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!