September 30th, 2013 §
Here we are again. A crossroads.
The third of many we will have.
I’ll give a bit of a recap. I know it gets quite technical but documenting the details is important for those who also have metastatic breast cancer.
It’s almost one year to the day that I was diagnosed with metastatic breast cancer in my bones and lymph nodes. I started on the cytotoxic daily drug Xeloda first (in addition to monthly infusions of Zometa) which gave me six months of success, shrinking the amount of cancer evident on PET scans.
In April 2013 when my tumor markers started rising I started on the hormonal combo of Aromasin and Afinitor (and also switched from Zometa to Xgeva because of difficult side effects I was having). I started on a 5 mg/day dose of Afinitor with a 25 mg dose of the Aromasin. I gradually increased the Afinitor dose to 7.5 mg/day, and then when my markers began to rise again a few weeks ago, I started on 10 mg a day.
It has now been five months on this combo (in all of its different dose strengths) and my markers are rising. This chemo is no longer working. So, it’s time to decide what to do next.
Regular readers will know that this is typical of metastatic breast cancer: some therapies may not work at all while some will work for a while. Ultimately, though, the cancer becomes resistant to each of these treatments and will progress. Sometimes you get a great response and can reduce the amount of cancer that is present. Oftentimes you settle for the success of “stability” where the cancer isn’t reduced, but it also isn’t growing. It’s often referred to as hanging out with “Stable Mable.” This is still a good response in most people’s books.
Especially when your cancer is still confined to your bones and lymph nodes, stability has the added feature of being life-saving: as long as the cancer is in those places it cannot kill you. Only once it metastasizes to organs can breast cancer kill.
So… now it’s time to decide what to try next (this part gets technical). Right now it’s looking like I’m headed to a clinical trial of a drug that has shown promise in breaking the resistance of hormone sensitive breast cancers especially in people like me whose cancer displays a Pi3k mutation (40% of people with ER+ breast cancer have one of these mutations). This experimental drug would be in combination with a drug commonly used for my kind of cancer (Faslodex). I’ve enrolled with the clinical trial team. This is a Phase II trial so I would be guaranteed to get the experimental drug.
What does this mean? In simple English, it means I’m trying a new drug that’s designed to break the resistance of this particular kind of cancer to treatment. It seems to be especially effective for those with the type of cancer mutation that I have (Pi3k-alpha). If this drug makes the cancer susceptible to therapy, then the other drug I’m taking can do its work. This class of drugs is at the forefront of where cancer research trials are right now.
I’ve been pre-screeened and have a few more hurdles to clear: scans, bloodwork, and a three week “washout” period where I must be chemo-free to allow any residual effects of my current treatment to clear. Am I nervous about a period with no safety net? Yes, a bit. But I also am curious how my body will react to having current chemo clear my system. I’ve had a lot of trouble with things like high blood pressure, high cholesterol, rapid heart rate, shortness of breath, and headaches in the past few months. I’m interested to see how many of these will improve.
The new drugs will have their own series of side effects, some of them might be similar and a few may be different and more serious. So this three week period sits okay with me because if my current treatment isn’t doing anything anymore, it’s of no use anyway.
There will be so much to share about being involved in a clinical trial. And I will share that with you, should I make it through the final screening process. I am learning so much as I go and I think there is a real chance here to inform others about the experience. Trials are as varied as can be. Each has criteria that must be met. Sometimes you end up on the good side of these and sometimes you don’t.
My oncologist looked at a host of trials before we chose this one. I was ineligible for many of them because of the drugs I have already tried, my particular features of my cancer, what cities the trials were offered in, when they were enrolling patients, etc. Some were not attractive to me because of the phase of trial that it was (I’ll explain in a separate post the differences between Phase 1, 2 and 3 trials). I am glad to be in a trial where a drug has already passed initial safety standards and will also be given to every patient in the group (there are no placebos in this phase of trial).
It’s important to note that a clinical trial should not necessarily be viewed as a “Hail Mary” meaning it’s the last remaining hope. In reality, my sense is that this is very rarely the case, at least with Phase 2 or 3 trials. They can only establish true efficacy in people who are still at certain phases of the disease process and haven’t had too many chemotherapy agents already.
To me the key was to find a trial that had a good scientific basis for success, was currently enrolling patients and was within commuting distance. In addition, I think it’s best if the standard of care drug is one you would already be considering using at this point in your treatment. There is a database at www.clinicaltrials.gov where you can search for trials.
I have reserved my spot in this trial. If I meet the testing criteria I will be one of 60 patients nationwide on this particular protocol, about 10 at my particular location. I view it as an opportunity. It is well-suited for my cancer at this time in treatment. It’s using the newest thinking in targeted therapy based on genomic analysis.
