I am writing this on Monday night; by the time email subscribers read this it will be Tuesday and I’ll be done with chemotherapy again, having risen before dawn to head down to New York’s Memorial Sloan-Kettering
First let me report the good things. I have had some great days after my transfusion last week for severe anemia (expected often now after this much chemo).
On Friday night I drove Colin in heavy traffic to his first travel baseball game (took two hours). Then I sat watching warmup and the game which was another 3.5 hours. Then an hour home. I am detailing that time to brag. Look what I did with my son.
It wasn’t physically easy for me. But it was joyous. We got so punchy in the traffic jam that we were waving our hands in the air “seat dancing” to the music. We nicknamed a car “Duck Dynasty” that was broken down by the side of the road and then got lost at the venue and ended up 4-wheeling over gravel hills. We had a blast. Here is my precious middle child when we arrived at the field. The team won which was exciting. It was his first game on a full-sized field and also under the lights. I also got to take him 
to another game on Sunday; the team lost that one but it didn’t much matter to me. I got to not only be there to cheer the boys on, but also bring them water and popsicles on a scorcher of a day on the field.
The medical update since the last post is that in short, there isn’t a good clinical trial that I qualify for/am willing to enroll in right now. The chemo regimen that I am on makes me ineligible for some because it affects my blood counts so severely each time now (quite a catch-22, I would need to go off chemo to even have a chance at being considered). One trial I can’t be considered for because there isn’t enough tissue left from a previous biopsy to use it for required testing. Because my cancer is primarily in bones or other places inaccessible by surgery, this is not an easy problem to fix.
Now I’m going to get a bit technical. I’m hoping to explain a bit about how the different clinical trial types work since many people don’t know these distinctions. Consider this your breast cancer education for the week! Yeah, you know I’m not a doctor so I’m explaining this to the best of my ability. Ask a doctor for more info, especially one who works in clinical trials to be sure the trials you or a loved one might be considering work the same way.
Here we go:
One type of Phase I clinical trial (which I would qualify for) is risky enough that this option isn’t reasonable to me right now. Let me clearly state that they may become very reasonable options at some point soon and I totally understand why other people choose to do them! These particular phase 1 trials I’m opting out of for the time being are the kind that are testing safety of a medication previously untested in humans. That is, they don’t yet even have a dose that they know is safe. They are called “dose escalation Phase I trials” which means they start with a low dose they think is safe and gradually increase the dose until the side effects become too bad and the test subjects can’t continue and they stop participating. They do these on a small number of people.
This process establishes the maximum tolerable dose and the company hopes to then proceed to a Phase II trial. That Phase II trial tests if that established maximum tolerable dose even does anything measurable (Phase II trials test for efficacy: is this drug keeping the cancer stable or even causing it to shrink?).
To complete the clinical trial trio, a Phase III trial tests the “current standard of care” plus the trial drug against the current standard of care alone. That is, does adding this drug to a treatment that is a normal one for this cancer improve outcomes above and beyond just giving the treatment the patient would normally get (are results better? The same? Worse?). For ethical reasons there are no placebos used alone instead of treatment in Phase III trials in metastatic breast cancer. They would be used only to combine with the standard of care treatment. No patient goes untreated. All get the usual treatment as the guarantee.
This process means that during the Phase I dose escalation trial I first mentioned 1) you don’t know if the trial drug is safe, 2) you don’t know if that dose is too low for some or all of that time to even be doing anything, even if it is eventually going to be efficacious, and/or 3) if it even works at any dose (without making things worse). This means continuing with your cancer potentially untreated for months, an often dangerous proposition in metastatic cancer.
I don’t want to go into more details of those trials but I do think it’s important for me to continue to explain the way that some clinical trials work with metastatic breast cancer.
As I think I mentioned in my last post, the likely immediate plan was to increase the dose of one or both of my current chemo drugs. Because I opted not to pursue enrolling in a clinical trial I will remain on IV chemo. If I had chosen the trial I would need an additional two weeks without any chemotherapy to complete the mandatory washout period where I do not use any medications to treat the cancer because their presence in my body could affect the trial drug results or side effects.
I am going in for an increased dose of Carboplatin and steady dose of Gemzar on Tuesday. I did have one increase already in the Spring on my Gemzar dose. We will see what kind of response we can get from this Carboplatin increase, if any. It will hopefully buy us some time until some other trials open up and/or we can consider if we can do a biopsy once we see a current CT scan.
A few readers were concerned that I was relying too heavily on tumor markers in my decision-making. In short, I’m not. I am well aware (as I’ve said in almost every post except last time) that markers, particularly CA 15-3, are not reliable for many people. This is why this test is not used as a screening test for people to find out if they have breast cancer. If it were valid they would use it instead of or in conjunction with routine mammograms.
I know many doctors don’t use blood tests for markers at all and for some types of breast cancer they are totally worthless. Trust me, oncologists at Sloan-Kettering are well aware of all of this information as am I. The most important piece of information is a history of them in me and how they correlate with scans and my disease progression. I am one of the people for whom they are tightly and reliably correlated with my disease. We have had seven years of studying them in my particular case and two years with close monitoring during metastatic disease. So while I definitely appreciate the concern, you can rest assured that we make decisions with all of this in mind. It was my error in not putting that usual caveat in that last post.
So… for now the plan is: higher dose of one of two chemo agents on Tuesday. Test markers to see what they’ve done in last few weeks.
In case you are curious, going for chemo doesn’t just mean getting two drugs. The infusions I will get on Tuesday are numerous. I will get the following 8 infusions in this order: Decadron (helps with nausea and mainly to help prevent an anaphylactic reaction to Carboplatin because I’ve had more than 6 infusions), Pepcid (helps with anaphylaxis prevention and also bonus heartburn help), Benadryl (helps prevent anaphylaxis), Carboplatin (chemo agent #1), 1 liter fluids (helps prevent dehydration and bonus helps to keep kidneys functioning well to avoid high creatinine levels that can be dangerous), Aloxi (anti-nausea, blocks signals from stomach), Gemcitabine (chemo agent #2), Emend (blocks nausea and vomiting signals from the brain).
Away I go… thanks for the support. These days of uncertainty are difficult for me. I like a plan.We have a short term one and I am, as always, moving forward. As I wrote in a prior post and re-read tonight:
Cellular biology is King.
But paired to that fateful ruler
I shall be an argumentative, rebellious Queen.
Wring the most out of each day.
Find those bits of joy and beauty,
Make sure that what I’m doing isn’t waiting around to die.
For truly, that would be a waste.
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