A Visit with Radiation Oncology

In October, 2011, I had a visit with a radiation oncologist at the time my tumors began to grow following my initial chemotherapy. (See the post entitled Tumor Growth? Exploring Cancer Treatment Options from 23Oct11). While Dr. Gaspar was willing at that time to do a work-up on me to see if radiation oncology could be helpful, but did not push it, I decided that there was no need to proceed with radiation and began the course of chemotherapy that has persisted off and on since that time.

With what may be the first signs of possible complications from the tumors—increased fatigue and shortness of breath, and perhaps more right-side pain than before—I asked my oncologist for a new referral to radiation oncology. I had my appointment today, and after a thorough review of my case and a physical exam, Dr. Gaspar once again concluded that there was not much of anything they could do for me now. The risk of side effects from the radiation continues to outweigh any possible benefits. I'll contact her again if problems arise. Jana and I are very satisfied with the outcome of the visit. It seems to make perfect sense.

David

Less Chemo Fatigue. Why?

The latest round of chemo produced significantly less chemo fatigue than normal. Usually, the fatigue begins on Friday evening after my Wednesday infusion and continues through Saturday and Sunday, and then lifts through about mid-week, so that by Thursday, I am most of the way back to normal. This time, I had only minimal fatigue on Saturday and Sunday. Why?

Three possible factors come to mind:

1. Current thinking about chemo fatigue suggests that it is caused, at least in part, by substances called cytokines that are released into the bloodstream by dying cells. It's like the body is telling you, “Hey, you're injured. Find a place of retreat where you can lick your wounds and heal.”

I have an hypothesis that when I begin a new series of chemo after a break (11 months this last time), the chemotherapy agent, pemetrexed, has lots of vulnerable cancer cells to kill, so lots of cytokines are released producing lots of fatigue. Given that pemetrexed only works on actively dividing cells, not all vulnerable cancer cells are killed with the first infusion, so there is a new crop of dividing cells ready to be killed by the next dose three weeks later. It seems to me that there would be fewer cells left that are sensitive to pemetrexed with each infusion; consequently, the fatigue would fade in severity. I have my next CT in a couple of weeks, and my guess is that my tumors will not have shrunk much, if at all, because six round of pemetrexed have gathered all the low-hanging fruit.

2. Perhaps the extra energy from the supplemental oxygen reduced the fatigue.

3. We started a new tradition this spring, and Jana makes me a “chemo cake” each time I have an infusion. This time, however, I got a chemo car instead of the cake. I bought a red, first generation Mazda Miata sports car. Do you think the new car helped fight the fatigue better than a cake?

Hello 2 O2

It's been a while since I've added anything to the blog, but that's because things have been pretty routine. However, since we've been doing more active work outside this summer I've been bothered more by a shortness of breath than before. For example, we recently removed recycled rubber from the walkway between the patio and the back yard, rearranged/replaced stepping stones, and adding pea gravel between the stepping stones. I found that only a little effort made me very short of breath and fatigued, and I had to take frustratingly frequent breaks. When we went bird watching with friends, I typically did not try to walk with the others because of my shortness of breath. Even light exercise like cooking turned me into a certified “mouth breather.”

So when I went to see my oncologist prior to my latest round of chemo, I asked to be evaluated for supplemental oxygen. I took a walk with a nurse, and my pulse oxygen level quickly dropped to the point at which I qualified.

The oxygen equipment arrived that evening—a two-part unit that contained an oxygen concentrator and compressor, two large and two portable oxygen tanks, a sort of pack with a shoulder strap for carrying a portable tank, and several nasal cannulas.

I placed the oxygen concentrator downstairs in the finished part of the basement. The concentrator removes O2 from the air, and a tube attached to the concentrator provides me with oxygen when I'm working at the computer in the workroom, doing something at my workbench in the basement, or watching TV in the family room. The compressor is connected to the concentrator and used to fill the small oxygen tanks for use upstairs and outside.

It's been almost two weeks since I got the oxygen equipment, and my use of it is still evolving. When I requested the evaluation, my concern was to have oxygen while active—doing light exercise around the house, more strenuous activity outside, or while walking in the mountains. It turns out that I use it more while sitting quietly in the house reading, working on the computer, and watching TV. While I don't feel like I really need it at that time, my pulse oximeter shows that my O2 level is below the expected 94% level. While working in the garage, I wheeled one of the larger tanks out there and found that worked better than carrying around the portable tank although it was something of a hassle working like a diver at the end of a long tube, but I enjoyed not getting short of breath. I am interested in seeing how my use changes with experience.

It's good to have the oxygen, but disappointing to need it.