It’s scary, yes. But if it doesn’t work I still have standby treatments to go to (and other trials by that time that I hopefully would be eligible for). I know there is no cure. But maybe this one will give me a chunk of time.
I won’t go into details here but I know people will ask what’s involved. The treatments will be injections (Faslodex is two big intramuscular injections in the butt every month after doses every 2 weeks the first month) combined with daily oral capsule (the experimental drug). I will also continue to get an Xgeva injection in the arm each month. There will be a strict schedule of fasting bloodwork in NYC every two weeks and scans every 8 weeks to monitor the cancer’s growth. I’ll have to keep a medication diary. I’ll let you know how everything else works once I am underway. It’s a lot of work, especially in the first two months including all of the meetings and tests just to get started.
There are so many questions I know people will have. If you post your questions in the comments I will do my best to answer them in future posts if I can. You may post them anonymously if you like. For now I’m not going to state the name of the drug (actually just a string of letters and numbers) until I’m actually enrolled.
It was quite devastating to get the news that the current chemo isn’t working anymore. It always feels like the rug being pulled out from under me. I always cry. I always feel like I’m falling.
But plans are my safety net. Options are my lifejackets.
I leap from treatment to treatment on my tippy toes, knowing if I place too much weight I will sink.
This is the dance I do now. Forever.
September 13th, 2013 §
It’s always right when they pull the bar down over my head and jam it into my lap on the rollercoaster that I silently start screaming, “Wait! I changed my mind! Let me off!”
By then, however, it’s too late.
With a jerk the car moves forward, its underbelly grabbing the hooks to lift it skyward.
By the time we are moving, climbing, the car is making a clicking sound and I am sure this was a mistake. I wedge my knees against the back of the seat in front of me to minimize my movement.
I steel myself, knowing the drop will come whether I like it or not.
And then there is that moment, that nauseating violent moment before the floating…
For a brief portion of a second I’m airborne, held in by that suffocating bar. Down we go and I slam back into the seat. I tell myself it will be over soon. I just need to ride it out. It will end.
These days I’m on a roller coaster ride that doesn’t end — well, not anywhere good, anyway.
When we last met here for an update, I said the increased dose of chemo had shown a response. That response is proving to be short-lived. Yesterday my tumor markers were up again, back in the range where we need to discuss changing chemo again. It’s been about four and a half months on this chemo combination of Aromasin and Afinitor (I continue with monthly Xgeva injections).
This is the cycle of metastatic breast cancer: chemos inevitably fail. The cancer becomes resistant, mutates, signals a new pathway to drive its survival. We have no way to know how long each will last. When you read studies and “success” is deemed an extra two months of progression-free survival you know you’re dealing with heavy realities.
The immediate plan is to increase the Afinitor one more time, to the maximum. I’m told no one tolerates this dose regimen for long because of the side effects. But I’m almost at that dose now anyway, so let’s give that a go. Even if I can get a response for one month, that will allow me time to figure out what will come next. The two options are to continue with a targeted, anti-hormonal therapy of some kind or begin IV chemo after having a port put in. There are pros and cons to each, I won’t go into them here. Once I’ve made a choice I’ll fully explain it, of course.
And so, for now, I increase the dose. I wait. I retest again one week from now, and two. By then we’ll have a plan, and likely be moving on. Another tally mark of treatments tried to buy me time.
It’s too soon:
I fear the safety bar is not locked.
I fear that each time I reach the top of the hill again I’ll be ejected from the ride, skyward, only to plummet to the ground.
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Two housekeeping notes:
1. If you only want to read updates on my chemo status and current health, I make it easy for you by titling these posts “Update” + the date as the title.
2. I’m pleased to report that this website is now optimized for mobile device reading. If you read the posts on your smartphone or tablet you will note that you no longer have to scroll left and right to read; the posts are nicely contained in columns. There is a menu at the top to navigate the site and a clean layout. To comment on posts on your device, look at the end of each post for the “replies” link to click. This should make it easier for those of you on the go to leave a comment.
August 6th, 2013 §
Hi all,
I may not be posting much this month. Now that all three of our children are home from camp the house is busy and we are readying for school. Public school here starts the last week of August so we have less than three weeks remaining of lazy summer days. I will make sure to post anything important news-wise.
My tumor markers have not climbed any higher in the last two weeks though they still remain slightly elevated from levels a few months ago. Both of my oncologists feel my current chemo regimen of Aromasin + Afinitor is still working. Nonetheless, we would like to see if we can drive the number down further and erase that gain. We are still getting a sense of how much variation is normal with this imprecise test.
