Wednesday, August 10, 2016

Next step: surgery

It’s been some time since I wrote about my impending CT scan, and what it might mean for my treatment. Teresa and I got the results of the scan at the end of July, and now I’m about to take the next step: surgery two days from now, Friday, August 12.

What the CT scan showed was that my tumors were no longer shrinking. If they had continued to shrink, as they had done over the first six months of my chemotherapy, we might have answered the question of what to do next quite differently. But the fact that the tumors were no longer shrinking was a sign that the next stage would be that they would begin to grow again. Even though we don’t know when that next stage might arrive, it might well be soon, and our oncologist made clear that she felt it would be better to undertake this clinical trial before the tumors began to grow. That’s probably partly because I’m stronger now than I would be then, but it’s also because the surgery itself requires a break from chemotherapy, and it’s better to take that break while the tumors are still in check.

Meanwhile the CT scan also showed that the cancer still seems to be confined to my liver. They won’t know for sure if that’s so until they actually start the surgery and look, but assuming it is so that means I’m still eligible for this clinical trial, which is designed for cancer that is, like mine, only in the liver.

The surgery does not remove any tumors; with my cancer that approach, called “resection,” isn’t feasible. Instead, it makes possible a targeted assault on the tumors by chemotherapy sent directly to the liver. The surgery will implant a pump, about 4 inches wide, on the left side of my abdomen, positioned if possible so as not to bump against my ribs on the top side or against my belt on the bottom. It turns out there is room in one’s abdomen to insert an object this big – and once it’s inserted they’ll be able to see where it is beneath my skin, and insert a needle into it to load the chemotherapy. The pump is cleverly designed: it apparently uses my body heat to cause freon gas in one compartment to expand, and that in turn pushes the chemo in a second compartment out into a tube, which is connected to the artery leading to my liver and so can deliver the chemo directly into the liver. 

There's a bit more to it as well. As part of putting all this in place they also take out my gall bladder; I gather the gall bladder is almost as useless as the appendix, but the chemotherapy that’s going to be hitting my liver can destroy the gall bladder inside me, and that wouldn’t be good. They also have to do some reworking of my abdominal blood vessels, to make sure that the only artery bringing blood to the liver is the one that the tube from the pump is connected to; that way they can be sure that all the blood in the liver is delivering chemotherapy with it.  

Doing all this requires about three hours of surgery, and also involves cutting through the abdominal wall – and so after the surgery itself I’ll probably be in the hospital for a week. Then I’ll be recovering at home for about two months, though I’m certainly hoping to be back on the computer long before that.

Meanwhile, two weeks after the surgery, we’ll go back to Sloan Kettering and they will load the pump with a two-week dose of chemotherapy, and the pump will start sending it to my liver. I gather that the drug they’ll be using, called FUDR, can be less fun than the two I’ve been on till now, but I’m hoping that I will not have too much trouble with it. Sloan Kettering, meanwhile, will be carefully monitoring my liver to make sure it’s not too stressed by all this medicine coming at it. Once this is all underway, I’ll have two weeks on this chemotherapy and then two weeks off.

About the same time that my first pump dose is finished, and four weeks after the surgery, they’ll restart the intravenous chemotherapy I’ve been having up till now. Probably they’ll modify the drugs I get this way: I was getting two, gemcitabine and cisplatin, and it looks like they’ll continue the gemcitabine but drop the cisplatin, which is an irritant and has in fact irritated a vein in my left arm. What the intravenous chemo does that the pump chemo doesn’t is to reach the whole body, and therefore to guard against any spread outside the liver. The net result is that I’ll be getting a two-punch approach, which is exactly what I like about this trial.

Will it work? There’s no guarantee; this is, after all, a clinical trial. But the results Sloan Kettering has gotten so far – this technique has been used in trials for some time – are encouraging. If it works, even imperfectly, it gets me that much more time to enjoy my life, and meanwhile improves the odds that I’ll get to take advantage of the wave of research on other treatments that’s now underway. And if it doesn’t work, there are other possibilities right now as well. So I’m quite optimistic.

And that's what we'll be involved with for the next month or two!

