“The Beat Goes on” (Bono, S. 1967)

The seemingly never ending quest for the next steps in my cancer treatment took us back to Houston this week. On Wednesday I had another chest CT scan, had an appointment with a radiation oncologist, and a PET scan. What had been interesting the first time around (CT, PET, etc.) has lost its allure and become old. On Thursday, we met with the regular oncologist again.

I wrote last week about the difficulty of serving two masters, so it was interesting to hear the oncologist tell me that I was the “captain of the ship,” and the doctors are there to advise me. I didn’t bother to describe how it looks from the patient’s point of view. I may be the Decider to quote President Bush, but weighing the various points of view is not easy. As least I have the advantage of having some grasp of the subject matter and finding it very interesting.

The recommendation from the Scott and White oncologist is to have the chemotherapy. The radiation oncologist at M. D. Anderson seemed to second that opinion but added a round of radiation to follow the chemo. The other oncologist, whose background in internal medicine, suggested having the radiation therapy first and holding off on the chemo until later, if at all. I have attempted to capture his logic below:

1. Mesothelioma appears to be limited to the right chest cavity.
2. I have no symptoms or complaints from the cancer itself at this time.
3. There is little definitive evidence of tumors on the CT or PET scans. The increased glucose update measured by the PET could be caused by inflammation and tissue repair as much as by cancer.
4. Given the small amount of cancer evident on the scans, one cannot use the PET to determine whether or not chemotherapy is effective. The scans do not have that kind of resolution. 
5. There is no research to suggest that chemotherapy is more effective when there are few cells than when an observable mass is present.
6. IMRT is potentially “curative” while chemotherapy is not. Radiation has a good track record of producing local control of cancer following an extrapleural pneumonectomy (which I was going to have); however, the effectiveness is not clear following a pleurectomy (which I did have).
7. Therefore, start with the radiation because it has the potential to kill cells, then follow up with the chemo when there is enough tissue visible on a CT to determine it’s impact on the cancer.

At this time, I think Jana and I favor this approach although it means I’ll have to spend the work week in Houston for some time, perhaps two months. What’s really interesting is that the radiation oncologist has placed my case on the agenda for review by all the Thoracic Center staff (oncologists, surgeons, radiation oncologists, etc.) for Tuesday. They will put their many heads together and come up with a recommendation that we will hear on Wednesday. We’re really looking forward to what they come up with. Then the captain gets to weigh the evidence and make a decision. One thing is certain, there is no choice that is clearly the best. I don’t suppose it means that it doesn’t matter which decision we make, but it sort of seems that way.

La de da de de, la de da de die.

David

PS Thing are going well. I’m feeling better every day, and the discomfort from the surgery is decreasing. I’m getting out and walking for 40-45 minutes most mornings, and I hope to be off the vicodin in a few days. I'm cooking roast beef in red wine for dinner tomorrow night, and it would have been nice to have a glass of wine with my dinner, but I can't do that until I'm off the vicodin.