Tuesday, October 20, 2009
Two medical things happened today.
And one personal thing:
Thank you to all my internet women attorney friends who sent me the above ingredients for a healing charm bracelet to wear during my chemo. The last charm was soldered on by my friends at MaMo Jewelers in Seattle, who did the whole thing gratis. As you can see, the finished product is quite lovely. I would like to say I will wear it in good health. And I will eventually.
Now down to the mundane things.
First, I got a "Power Port" installed in the right side of my chest, this morning. The port will make it easier to receive chemotherapy by injection. Rather than finding a vein with a needle in my hand or arm each time, one that has to last for up the 6 hours for the chemotherapy treatment, the port gives an immediate pathway for injection of the chemotherapy into my subclavian vein. The subclavian vein is located next to my collarbone.
My friend, A, drove me to Group Health Central early this morning where it was installed. I had to disrobe and don the ever famously attractive hospital gown, my blood pressure and pulse were taken, and an IV was inserted. The nurse on duty hit a nerve going in, so that was quite painful, and then the pump for the IV didn't work so that had to be replaced. I was not in a very steady state by the time they wheeled me down to lower level A for the operation. Luckily the fellow who did the insertion, was a real pro. He said he had done in excess of 500 of them in the six years he had been at Group Health. So even though I was tearing up at an alarming rate, I felt comforted. Especially when they added the sedation to the IV drip. The team that worked on me was very professional and it seemed I might not have been the first one to lose it in the pre-op phase...
The team worked smoothly to drape me. They used an ultrasound to see if they could reach the subclavian artery with the tiny catheter that is attached to the port. If not, they would have gone for the jugular (literally). Then, they created a one inch incision directly below the artery. And, using a continuing series of xrays to guide them (this is what I remember him telling me they were going to do before we started--I have to confess I was rather out of it at this point in the procedure, thank G*d), they first inserted a wire all the way down to my abdomen and then used it as the guide to insert the catheter into the artery. After the catheter was inserted, they withdrew the wire, positioned the port right below my skin, and sewed it all up. Now I have a 1-2" purple plastic triangular-shaped 'pincushion' in my chest about 6 inches below my shoulder. Phlebotomists and the oncology infusion staff can insert a needle into the port for either blood draws or chemotherapy, and always be assured of good access to my blood supply.
The chemotherapy drugs, when injected into the port, will enter the subclavian artery and mix with my blood which is in the process of flowing into the atrium of my heart. The atrium is not the active part of the heart, but more of a holding chamber. From the atrium, the chemo/blood mixture is pumped into and out of the ventricle of my heart; the right ventricle pumps blood into my lungs to be oxygenated and the left ventricle pumps the oxygenated blood out to the body through the aorta. I am assuming that the chemo will enter the left atrium and exit goes through the left ventricle, but I am not the expert here, so I may have gotten my right and left mixed up. Particularly because this is lung cancer we're talking about and maybe it will go directly to the lungs. I blame the sedative agents for my amnesia. I also bless them too.
I really don't know much more of what went on during the procedure other than I dozed off and woke up after all the exciting parts were done. My intrepid team told me it went just perfectly and I was wheeled back up in a haze to the 4th floor, where they kept me for observation and breakfast until 11 am, at which point I was discharged and my dear, patient friend, A, drove me home.
Second, I received a call this evening from Dr. F at Group Health, who is covering for Dr. N, while he is attending a medical convention in Colorado.
The Seattle Cancer Care Alliance Tumor Board met and discussed my case today. Dr. F talked with Dr. M, the lung cancer specialist from SCCA afterwards and here is where we are going:
There is too much disease in my mediastinum to do a mediastinoscopy. Apparently Dr. N thought a mediastinoscopy could remove the tumor as well as biopsy it, but Dr. M and SCCA et al were of the opinion that there would be too much danger that microscopic portions of the disease would be left in the mediastinum following surgery, and eventually spread again. The CT scan already showed the lymph node involvement, and the damage to the nerve of the vocal cords was already indicative of the presence of the tumor. Of consideration was that it was also difficult to get at by surgery.
Because a biopsy of the mediastinal nodes was likely only to confirm the presence of the disease that has already been diagnosed, the Tumor Board recommended that I go straight for treatment. They recommended chemotherapy first, followed by maybe surgery and then radiation. There is a less than 50% chance that I will be cured, but they think it's worth taking. Dr. M wants to aim for cure by using a combination of cisplatin and pemetrexed. This would be done in 3 (not 4) cycles of chemotherapy, once every 3 weeks. At the end of the cycles, or at 9 weeks, plus a week or two for recovery, they would do a CT scan. If the response was very good, then they would look at surgery to excise the remainder, followed perhaps by radiation. If the response to chemotherapy was good, not very good, meaning no further growth, they would drop the idea of surgery and go on to radiation.
There's a lot of controversy, Dr. F said, in the field of how to time the cancer treatment. The cisplatin/pemetrexed combination looks good together as a chemo modality but there is no data on how it mixes with radiation. Dr. F said that NCCN, the medical organization that develops professional practices for cancer treatment, recommends a combined chemo and radiation therapy using cisplatin and another chemotherapeutic agent known as etoposide, but that Dr. M thinks the regimen he has proposed would work just as well for me.
I will start the chemo not immediately, but next week, because they need to give me a shot of Vitamin B-12 a week before commencement to lower the toxicity of the effect of the chemotherapy on me. I also will need to start taking folic acid daily in the week before. I also will be taking a high dose steroid, dexamethosone, the day before and the day after chemo.
The second punch biopsy of the lower left lobe of my lung that Dr. M initially proposed, would be to see if the tumors had EGF receptors which, if so, would mean that erlotinib (Tarceva) could be used--but Dr. F said that erlotinib has not been shown to be curative. So if I want to go curative, it would mean doing the chemo/surgery?/radiation route.
The other news is that Dr. F went back over the PET scan with a radiologist today and I have a fairly large cyst on my pelvis coming off an ovary. It did not light up during the PET scan so it's not metabolically active, and probably only a simple cyst. But Dr. F wants to check for the presence of OCA 125 markers in my blood. This is indicative of ovarian cancer, but there can be lots of false positives with the test too, so he proposes testing for the CEA marker as well, which is an indicator of lung cancer.
After I return the loaner car to Carter Subaru and pick up my car (they were great about returning the car a day late as I was too woozy today to drive), I will be going to Northgate Group Health tomorrow for the B-12 shot and the various meds, as well as the blood tests that Dr. F has ordered. He is also ordering the vaginal ultrasound, which will be done at Group Health Central.
Finally, if my voice does not return after treatment, Dr F suggested collagen injections into the vocal cord. He said they could last longer than a few months.
My chemotherapy should start next Wednesday or Thursday. I am leaning toward Thursday because I would have the weekend to recover from some of the worst of it. I hope I got most of the facts here straight because it has been a long, tumultuous day.