First Chemo Date Set!

Last Friday, Dave and I met with my medical oncologist, Dr. Seth Cohen, for the first time. I'm now officially out of the "surgery" stage of treatment and onto the "chemo" stage. I won't need to see Dr. Tartter again until after radiation is completed. Dr. Cohen is a really friendly, patient guy, fairly young but knows his stuff, and as David commented proudly, not as elegantly balding as he is. We talked about the plan for my chemo and got the first appointments set: MUGA (heart scan) and chest x-ray on 3/22, port implant and first infusion on 3/29. After these treatments get started, we'll set up an appointment with a radiation oncologist to talk about that step.

First, Dr. Cohen asked me to explain how I understood my diagnosis, based on the results of my two surgeries. I explained, rather self-consciously, and joked that it felt a little like a test. Dr. Cohen said I passed. I think he did this not only to find out where to start the conversation, at diagnosis or at treatment, but also to know at what level he could talk with me, I mean, at what level his descriptions and explanations should be. I thought this was a smart way to get to know me quickly. Is that part of med school training? Then we talked about the drugs and side effects and had a quick physical exam. My incisions are healing really well. The lymph node incision under my arm is still bumpy (that will even out), and the skin around it is tender and swollen. That's normal. David noted that if he pokes his own underarm (or Sappha's) several times, it hurts, too. Is this area sensitive because it's under the arm, or is it under the arm because it's sensitive? A deep thought, though not one Sappha wants to ponder at the moment, seeing as she is trying to protect her underams from her father's poking.

Anyway, Dr. Cohen is recommending a course of chemotherapy called AC/T: 4 cycles (2 weeks apart) of Adriamycin (also called Doxorubicin) and Cyclophosphamide (also called Cytoxan), followed by 4 cycles (2 weeks apart) of Taxol (also called Paclitaxel), for a total of 16 weeks of treatment.

Before the first session, I’ll have a heart scan in order to assess my heart function. We are expecting this to be normal, but Adriamycin can cause damage to the heart muscle and may ultimately lead to heart failure in some patients. It would be unlikely for me to experience this complication, however, given my age and otherwise excellent health. The chest x-ray will likewise be used to evaluate my heart and lung function, as well as to reaffirm the doctor’s belief that my cancer has not spread outside of the breast to my lungs. These are routine pre-chemo tests and do not reflect any suspicion that my prognosis might be worse than stated earlier.

On the morning of the first infusion, I’ll go in early to get my port implanted. Think of it like an outlet that they’ll “plug” the drugs into. The port (Medi-Port and Port-a-Cath are some common brand names) will make chemo easier by eliminating the need to find a vein in my arm for each infusion. Although I have enviably large veins in each arm and pale skin that makes finding them very easy, the repeated doses of chemo, along with the required blood draws and other injections, start to cause wear and tear. Additionally, these are brutally powerful drugs that can “burn” the skin and veins; placing a port in a large vein minimizes that risk and discomfort. And since I won’t have a needle in my arm, I’ll be able to move around more comfortably during the infusions. The port is about the diameter of a quarter and about a half-inch thick. It will be implanted entirely under my skin, about two inches under my collarbone, with an attached tube (the “catheter” part of the Port-a-Cath) inserted into my Superior Vena Cava, a great big vein right next to my heart that will energetically funnel the drugs to the furthest reaches of my body. When they want to use it, they will just give it an alcohol rub and a little numbing medication and stick a needle in through my skin and the plastic top of the port. It’s completely hygienic; I don’t have to worry about it when showering, for example. There will be a noticeable bump under my skin where the port is, and a small scar from the surgeries to implant and remove it. But at this point, I’m not so much worried about the bump or scar! The surgeries are short, but they do require more than a local anesthetic. So I’ll be out for a bit, but then they can use that baby for the very first infusion later that morning. No waiting time!

Before each infusion session, I’ll have a blood draw and they’ll measure my levels of white and red blood cells and platelets. The white blood cell count is particularly important because the chemo will lower my white blood cell count, making it more difficult for me to fight infection. If my levels are not high enough, they may have to delay my infusion. To help keep my counts high, I’ll return to the hospital the day after each infusion for an injection of Neulasta, a drug that stimulates the growth of white blood cells. Fun fact about Neulasta: it’s made from the bacteria E. coli! Also, I’m to do what I can to avoid injury and infection, through diet (no unpasteurized or cured stuff; cook foods thoroughly and limit consumption of uncooked fruits and vegetables, especially those that can’t be peeled; limit any alcohol intake to one drink per week; we’re also keeping an even more organic kitchen than usual; and so forth), lots of handwashing and glove wearing, staying away from sickie kids and adults (so no field trips with Sappha’s class, for example, and no live bacteria immunizations for Finn until chemo is over), and resting when my cell counts (and energy levels) are the lowest, about five days after each infusion.

The infusions themselves will take about 2 hours. I can hang out in the “Infusion Suite” by myself each time, but someone is supposed to accompany me home. The “suite” looks more like the business class section of an airplane, with curtains in between the faux leather recliners. You can close yourself in or leave the curtain open. There are televisions, and Dr. Cohen said that the nurse will bring you a DVD player if you request one. It seemed pretty quiet on the morning I was there. An 80-year-old man (I know because he mentioned his age a few times) was also doing the “intro tour” that morning. He was a real card, flirting with all the nurses and telling jokes and making other saucy remarks (some about his pants, some about his meds). He’ll definitely liven up that joint, though I’m not sure I’d want to be his chemo co-passenger every time. I’ve heard that you really get to know, and even become friends with, the others (patients and nurses) who are on your schedule. We’ll see what my alternate Thursday morning group looks like.

I am still planning to get a second opinion at Sloan Kettering, though I feel very comfortable with Dr. Cohen's advice, which matches what I've found in my own research, and with Dr. Cohen himself, who is very straightforward, clear, and available. My appointment at MSK is on 3/21. I particularly want to know if there are any clinical trials going on at MSK with triple negative cancers. Dr. Cohen said that some of his patients participated in one recently, but it was for node positive patients, not node negative like me. According to the statistics that Dr. Cohen showed us, for a 30-year-old with a Grade 3 tumor, less than 2 cm, lymph node negative, the ten-year survival rate with surgery and radiation is 70%. Adding chemo increases it to 86%. That's pretty good, I guess, but it would be even better if I could have hormone therapy. Damn! I was there were something targeted right now for us trip negs.

On the positive side, chemo works best on fast-growing cancers like mine, especially now, if there are any stray cells floating around my body. (Of course, it's possible that I have absolutely no cancer at all in my body right now.) One of my favorite quotes about chemo on the breastcancer.org site: "Cancer cells' growth is unwieldy and uncontrolled—they just don't have their act together like normal cells do. When normal cells are damaged, they are like a big city with a fire and police department and trained emergency squads to come and 'put out the fire.' Damaged cancer cells are more like a disorganized mob with a bucket." —Marisa Weiss, M.D.

So, in short, I'm not afraid of chemo and its side effects (which I will outline in a future post). I'm glad that I have it as a treatment option. I'm glad that I have an excellent chance of far outpacing that ten-year mark.