Back in the Chemo Chair Again

Yesterday I had one of my periodic CT scans and got the results from my oncologist today. It's been almost 11 months since my last chemotherapy in April, 2013. Before going to see doctor, I reviewed my old CT or CT/PET reports and found that pemetrexed had generally decreased tumor size slowly while I was receiving it, which led me to think it was time to begin again. The latest report showed continued, slow increase in size, and there was an indication that the cancer in the area of the diaphragm has been pushing down on my liver which is not good. \

I have also been concerned about the mutations that are occurring in the tumors. My understanding is that when cells turn cancerous, the proofreading of the DNA when cells divide is damaged so that copying errors, a kind of mutation, become more frequent. I suppose many of these errors may kill the cells before they can grow, but as in evolution, some persist and reproduce. Some of these mutations give the cells the ability to grow and develop into well functioning tumors by acquiring the capacity to develop needed blood vessels to provide food to the cells and the ability to avoid detection by the immune system, for example. If pemetrexed takes out some or most of the cells that are undergoing cell division, then it may be removing some of the cells that are of benefit to the cancerous tissue and harmful to me. Ultimately the cells may acquire the ability to neutralize pemetrexed, but until that time, the drug can help keep the tumor-positive mutations from taking hold.  

Taken all together, my oncologist wanted me to go back on chemo, and I agreed. They arranged for me to get back into a chemo chair in the infusion center today, and I received my first new round of pemetrexed. I'll be getting chemo every three weeks now and will continue until it stops working, or until there are better options available (for example, a drug that unmasks cancer cells so the immune system can find and kill them). 

Luckily, the side effects of pemetrexed are not horrible, mostly a few days of fatigue, but it is something of an inconvenience and limits our flexibility.

What It's Like in the Chemo Chair

I'm not sure I've ever written about the process of getting pemetrexed, so I thought I'd write a description today in case anyone would find it interesting.

After checking in at the desk, I go to the waiting area while I wait my turn. They have a good selection of donated magazine there, and look for something interesting to read. Then an assistant comes in and takes me back to my chair. The chairs are like large recliners, and are in cubicles separated by walls or curtains and face a wall of windows that look out on the hospital and the mountains beyond. The cubicle has chairs for visitors, a table, a TV, and more magazines.

Then the nurse comes in and we begin. She (always been a woman) verifies my identity and ask questions about my current health that she enters into a computer on a rolling stand. They have to calculate how much pemetrexed I need based on my weight and height, and today I had to have my height measured for this year, and it has to be witnessed by two people.

She then accesses the port in my chest and attaches it to a bag of saline, and she also attaches a bag of Kytril, an anti-nausea drug, that infuses for ten minutes.  In the meantime, the oncology pharmacy is preparing my pemetrexed infusion based on my weight and height. When it is ready, she returns with the drug which is shrouded in a brown plastic bag, and with another nurse they verify who I am, what my patient number is, and what medicine I'm getting. Then the infusion begins and lasts for 10 minutes. She deactivates my port, and I am ready to go.

Most of the time is taken up sitting in the waiting room and waiting for my pemetrexed to formulated. I sit back in the recliner, and I always find something to read. Today I found a copy of Science magazine in the room and had the pleasant surprise of reading an article about the domestication of the dog that quoted Greger Larson, the son of our friends Roger and Jane Larson.

I don't typically like to drive after chemo (even though it does not seem to have any affect on me), so Jana goes shopping while I'm in the chair. Today we went to Schlotzky's for one of their good sandwiches on the way home.

The Cancer Chronicles

I've got a good book to recommend. When science writer George Johnson's wife was diagnosed with cancer he began a detailed study of the disease. His book "The Cancer Chronicles" uses his wife's diagnosis and treatment as a framework for describing what he learned. As we age, cancer seems to enter more and more of our lives, so if you'd like to know more about the disease, I highly recommend this book. Johnson and a great explainer.

http://www.amazon.com/Cancer-Chronicles-Unlocking-Medicines-Deepest/dp/0307595145/ref=sr_1_1?s=books&ie=UTF8&qid=1391718820&sr=1-1&keywords=cancer+chronicles

Asbestos Facts

Last Friday was Mesothelioma Awareness Day, and I have been asked by the Mesothelioma Cancer Alliance ( www.mesothelioma.com) to share some facts about asbestos, the cause of mesothelioma.  I can's say that I support a complete ban of asbestos, but its use should be limited to those that are safe and for which there is no better product. Interestingly, my oncologist says that because there is no heavy industry in Denver that uses asbestos, teachers are the occupational group with the highest incidence of mesothelioma here. 

September CT Results and Actions

I have been on a chemo break for four months now.  Yesterday I had a CT scan, and today we saw my oncologist.  The scan showed essentially no growth in one area and a small amount in another.  Dr. Camidge recommended not returning to chemo now, and I readily agreed.  We’ll wait three months between CT scans this time instead of the usual two.

That’s the good news for today, but we had a good discussion of the course of my disease, and what follows is a summary for any who might be interested.  No one was expecting mesothelioma in May, 2010 when the surgeon went in to do a thoracoscopic procedure to end the pleural infusion in my right lung.  When they found cancer, I went through a battery of tests to determine if I was a candidate for an extrapleural pneumonectomy—the removal of my lung—which had the potential of providing a cure.  I qualified, and when they went in, they found cancer in the sack around the heart and decided not to remove the lung.  Instead, they removed the lining of the chest cavity, the pleura, and removed as much of the cancer as they could.  One of my surgeons was very experienced with mesothelioma and must have done a very good job of getting out as much of the cancer as possible because I am still alive three years later.

