Doctor's Appointment after Final Chemo

It's been five weeks since my last chemotherapy. I had an appointment with my oncologist today to get the results of recent lab work and a CT scan. My blood and kidneys are in good shape. The CT scan showed an increasing accumulation of fluid near the pericardium that will be examined with an echocardiogram in a little over a week. The doctor doesn't think it is anything to worry about, but then they never thought they would find mesothelioma when they did the thorascopy either.  The cancer in the pericardium cannot be imaged by a CT scan, so there is no way to know if it has changed; however, the tumors that can be seen in other parts of the right chest, seem to be smaller than in the last scan.

My blood sugar levels are high again as they were a few years ago, so he started me on metformin. That and elevated blood pressure may be at least partly the result of the chemotherapy. We'll have to see what happens with time. I am looking forward to the echocardiagram, however, because I have not had that test before. Another opportunity to learn.

I want to urge you to take a look at the Uncle Sam and Gini entry if you have not done so yet. If you make it to the end, I’d be curious to know what you think.

There's not much cancer news now, so if you check by here periodically, you might want to extend the time between visits because I do not expect to write any new posts for a while. If I do, I'll put a note on Facebook so my friends there we know to take a look at Cancer Couple.

Best wishes for a beautiful spring (or fall for those in the southern hemisphere).

David

Uncle Sam and Gini

Returning to the States in 2008, I was struck by the extreme range of income visible in the US compared with the military communities with which I had been associated overseas.  Over the past two and a half years, I have become convinced that income inequality is a serious problem for the US and wrote a piece to put my thoughts in order. 

I would be honored if you would take a look at Uncle Sam and Gini in the Other Pages column on the right, and let me know what I got wrong in my analysis.

Thanks.

David

This and That

Second Time to Ring the Bell

I don't know if they do this everywhere, but both the M. D. Anderson Cancer Center and Scott & White Healthcare have a big brass bell that patients ring when they have completed a course of cancer treatment. I rang my first bell at M. D. Anderson in late February, 2002 when I completed my radiation therapy for prostate cancer. Yesterday, I rang the bell after completing my chemotherapy for mesothelioma. It's possible that I'll have one or more additional chemotherapy courses later, but I'm glad to be done for now.

I'll go back for a PET scan and blood work in a month. and the results will set a baseline against which to compare scans and blood work every two months after that.

Jana's CML Blood Test Results

We also got blood test results for Jana yesterday. By mid-July, four weeks after starting Gleevec, Jana's white blood cell count had dropped about 96% and into the normal range. It has remained low since then, and the count on January 20 was actually slightly below normal.

The results of a more sensitive PCR blood test using DNA has also been positive. The test compares the ratio of the cancerous product of the cancer cells with the product of a ubiquitous product of all cells. The goal is to reach zero percent which is called the complete molecular response. At that point there are probably still aberrant stem cells turning out cancerous white blood cells, but the number is too small to be detected by the test.

Here are the results of her three PCR tests for the BCR/ABL translocations.

July 14, 2010: 6%

October 14, 2010: .05%

January 31, 2010: .04%

The change from October may not be particularly meaningful. It's in the right direction, but could be a result of the unreliability of the test. The report provides no interpretation. However, given the 96% drop in the WBC count in the four weeks prior to the first PCR test, I imagine the drop by October would be considered what they call a major molecular response. A complete molecular response is usually accomplished within 12-18 months of treatment with Gleevec, so the timeline for the complete molecular response stretches many months in the future.

David

Oncologist Visit and PET Results Prior to Chemo Round 5

On Thursday, I had an appointment with my oncologist prior to the start of my fifth round of chemotherapy. We reviewed the results of my PET scan (see post from July 5, 2010 ) from the day before, and the results were positive. There has been no spread of my mesothelioma outside of the right half of the thorax, and those nodules showing enhanced sugar usage have remained stable. The current PET was compared with one from June before the removal of the tumors in July, and the absence of those tumors was noted. I also learned that my 6th, 7th, and 8th ribs were broken in the rear during my July surgery in which the 7th rib was removed, and the breaks have healed. I judged it to be a positive report.

I also asked about the growth curve of my tumors. I assumed that the size of the tumors would increase geometrically because each cell division doubles the number of cells. For example, one cell becomes two, then the two cells divide giving four, etc. I assumed that growth would be rapid near the end of life, but the doctor said that was not a characteristic of this disease. The growth rate is more linear. That was reassuring because I do not want to be caught up short at the end. As the end comes near, things have to be put in order, and explosive growth might be a problem; however, it might mean a longer period of suffering.