Side effects on this Aromasin/Afinitor combo are cumulative in severity, so the longer I am on it, the worse they will become. Currently my major issues are fatigue, immunosuppression (making travel and being in public places risky), mouth and tongue sores, joint pain, muscle aches, skin breakdown, itchy scalp, sun sensitivity, high cholesterol, high triglycerides, increased blood pressure and rapid heart rate. Loss of appetite and associated weight loss are also factors. Yes, I know: to look at me you’d never know all of these plague me. I try not to talk about them too much but they are there.
Because I know many readers will be interested in potential remedies for some of these problems, I should say that I do have all of the treatments I need to deal with these side effects. Some of them are just the way it is, and you have to just adjust if possible. Others like mouth sores and skin/scalp issues can be very successfully treated with topical steroid ointments and liquids (some believe coating the Afinitor pills with food prevents mouth sores but this is actually just a coincidence. It’s not the contact with the mouth that causes the sores, it’s the mechanism of action that does. Blocking the mTOR pathway causes oral mucositis and stomatitis. Starting initially on a smaller dose and working up to the final one does seem to help with the initial outbreak of sores though). Walking helps both the joint pain (despite initial pain) and fatigue, while occasional Ativan helps the blood pressure, heart rate, loss of appetite, and some muscle issues. These are some of a few of the things that my oncologists and I have found to help.
One of my oncologists told me I was “at the precipice” with my side effects; my body could not tolerate a higher dose (currently I take 25 mg of Aromasin and I alternate 5 and 10 mg doses of Afinitor to average 7.5 mg/day). A meeting with my other oncologist today yielded a decision between that I would increase my chemo dose ever-so-slightly to see if I can tolerate it while hopefully get a response.
This type of situation is where the art of oncology comes in. I give a liberal interpretation to the term “art.” I think it’s educated guesswork, creative thinking. The science is the foundation but the application and choices are sometimes educated guesses.
We don’t know if a small increase will affect the tumor markers. It might. It might not. Can my body handle more? That’s an unknown too.
I think of it like the old fashioned scale in the doctor’s office– the one with the weighted bars that you slide left and right until they balance. The nurse gets close to the target, then nudges the bar bit by tiny bit until just the right balance is achieved. This is what we are trying to do: balance quality of life (side effects) with maximum efficacy. Where that line is, we do not know. It varies for each person.
We’ll test again in another week (two weeks since my last one), but it’s unlikely we would see any result that quickly. At least we will see if the markers are continuing to hold steady.
As far as this website, I have many ideas brewing for blogposts soon. Readers have also contributed some great ideas and asked questions that I will do my best to answer.
As always, thank you for the continued support.
May 24th, 2013 §
It’s Friday! I want to put a post up today because I know it’s been a while and people worry when I am not making posts. All is fine, it’s been a very busy week with a lot of routine medical appointments. Side effects from the new chemo are starting in and phrases like “mouth sores”, “high cholesterol,” and “follicular head pustules” make me certain that the person who called it “crazy, sexy cancer” was delusional about what cancer really is. There’s a lot that’s crazy but I don’t personally find a lot of sexy in it.
I’m getting help from my team in dealing with all of the side effects and have more appointments with more specialists in the next few weeks. For now things are stable and the next two weeks will proceed as planned. I’m still on Aromasin (25 mg/day) and Afinitor (7.5 mg/day). It’s the Afinitor that’s kicking in with my various problems. My tumor markers have shown a response to this combo over the last 6 weeks so we continue with it for now. I also received my monthly injection of Xgeva to strengthen my bones.
I wish you all a good Memorial Day weekend, especially our military personnel and their families.
The photo above is from 2002 by the way… where have eleven years gone?
I also want to mention that my last post, “There’s No Room for That in This (Six Minutes)” is the foundation for what is now a song titled “Six Minutes.” Over the past few weeks musician Doug Allen and I have been working hard on it and we’re almost done. I wrote the lyrics and he found the perfect music to bring those words to life. We are both so proud of the song and will be sharing in the future. His latest CD is available now and I just love it; it has two songs that have been on movie soundtracks… who knows where “Six Minutes” might land! More to come on this project.
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I get a lot of emails and comments with questions about cancer and how to help those who have it. Let me say clearly that I never think I speak for everyone with cancer. I do believe that asking questions is good, and even if you don’t think my answer is right for you, at least you might look at the issue a different way and clarify your own thoughts.
If people like this format I may continue to post letters/responses more often. I have often thought we need a grief/loss/illness etiquette column and I’ll gladly do my best to help.
This week I received the following excellent question.
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Hello…
I’m a 31 yr old only child whose mother was just diagnosed with squamous cell carcinoma a week ago.
