A day of some disorder: two notes from today's chemotherapy

On our way to Sloan-Kettering at 6:30 this morning, as usual with many other hardworking folks on their way into New York City, we heard sirens. Teresa pulled us over to the next lane to make room for what turned out to be a mini-convoy: a couple of SUV’s, and two or three smaller cars, all with lights flashing and at least one with a siren going. I’m not sure any of them were marked police cars. Who would have a convoy like this? Of course we don’t know, but one likely guess is that it was some public official, and the most plausible candidate (no pun intended) would be New Jersey’s Governor Christie. Was he on his way to some Trump event? Or to some function that actually involved New Jersey? Either way (and of course assuming that it was in fact Christie, and that he didn’t have some genuine emergency to go to as part of his official duties), I find myself annoyed. Lots of people on the road this morning had pressing business, Teresa and I among them. Why exactly does the Governor (if it was the Governor) get to shunt everyone else aside for his business? This doesn’t seem like public service; it’s more like a privilege of power.

Nevertheless we made it into the city without too much trouble, visited the hematologist (who suggests I go off the blood thinner and replace it with a daily baby aspirin!), then had blood work, saw the oncologist (who was attentive, as always, but seemed to be in a hurry), and then had chemotherapy. For me the treatment was pretty straightforward, though for some reason the infusion hurt more than usual. When the nurses realized this was so, they became quite concerned about the possibility that some of the chemotherapy drugs themselves might have leaked into my arm. That would be unfortunate – not terrible, because these particular drugs are irritants but not destructive for ordinary tissue – but the nurses didn’t think that had happened, and some hours later I don’t see any sign that they were wrong. So, in short, things went pretty smoothly for me.

But while Teresa and I were sitting in my treatment cubicle, the public address system called for emergency response – to the chemotherapy area where we were! As we learned, down the hall another patient, an old man, had been found unconscious and unresponsive. Apparently, in the end, this wasn’t some grave reaction to chemotherapy but something more mundane – he’d choked on a fig he was eating, and when the fig was dislodged, he recovered consciousness and appeared to be okay (though he was still transported to another hospital’s trauma ward). The lesson wasn’t that chemotherapy is dangerous, at least not directly, but that chemotherapy by yourself is dangerous. Who knows what can go wrong at any moment? There are all sorts of reasons not to try to deal with cancer by yourself – but saving you from unnoticed emergency turns out to be another. Don’t hike alone, and don’t get chemotherapy alone either.

My dental adventure

Two weeks ago I had to make a return visit to the dentist. Going to the dentist when you have cancer is a complicated business – the visit has to take place 1-4 days before a chemotherapy session, and must be preceded by blood tests at Sloan-Kettering, both requirements presumably meant to insure that my immune system and general health are up to having dental work done. I’d done all that a few weeks earlier, because of a pain somewhere in my upper right molars. That visit produced a possible quick fix: a filling fell out with a little nudge from the dentist, so she put it back in with fresh cement or glue. But she told me that the tooth with the loose filling was one back from the tooth I’d thought was the most painful – so I knew I might need to return.

After a few days, the pain in my upper right molars returned. It wasn’t very bad, but it was there. So I did the pre-dentist steps again and returned to the dentist for another look. I went back on a Tuesday, the day before my scheduled Wednesday chemotherapy. This time the dentist concluded, perhaps with the aid of a new x-ray, that the problem was in a tooth that long ago had been the object of root canal work. So she sent me off to a root canal specialist. I left my dentist’s office at about 8:15 AM and walked about a mile and a half north to the root-canal specialist, who (amazingly) had given me an appointment at 8:45.

The root canal specialist gave me another x-ray. This one I’d never had before – it was a stereoscopic view of my jaw. The technology was interesting, but the results weren’t good: it turned out I had a quite substantial infection in the tooth with the old root-canal, and that the tooth itself appeared to have cracked. That meant that a root canal wouldn’t work because the tooth was likely to disintegrate. And that meant I needed to have the tooth pulled. They referred me on to an oral surgeon, who gave me an appointment for 11:30 that morning. They also charged me only the amount my insurance would pay for the visit – another courtesy.

I walked back south about half a mile to the oral surgeon’s office. I was way early for my 11:30 appointment, but while I waited I called my oncologist’s office to tell them what was happening. As it turned out, I was called in to the oral surgeon early, a little before 11. The oral surgeon was ready to go. My recollection (rather a lot happened quickly, so I may not be recalling perfectly, but this is what I think happened) is that he understood I was a cancer patient, and so he called the oncologist’s office too. He came back and said that they’d said he could go ahead as long as I wasn’t on blood thinners. But I am on a blood thinner, Xarelto, so I told him that, and he called the oncologist again. This time he came back and said that based on his conversation with the office we could go ahead; he himself didn’t feel Xarelto posed a big problem.