I also learned that I will have only six rounds of chemo instead of eight. I don’t’ know where we got the idea that I would have eight rounds, probably from the thoracic surgeon, but I was pleased to know that I will have only to do one more. Then the imaging will be updated to form a baseline that will be repeated every eight weeks.

All in all, I found it to be a positive appointment, and I think I am still in the long tail (see The Median Isn't the Message in the Other Page Section).

David

Chemo: Round 4

I began my fourth of a possible eight round of chemo therapy on December 30. It has become somewhat routine now in terms of my knowing what to expect at different points in the cycle; however, this round involved a new wrinkle—monitoring my blood sugar levels. In the weeks prior to this round, I discovered that my blood sugar levels were high. Several years ago, I was borderline for diabetes, so my doctor started me on metformin, and I began to watch my diet, lose weight, and exercise regularly which allowed me to reduce my blood sugar to acceptable levels and get off of the metformin. Since I’ve developed cancer and had the various surgical procedures and chemotherapy, I have stopped exercising and my weight has crept up somewhat, and my blood sugar levels are higher than they were before I started taking metformin.


I talked to my doctor about my blood sugar levels before beginning round 4. He said the steroids were likely the cause of the high glucose levels and at first suggested not taking them this round. Then after some discussion, the decision was to continue with the steroids but to monitor my blood sugar. The normal routine with the steroids is to have two pills at the time of the chemo infusion, then to take two in the morning and two in the evening for two days then one in the morning and one in the evening for two and a half days.

When my blood sugar level hit 436 at 10 pm on the first day after chemo and was at 374 the next morning, I took two steroids and began looking at other options. Given that it was the New Years weekend, I did not try to contact my doctor or the oncologist on call but did some reading on the internet. I knew from previous reading that Benadryl has anti-vomiting properties, and I had heard it being given by IV to a nearby woman in the infusion room, so I begin looking at the recommended dosage for nausea and if there were any drug interactions between Benadryl and the other drugs I was taking.

From what I could find, it looked like Benadryl is a very safe and very useful drug, so I decided to take it in place of the steroids and hope that my nausea would be controlled. I would taper off the dose just as the steroids were tapered off, and stop the Benadryl on the same schedule as the steroids. It worked. The doctor had said that he was concerned about blood sugar reading above 300, and by the day after stopping the steroids my levels stayed below 300. My levels are still too high, so I will have to talk with the doctor about where to go from here, but I was pleased that I was able to get below 300 without nausea.

Fatigue was a bigger problem than usual this time. Usually on about the fourth day after the infusion, I hit a wall of fatigue that lasts for four or five days. This time, it seemed worse than before, and I did little those days; however, by a week or so after the infusion, I was sufficiently energetic to work most of the day in the yard raking, mulching, and bagging leaves. From what I can tell, the cause of fatigue associated with cancer treatment is not well understood. I had some fatigue when undergoing radiation treatment for prostate cancer. I hypothesized that dying cells gave off compounds that told the body that it was injured and to take shelter and lie low. If so, then it seems that my chemotherapy must be killing more cells than my radiation did because this fatigue is much greater than what I had before.

David

Posting Hiatus

Our cancer news has become pretty routine, so I do not expect to add any posts until after the New Year. I’ll put an announcement of Facebook when I add the next post. Thanks to all who stop by to check in, and best wishes for a great holiday season and a happy and productive New Year.

David

A Good Source of Oncology News

Take a look at the top listing in the sidebar to the right.  I added a section with links to oncology information.  The first site, OncologySTAT, provide lots of information including free access to journal articles.  If you're serious about learning about cancer, I recommend taking a look.

David

Low-Dose Asprin May Lower Cancer Rates

Check out this article from the New York Times: http://www.nytimes.com/2010/12/07/us/07aspirin.html?hpw.  It looks like all adults ought to discuss starting a low-dose aspirin regimen with their doctor at their next checkup.

David

CT and Blood Test Results, Chemo Round 3

I completed my third round of chemo about two hours ago, and all went well.  I feel good.  I just wish I'd feel as good on Monday through Wednesday.

We saw my oncologist before chemo, and he reported that my blood counts, liver tests, and kidney function were all good.  He also had results from a comparison of my recent CT results with the scans from September and from before my surgery.  There was no noticeable change in the right thorax and no evidence of metastasis outside of it.  Given that they could not see any clear tumor mass the last time, I take the findings as an indication that my disease is at least stable. The results strengthened the cancer patient's chief bulwark against despair--the hope that treatment will at least provide a meaningful extension of life.

