It’s the day after my CT scan; we don’t know the results yet and won’t learn them until we see the oncologist tomorrow.
It’s an anxious moment, the sort of moment I imagine many, many cancer patients have experienced. Different people must react to these moments differently; I don’t feel upset, but I am certainly intent. The way this moment arrived is this: back at the start of December, 2015 the Sloan-Kettering physicians decided I should have nine weeks of treatment, or, more precisely, three three-week cycles of two weeks when I received intravenous chemotherapy and one week off. Then they would do a CT scan. I’ve now done those nine weeks of treatment, and had the CT scan. I also now understand my illness, and my treatment options, better. But there is a lot I don’t know, and quite a bit that no one knows, about what to do now. So, partly to collect my own thoughts and partly to describe one of the difficult elements of being treated for cancer, I’m going to lay out the possibilities as I understand them now.
I know that I am feeling quite well, and people – including my oncologist -- tell me I look well. The fact that I’m in as good shape as I am after these weeks of chemotherapy is a good sign, not only that I’m tolerating the chemotherapy well but also that the chemotherapy is having an impact on the underlying cancer. The last time we saw the oncologist, she felt confident enough that she told me I could take on a two-year-long work project. But she also said that of course we wouldn’t know for sure how I was doing until we got the CT scan results.
So now we’re about to learn those results. I wish there weren’t a two-day wait between the scan and the results, and I’ve imagined a phone call ending the suspense, telling me that the scan shows the tumors have almost disappeared. Or a call saying my condition is critical and I’d better get to the hospital right away. Neither has come. That may be a sign that the news, when we get it, will be neither miraculous nor horrifying.
Perhaps the scan will show that my tumors have actually grown. It seems unlikely but I guess it’s not impossible. In that case, I’ll have to attribute my feeling good not to any actual progress against the disease but to the many medications I’m taking (and to my wife’s excellent power shakes, with which I begin every day). And then we’ll need to figure out what other treatment possibilities there are (I’ll get to these in a moment).
Perhaps the scan will show that my tumors have neither grown nor shrunk. Hearing that would certainly be better than learning they’ve grown. My guess is that they were growing before I started the chemotherapy, so in fact this news would point to a clear victory for the treatment, namely that it halted their growth. Since I am feeling relatively well, I guess I could go on feeling this way indefinitely, and perhaps one way to do that would be to continue with the chemotherapy just as I’ve done over the past nine weeks. (There may be other ways too, but again I’ll get to these in a bit.) That would work as long as the chemotherapy remains effective, and as long as the side-effects of the chemotherapy don’t multiply.
Perhaps the scan will show that my tumors have shrunk. “Shrunk” seems like a clear enough word, by the way, but I’m not sure it is. I’ve seen a study, from physicians at Sloan-Kettering, in which it appeared that a less-than-20 % decrease in tumors did not count as a “response” to the treatment. That might mean that some amount of shrinkage doesn’t definitively indicate an effect of the chemotherapy – though it may also be the case that even a little shrinkage may correlate with a better prognosis.
Anyway, if my tumors have shrunk, that’s great – but it also opens up a set of questions we haven’t had to wrestle with up till now. My sense is that when my chemotherapy began, the Sloan-Kettering physicians felt there really wasn’t much alternative. I needed treatment right away, and this chemotherapy was the clear treatment of choice (the same study calls it the “gold standard”).
But if the tumors have shrunk, I may have choices. For one thing, I may be well enough that I have time for steps that would initially delay treatment for the sake of delivering better treatment later. That’s a bit opaque: concretely, what I mean is that, provided the cancer has not spread beyond my liver, I might then be a good candidate for a clinical trial that’s ongoing at Sloan-Kettering. In this trial, they implant a pump beneath the skin of my abdomen and connect that pump to an artery that leads directly to the liver; then they fill the pump with chemotherapy medication by injection, and the pump delivers the medication straight to the liver. To get this started entails major surgery, and I couldn’t receive any chemotherapy until I’d recovered from the surgery itself – but now I may have some time in which to do that. The study I’ve referred to, just published in the last month, reports data suggesting that this approach is considerably more effective, on average, than the treatment I’ve had so far.
But (there’s always a but, or in fact several) it’s not effective in every case, and even when it’s effective it’s not always as effective as the treatment I’ve been having so far. In addition, while the clinical trial seems to attack the cancer in the liver more powerfully than the intravenous treatment I’ve been receiving, my impression is that the intravenous treatment probably does more to prevent cancer developing somewhere else in my system – precisely because the intravenous treatment, unlike the clinical trial treatment, isn’t aimed directly and solely at the liver. The intravenous chemotherapy would actually continue along with the clinical trial, but the problem with that is that my oncologist says that patients receiving the clinical trial chemotherapy may not be able to handle as much of the intravenous chemotherapy as those who are on only the intravenous chemotherapy can. Also, it turns out that the circulatory system in the abdomen varies a lot from person to person, and in my case the artery to the liver is smaller than usual, a fact that increases the difficulty of successfully hooking the pump up and keeping it in place. So judging whether I’m best suited for this clinical trial or for more of the solely intravenous treatment is quite a delicate matter.
And then there are other questions. If the tumors have shrunk enough, should the possibility of liver surgery (called a resection) come into the picture? Are there genetically-based treatments that might work for me (something Sloan-Kettering is already looking into)? Jimmy Carter’s brain cancer was treated with an immunotherapy drug called Keytruda; should I be trying to get this drug? And are there other clinical trials under way that might be more effective? Should I also explore possible treatments from Chinese medicine? None of these options was relevant while Sloan-Kettering was bringing me back from the acute difficulty I now realize I faced at the beginning of December. But now all these options may need to be considered – depending, of course, on just what the results turn out to be tomorrow.
So this is, as I said, an anxious moment. It’s a hopeful moment too, and I am very happy to have this renewed hope, but oddly enough this moment is more anxious because it is also hopeful.