And so we started. He gave me two injections of anesthetic. At that point my cellphone began to buzz. It was in my shirt pocket and, though I felt it was a bit improper, I decided to check who it was – and it was Sloan-Kettering. I answered the phone and the nurse from the oncologist’s office was on the line; she told me that I needed to be off the Xarelto for two days before having my tooth removed. (Pulling a tooth involves bleeding; Xarelto increases the risk of uncontrolled bleeding.) I said that that was the opposite of what the oral surgeon had understood, and gave the phone to him. He and the nurse then talked, and the result was that my tooth stayed in that day.

By this time I was upset. Looking back I think I was somewhat unnerved by the quick escalation I’d already experienced, from a visit to my regular dentist to a trip to the root-canal specialist and then on to the oral surgeon. But I was also unhappy about the fact that the oral surgeon had already started anesthetizing me when the nurse called me. So then I called the oncologist’s office again, from the oral surgeon’s chair, and insisted on getting entirely clear what was going to happen next. The nurse called back and told me they could move my chemo appointment from the following day, Wednesday, to Friday. This last-minute adjustment, which I appreciated, meant that I could stop taking the Xarelto and be off it for two days before the oral surgeon pulled the tooth on Thursday (and that’s what we did; at their instruction I also consulted the Sloan-Kettering physician who deals with my blood thinner prescription, who confirmed that two days off Xarelto was what I needed). In the process I spoke sharply to the nurse about not having been called back more quickly earlier that morning, and she spoke sharply to me in return; in hindsight I wasn’t pleased with either of our reactions – and I hope I didn’t make them feel I’m a “bad patient.”

Anyway, on the Thursday I had my tooth pulled. (I’d never had a tooth pulled before, and I thought it was all pretty alarming – lots of drilling and pulling, though no pain at all – but it really went fine. And in yet another courtesy, the oral surgeon’s office charged me only what insurance would cover.) Then on Friday morning I had chemo; the oncologist’s office had arranged for the appointment to start at 7 AM at my request, so that I’d be done in time for what I had scheduled for Friday afternoon. Chemotherapy went quickly and smoothly, and I was at New York Law School by early afternoon. There I was part of the opening session of a conference I’d been working on for most of the school year. The conference continued through Saturday and half of Sunday, and I was there, sometimes chairing or facilitating sessions, throughout. So now I know that I have the strength for dental surgery, chemo and a 2-3 day conference all in a row – actually a happy ending to my dental adventure.   

Metformin and me

Among the various medications I’m taking to supplement the chemotherapy is a drug called metformin. It’s a diabetes drug and I don’t have diabetes. So what am I doing taking this drug?

Our oncologist agreed to prescribe it – which she can do, even though this drug is meant for diabetes, because physicians are allowed to prescribe off-label uses of medications. She agreed because she felt the drug would be safe to take, and it had shown some benefit in pancreatic cancer patients. (Presumably those were patients who were taking metformin because they also had diabetes.) Pancreatic cancer is one of the gastric cancers, and what works against one gastric cancer may work against another. But as to liver cancer, our oncologist said, there wasn’t yet any similar evidence, so she would only prescribe it if we understood that she had absolutely no idea if it would benefit me. That seemed fine to us.

But is the possible benefit metformin brings just a medical coincidence, or is there a reason why a diabetes drug might be of use against cancer? The answer is that there is indeed a reason, and the reason has to do with what’s wrong with cancerous cells. It turns out, as Sam Apple explained in an article in the recent New York Times Magazine focus on cancer, that most cancer cells, to put the point crudely, are extremely hungry, in fact madly voracious. They devour glucose and use it to make more of themselves, or in other words to assemble tumors.

A number of different factors may contribute to this behavior, but Lewis Cantley, who heads the Meyer Cancer Cetner at Weill Cornell Medical College, told Apple that one way to describe what’s going on is that the “insulin … signaling pathway” has “‘gone awry – it’s cells behaving as though insulin were telling it to take up glucose all the time and to grow.’” No less a scientist than James Watson (the co-mapper of DNA), tells Apple that “insulin is pro-cancer.” Watson himself, Apple writes, “takes metformin for cancer prevention; among its many effects, metformin works to lower insulin levels.”

Some or all of this may turn out to be mistaken, Apple notes. But meanwhile he reports that epidemiological studies find that “[d]iabetics taking metformin seem to be significantly less likely to develop cancer than diabetics who don’t – and significantly less likely to die from the disease when they do.”

All of this is good enough for Teresa and me – and that’s why I’m taking metformin.