Another few thoughts on the topics raised in yesterday's post on the "Why Us" question.  I did not mean to imply in that post that the decisions we make do not have an impact on our lives, only that some events like an automobile accident, winning the lottery, or getting cancer are essentially independent of our actions.  They are not part of some grand narrative.  My understanding of how our actions affect the world and ourselves is consistent with the Asian concept of karma.  My interpretation of karma is as follows:

1.  The world in an extremely complex and interconnected entity.

2.  Our interactions with the world, our decisions and the actions that we take, affect the decisions and actions of others, and those actions and decisions affect even others, etc.

3.  We are impacted by the decisions and actions of others and those influences are at least partly shaped by our previous decisions and actions.  Our decisions find their way back to us through the actions of others.

4.  On the average, good or right decisions return good or right results.  Bad or wrong decisions tend to bring bad or wrong results.

Think of a pond filled with many vibrating posts where each post represents an individual.  The wave-like rings that flow out from my post strike and are reflected from other posts near me and interact with the waves produced by the vibrations of other posts.  The resulting waves return to me.  While the interaction of the waves and the posts is extremely complex, perhaps complex enough to preclude prediction, causality is still involved, and on the average, right action produces positive results and wrong action produces negative results.  One person making right decisions in a field (families, communities, and nations) where most are making wrong decisions will not benefit the one making right decisions much, but as fields are transformed from being composed predominantly of persons making wrong decisions to fields filled predominantly with persons making good decisions, the quality of life improves.  The difficult questions are how to identify good or right actions and how to promote right action.

David

Why Us?

The other day, Cancer Couple received a comment from a mother of two young children in Australia who suffers from a difficult-to-classify brain tumor and whose husband is doing well after an autologous stem cell transplant for AML/APL leukemia. You see her beautifully written blog at http://coogeegoo.wordpress.com/.

In closing, she asked, “How do you deal with the "why us?" response that has no answer?” It is a question that I have given some thought to, so I want to share a few ideas.

Many behavioral scholars believe that humans have a built in sense of morality based on cooperation through reciprocity and punishment. It is in our nature to cooperate with others as long as there is reciprocity. I’ll help you, if you help me. However, because people sometimes cheat and do not reciprocate, we are naturally predisposed to punish violators. We have a well-developed sense of fairness that causes us to look for unfair behavior and seek punishment as a way of restoring fairness. An interesting article on the inborn morality of infants can be found here: http://www.nytimes.com/2010/05/09/magazine/09babies-t.html?_r=1&scp=1&sq=infant%20morality&st=cse

I believe our fairness detector is activated when bad events occur in our lives, and we look for reasons for those events. We want to find the meaning of the events so we can determine if someone has cheated so they can be punished. I remember my mother saying, “It’s not fair” with reference to my father’s development of malignant melanoma. He was a good man who worked hard to support his family and was always honest and fair in his dealings with others. My mother thought it was unfair that such a man should have cancer when others who in her view were not so good did not. She was searching for equity in a context in which fairness/unfairness, right/wrong did not apply. Some events have no meaning. The world is an incredibly complex place, and things we see as both good and bad happen essentially at random. That is, they are not part of some overarching, goal directed process. There may be causes for the event, but they are essentially random at the core, like winning the lottery.

I know Jana and I asked the question, “Why us?” but it is a question without an answer. It is as if a meteor had crashed through our roof and struck us down. We know what happened. We can understand the injuries caused by the mass of a meteor crushing our bodies, but to ask why the meteor hit our house instead of someone else’s is a waste of time even though asking the question is a normal response to the situation.

It is reasonable to look for the mechanistic causes of cancer, but the more we understand the biology of cancer, the more it appears that while some actions can reduce our chances of developing cancer, the initiation of any given case of cancer has a random component. A person may choose to smoke and knowingly increase his or her chances of developing lung cancer, but the actual development of the cancer lies in the interaction between the carcinogens in the smoke and the individual’s genetic makeup and lifetime exposure to cancer promoting life events. My father and his nine siblings grew up on a farm and spent a lot of time working in the fields under an intense sun, but he was the only one to develop melanoma. The development of cancer is entirely deterministic but of such a complexity that the absolute prediction of who will and who will not develop the disease is impossible to know at this time.

So that is my answer, Coogeegoo. It is natural to ask the question, “Why us?” but as you noted it has no answer. Please keep writing on your blog. You have at least one person who is not a friend or relative who is interested in monitoring your progress against this challenge that you and your family have been given at such a young age.

David