Sunday, July 17, 2016

Two reminders that chemotherapy is no joke

Here’s one: This past Wednesday, July 13, was my latest chemotherapy day. As the Sloan Kettering nurse was assembling the apparatus – the fluids being injected are mostly hung in plastic bags from a frame, and connected by one or more tubes to the final tube that ends in the injection needle – she installed an item in the line that we hadn’t seen before. It was, as far as I could see, a plastic coil, just a couple of inches long. Its purpose, the nurse explained, was to protect the nurses from any “aerosol” emerging from the chemotherapy fluid – I think by providing a contact surface, the coil, on which the aerosol could congeal so that it wouldn’t escape into the air. And the reason? Evidently even the aerosol version of some chemotherapeutic drugs can cause harm to people exposed to it. Our nurse said that there’s one drug she can’t administer to patients at all, because of the headaches that she gets when she tries.

And here’s another: At my chemotherapy session just before we went abroad, back on June 22, I felt more aching in my arm than I usually do. Some aching is normal, because at least one of the chemotherapy drugs I’m receiving is an irritant for the blood vessels through which it passes, but this was, perhaps, more. I didn’t raise this with the nurse till near the end of the process, and that was probably a mistake: the patient must speak up. But anyway, when I did mention it, the nurses took it very seriously. They concluded then that what I’d experienced was an “extravasation,” or in other words a leak in which some of the fluid being injected had escaped my vein and got into my arm; fortunately, they thought what had leaked was not the chemotherapy agents themselves, but just the hydration – i.e., the saline solution -- that concludes the process.

That may have happened, but I’m still not sure because of what followed over the next couple of weeks. What followed was some bruising, but also the gradual emergence to view of a vein that probably had always been visible in the crook of my left arm (where the chemotherapy injection went in) but now became evident, and a bit painful, up and down the arm for several inches. My oncologist looked at it and called it an inflammation. It’s still there as I write this now; it’s not a big deal in and of itself and I expect it will go away in the coming weeks.

But the fact that the inflammation seems to follow the course of the vein makes me wonder whether there actually was any significant “extravasation,” or whether – since the aftereffects seem to be concentrated in or near the vein – this is simply the irritation of the blood vessel by the chemotherapy that is, by design, flowing through it. Chemotherapy takes its toll, and evidently the irritation my chemotherapy causes can be cumulative. (Fortunately I don’t have the kind of chemotherapy that is tissue-destroying, rather than merely tissue-irritating!) So what would that mean? Nothing terrible, but I might need a “port,” a delivery point for the chemotherapy that’s installed for a prolonged period and takes the burden off the veins in the arm. Not yet, though: my right arm is fine and the most recent chemotherapy, injected there on July 13, went in without a fuss.

So in case anyone had any doubt: chemotherapy isn’t good for you, unless you need it to fight cancer. Then you want as much of it as you can possibly get!

One more example of cancer hospital advertising

This one, I’m glad to say, is from Memorial Sloan Kettering (MSK), where I’m being treated. In the New York Times Magazine’s May 15, 2016 issue on “The New Anatomy of Cancer,” MSK bought a full-page ad. That of course wouldn’t have been an accident; I assume that the Times advertising staff put lots of effort into generating institutional advertising for this issue, which also includes cancer-focused ads from City of Hope (in Los Angeles), Dana-Farber Cancer Institute at Harvard, IBM, Oregon Health & Science University’s Knight Cancer Institute, the Cancer Treatment Centers of America (a 2-page insert), and Mount Sinai (the back cover). A lot of money was spent to put these institutions’ ads in front of the readers of this particular issue of the Magazine.

MSK’s ad told the story of a firefighter named Danny Soto, who, as the ad said in large capital letters, “had a family history of cancer. We didn’t let it define his future.” It described MSK’s approach to his case, which “helped Danny gain more control over his treatment with a precise surgery and intraoperative radiation,” and offered more information at a webpage called “”

All of this seemed factual; of course no cancer institution’s stories are all happy ones, but I think it’s fair to tell a happy and truthful story. What I particularly liked, however, was MSK’s slogan, to which that web address alluded and which the Magazine ad highlighted: “More Science. Less Fear.” That’s simply correct; they are developing the science of cancer treatment and those advances do lead to less fear. All this an institution can rightly say, without claiming, or seeming to claim, that they’ve already found the key to fighting cancer. When someone finds that key, I hope they’ll advertise it, but right now, what it makes sense to claim, as MSK does, is focused effort and progress. More power to them.