It seems that my tumors are slow growing, not what I had expected from what I had read about the aggressive nature of mesothelioma.  It also appears that the chemo I’ve had has been effective in keeping it in check, but the researcher in me wonders how quickly it would have grown without the chemo given the slow growth during my chemo breaks.  In summary, it appears that relatively early detection, my generally good health, the skill of the surgeons, and the chemotherapy have combined to keep my cancer from growing too rapidly.  When I was diagnosed it was my goal to be in the long tail of the mortality curve (see the article by Stephen Jay Gould to the right), and so far, so good.

I also think psychological stress has played a roll in my cancers.  As far as I can tell there is no clear relationship between stress and cancer, but both of my cancers were detected in times when I was under greater-than-average stress.  My life now is virtually stress free, and our interactions with our daughters and their families and our friends are positive factors in our lives, so I think my body is better able to deal with the cancer and keep the spread low, especially since there has been no evidence on metastasis.  Thanks to all of you who read this blog for your support as well.

Good Cancer News

Jana and I both had visits with our oncologists today.  I have been on a two-month chemo break and had a CT yesterday to see what changes have occurred.  My scan was essentially unchanged from two months ago, so my doctor is happy with letting me extend my chemo break for another two months.

Jana has had periodic (usually every three months) blood tests for cells with the BRC-ABL mutation, the mutation that causes chronic myelogenous leukemia.  The number of cancerous cells dropped rapidly after she started on Gleevec three years ago and has remained at a low level since then.  Recently the concentration has been about 0.001% range.  This time, however, no cells were detected at all.  It doesn't mean that she's cured, but it does raise the possibility of going off of Gleevec if the cells are still undetectable in three months.  Research has shown that patients can go off of Gleevec for some time with out a problem.  If the cells return, then resuming Gleevec is generally effective in reducing the number again, and if it fails there are two other (apparently more effective) drugs that can be used.

All around, we were very happy with today's appointments.

100 Laser Shots to the Eye

I have just about all of the degenerative conditions of the pre-elderly, including glaucoma.  Yesterday I underwent a laser treatment for glaucoma that some of you may find interesting.

First a little background.  Glaucoma is a condition in which the internal pressure of the eye is too high.   Normally, the aqueous humor that fills the spaces in front of and behind the iris drains from the eye through a mesh-like structure called the trabecular network at the same rate it is produced.  With glaucoma, however, the exchange of fluid is out of balance and the internal pressure rises which damages the optic nerve if untreated.  My glaucoma is controlled by the use of two kinds of eye drops, but a relatively new laser treatment has been developed that has the potential to reduce or eliminate the need for drops.

The procedure is called Selective Laser Trabeculoplasty (SLT).  An earlier procedure used an argon laser to blast holes in the trabecular network to allow the fluid to drain, but the destruction it caused limited it to a single use.  The new technique is called “selective” because it only affects some cells in the network.  This laser is tuned so that only cells containing granules of melanin, the pigment that makes skin brown, absorb its energy.  As I understand it, the laser heats the granules and either kills the cells directly or injures them enough that they initiate programmed cell death and self-destruct.  With cell death, substances are released that activate aspects of the immune system that remodel the trabecular network and increase the outflow of aqueous humor.  The procedure can be repeated if necessary.

What is it like to undergo SLT?  First drops are used to constrict the pupil in the eye to be treated.  The drops can cause a headache, but that is generally the only pain associated with the procedure.  When the eye is ready, the patient sits in a chair opposite a chin and forehead rest similar to the ones used for a slit-lamp eye examination.  The doctor shines a low-power red targeting laser into the eye and aims it at the edge of the cornea.  When the beam is in the right position, the doctor fires the laser, and the patient sees a flash of green light.  The doctor moves the targeting beam to another location and fires again for a total of about 100 short that cover the circumference of the cornea.  I found the treatment to be completely painless, and it took perhaps five minutes to make the 100 shots.  I have to use anti-inflammatory eye drops four times a day for four days and go back in two weeks to see if the treatment was a success.   If so, then the other eye will be treated.

I was attracted to SLT because it has the potential to make structural changes to the trabecular network that provide at least a temporary “cure” for the disease.

School's Out For the Summer! -- Reprise

Today I got the results of my latest CT scan from my oncologist today.  My tumors remain stable.  In fact, they have not changed meaningfully since I started my latest round of pemetrexed chemotherapy last August.  Now, 12 infusions later, I got down on my knees and begged my doctor to let me take a chemo break.  Pulling out his whip, he yelled, “No and get back in that chair.”

Not really.  He thought it would be fine to take a break and come back for a CT in mid-July to see how things stand.  He is an outstanding doctor and an outstanding person.  It is a great pleasure to have him as my oncologist, and I’m especially pleased that he tolerates my questions and responds in ways that respect my intelligence.

Once again, as Alice Cooper sang,  “School’s out for the summer!”