are continuing to divide. Eventually they can get in the way of vital bodily functions such as swallowing and breathing." Harper's LC was diagnosed by lumbar puncture (spinal tap) and magnetic resonance imaging (MRI). If the cancer cells have accumulated in the meninges surrounding the brain, symptoms can include "headaches, confusion, vision problems, and hearing and balance disturbances," explains Dr. Rudnick. LC that has settled in the meninges surrounding the spine can show up as numbness or weakness in the arms or the legs or a tight, band-like sensation—something Harper had experienced around her abdomen before her diagnosis. Left to right: Harper with Moore on The Mary Tyler Moore Show, 1975; getting married to David Groh on Rhoda; 1974, as Tallulah Bankhead in Looped, 2010; signing her book, I, Rhoda, in 2013; and a quiet moment in Santa Monica with husband Tony Cacciotti in 2013. Mary Tyler Moore, Rhoda: CBS Photo Archive/Getty Images; Looped: Amy Sussman/Wireimage/Getty Images; I, Rhoda: Paul Redmond/Wireimage/Getty Images; Santa Monica: Splash News/Splash News/Corbis LC is never a primary cancer—it spreads from elsewhere. "This is a metastasis," says Dr. Rudnick, "so it's coming from another cancer in the body." In the case of Harper, "she had a lung cancer that was taken out years ago, and essentially, some of these lung cancer cells found their way to the brain," Dr. Rudnick says. LC is rare (affecting about 5 percent of patients with cancer), but doctors are seeing more of it. As Dr. Taylor explains: "Paradoxically, as treatments for cancer— particularly of the breast and lung—have gotten better and patients are living longer, that gives more time for the tumor cells to escape and hide in the nervous system. The immune system can't see tumor cells in there as well as it can in other places," explains Dr. Taylor. Harper could have kept her diagnosis private, but it was important for her to go public. For one thing, she wanted people to "understand that I wasn't lying to them about beating cancer" in her autobiography. She also hoped that this could be an opportunity to help people learn about her disease. She and her doctors showed audiences an MRI of Harper's brain on the TV program The Doctors. (Watch the video here.) Mainly, she wanted her fans to know that she is OK. Cuing Edge Treatment She is indeed OK. Although her illness is incurable, Harper is responding well to the cutting-edge treatments she has been receiving. "With Valerie, we were very innovative in our approach," says Dr. Rudnick. "We actually went back to her original lung cancer sample." Harper explains: "I had a lung cancer tumor removed in 2009 by a wonderful surgeon. And my doctor asked me at the time, 'Can we keep this for research?' I said, 'Sure, why not? What am I going to do with a little tumor from my lung?' I had no idea it was going to play such an important part in my life." Once Harper was diagnosed with LC, her team of doctors at Cedars Sinai was able to have the original lung cancer tumor tested in a process called next generation sequencing, which identifies specific genetic mutations within tumors. When the genetic makeup of a tumor is revealed, doctors can use that information to choose which cancer drugs might be most effective against the tumor. Even though Harper's cancer is in her meninges, the cancerous cells are actually lung cancer cells, and so the disease is being treated as a lung cancer. Hundreds of tests were run on her lung cancer tumor; and as Dr. Rudnick explains, the tests revealed "she has two very rare mutations in the epidermal growth factor receptor"—a protein that is found at unusually high levels on the surface of many kinds of cancerous cells. Next generation sequencing helped Harper's doctors decide which drugs might work best in treating her LC. Harper is being treated with the drugs Tarceva, which is a pill, and Alimta, which is injected (generic names erlotinib and pemetrexed, respectively). Harper's doctors have also taken a forward-thinking approach when dealing with one of the greatest challenges in treating LC: getting medicines across the blood- brain barrier. This barrier evolved to help protect us by preventing all sorts of microscopic objects (such as bacteria) from being able to pass from the bloodstream into the spinal fluid and brain. However, this also means that medicines often can't get into that area in high enough concentrations to be effective. But Dr. Rudnick looked closely at reports coming out of Memorial Sloan- Kettering Cancer Center (where he trained) suggesting that "it's possible to give large quantities of these drugs once a week instead of giving smaller quantities of them daily—and by doing that you increase the quantity of the drug in the spinal fluid. That's exactly what we've done with Valerie, and it has worked beautifully with her." Harper has also come up with some nifty tools of her own: "I talk to the cancer cells —I do the stuff that actors do, called visualization. I tell the cancer cells that they are the dumbest cancer cells I know because they are killing the host. I say to them, 'If you would just coexist with me, we could have a nice life!'" She tells of a friend also coping with cancer who imagines "Hasidic rabbis jumping out of a synagogue with little canes and caning the cancer cells. Another friend imagines cancer as black sludge in his prostate; he visualizes going in with a fireman's hose and hosing it all out." She has also made up a special acronym for one of her drugs: "Tarceva: To Aggressively Remove Cancer Everywhere, Valerie Announces!" TV History It's that kind of spunky optimism that has endeared audiences to Harper over the decades. She's been brimming with it her whole life. A gifted entertainer since childhood, Harper studied at New York City's famed Quintano's School for Young Professionals, where her classmates included Sal Mineo and Tuesday Weld. In 1970, Harper (who had by this point moved to California with her then-husband Dick Schaal) was performing in a play that only ran for two weeks—but at one of the performances, a woman named Ethel Winant, the then-head of casting for CBS, was in the audience.