I’m going home for the first time (parents in WI, I’m in IL) since the diagnosis and after reading this blog, I’m not sure what I should say to her. She is a pessimist by nature and already saying she would refuse chemo (the details of her condition and treatment plan are still in the works) so my dad and I need to figure out a way to keep her positive so she can indeed have the support she needs to fight it. I bought some colored paper and was going to list “reasons why you are a fighter” as well as post some motivational sayings/quotes on their bathroom mirrors, but the ones that came to mind now seem like the ones you SHOULDN’T say “you can do this,”,”stay strong,”
Do you have any suggestions on what I could write? Please keep us in your prayers, I am obviously terrified of the road to come.
—– J
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My response:
A few quick thoughts for you, J. I am so sorry about your mom’s diagnosis.
My first thought is that you all need time to adjust to the news. The way you react initially is not always the way you feel once you get your feet back under you. She needs a bit of time to not only adjust to the news but also to make this treatment plan. She doesn’t even know yet what she will be potentially recommended for treatment and yet you are expressing desires to coach her on how to feel.
Being supportive does not necessarily mean keeping her spirits “up.” Maybe what she needs right now is support for how she actually feels, not pressure to be acting a certain way. The best way to support her is to listen to her, and not try to tell her how she should feel. Let her adjust. And most importantly, respect whatever she chooses.
We love our families more than anything, but it’s her choice to make how she wants to live her life and how she wants to treat her cancer. It’s enough to deal with these diagnoses without feeling you are carrying the emotional burden of your loved ones on your back too. It will mean that she will know everyone rises and falls on her actions. That’s a huge weight above and beyond the physical and emotional toll she will be going through.
One of the most important things to do is to ask her how she thinks you could help her the most. I have a feeling putting up signs is not it, especially if you say she is a pessimist by nature. Signs around the house won’t change her attitude if a lifetime of experiences haven’t. Loving her, spending time with her, helping her with things that she might have trouble doing… those might be better. The key is to ask, really listen, and then respect what she says. Her needs might change (doesn’t want or need help now but needs it in the future) so you have to ask again during treatment.
If she decides to refuse chemo it will be tough, but it’s her choice. Chemo is very hard and is a quality of life issue too. Depending on what they are recommending and what the ultimate details of prognosis are, it’s important to respect what she opts to do while still encouraging her to see the benefits (as described by her doctor).
Those of us with cancer know everyone wants us to be “strong” and “positive” but it’s what we need to hear the least. It’s not like we haven’t thought of that already; it often just makes us feel like people are telling us how we should act because it makes it better for them if we act that way.
Negative emotions are normal with cancer, especially only one week after diagnosis… how could they not be? Not feeling free to express them may just be one more way she feels burdened by this disease right now.
Clearly you love her and want to help. The fact you are concerned with the best way to support her shows wonderful affection. The best way to do that right now, so soon after diagnosis, is to ask, and then respect what she says… That’s my best advice right now.
She will need time, but ultimately I think that she will be grateful for being allowed to express her emotions both negative and positive. I wish you all the best. Please keep us posted.
April 12th, 2013 §
I want to just send out a quick clarification about my chemo because I can tell from messages I’m getting that I didn’t explain well what has happened with my discontinuation of Xeloda. This particular chemo is now failing, yes. But that doesn’t mean it didn’t work. This is part of this disease of metastatic breast cancer. In some cases the treatment option never works; that is, your cancer doesn’t respond at all. You get no benefit from day one. You abandon it quickly.
Mine, however, falls into the other camp: it did work for a period of time. It did what it was supposed to, just for not as long as we’d hoped. That is, it did reduce the amount of cancer in my body for a while, it did hold progression at bay.
It’s no longer doing that, my counts are very slowly rising, but that doesn’t mean it “didn’t work.” It just means it didn’t work for as long as I would have liked.
Most people with advanced disease will be leapfrogging around all sorts of agents (chemo, anti-hormonals, etc.) to try to see what works. The cancer mutates and becomes resistant to most treatments that will get used. That’s when it’s time to move on to a different one. I know people that have been on at least ten different agents. That leapfrogging is just the nature of the path many others and I are on. A small percentage find one that works and it continues to work for a long, long time. Research is needed to find out why these particular cancers are more easily tamed. We do not know now why that is the case but researchers are learning more and more about the subtypes.
So while the stability was not as long as we’d liked, in this particular case it doesn’t mean it didn’t work. It did. For six months. But now we’re moving on.
In my case, because my cancer is estrogen-receptor positive, we’re trying anti-hormonal agents. Although I don’t have ovaries to produce estrogen, the fat cells and adrenal glands in my body still produce estrogen. I will be taking two drugs every day now, Aromasin and Afinitor. The plan is in place and I’m already starting taking them, slowly on the Afinitor because it has a side effect of bad mouth sores if started at a full dose. I won’t go into other side effects here because I don’t know yet what my particular response will be.
Thanks for all of the notes of support and concern over the last 48 hours during the PET scan and this new adjustment. As always, I can’t respond to every message but I do appreciate them all.
Here we are again. A crossroads.
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