Radioactive

As I compose this post, I cannot get the 1985 song “Radioactive” by English rock band The Firm out of my mind. But perhaps this will make more sense in a moment.

At the end of June 2018, I announced my intent to remain off cancer treatment. A decision so complex that it couldn’t be adequately addressed in a blog post. Simply put, after going through three very difficult therapies from 2016-2018, I decided to emphasize the quality of life over quantity of life.

My last palliative systemic treatment consisted of nine cycles/months of combination chemotherapy (carboplatin and paclitaxel). For a while, it significantly reduced the size of tumors in my lungs and spleen. Most importantly, it prolonged my life—and for that, I am very grateful.

But most cancer treatments are associated with toxicities, which can range from mild to severe. For example, my initial treatment consisted of daily radiation to my head/neck in combination with chemotherapy and was brutal with regard to side effects. In exchange for these toxicities, however, chemoradiation offered the “potential” for a cure at the time. It seemed like a fair trade.

Once my disease spread (metastasized) to distant sites, including my lungs and spleen, the intent of treatment switched from curative to palliative—providing relief from disease symptoms and helping me live longer. Accordingly, I became less willing to endure the side effects of palliative systemic treatment (chemotherapy, cetuximab, etc.) with cure no longer a likely option. This largely resulted in my decision to discontinue treatment.

However, I discussed my worsening cough during a recent appointment at Memorial Sloan-Kettering Cancer Center (MSKCC) with my oncologist, Dr. David Pfister, and Nicole Leonhart, ANP, RN. Absent chemotherapy, the tumors in my lungs continue to grow and create additional problems—chronic coughing, wheezing, shortness of breath, etc. To address my cough, Dr. Pfister introduced the concept of stereotactic body radiation therapy, or SBRT, to deliver extremely precise, very intense doses of radiation to cancer cells while minimizing damage to healthy tissue.

For more than a century, radiotherapy has been an effective treatment for cancer patients. But the new millennium saw the affirmation of SBRT, especially for the treatment of metastatic tumors. In fact, select patients with limited metastases treated with SBRT are long-term survivors.

During a follow-up appointment with my radiation oncologist, Dr. Nancy Lee at MSKCC, she informed me that SBRT is associated with fewer side effects than the conventional radiation therapy I received as part of my initial treatment back in 2016. Conventionally fractionated radiation involves low-dose fractions given once a day (e.g., 10–30 fractions of 1.8–3 Gy each), while SBRT involves giving smaller numbers of higher-dose fractions (e.g., 1–5 fractions of 6–30 Gy each). Accordingly, SBRT can usually be given in five or fewer daily sessions within a week. Fast, safe, and effective—there was a lot to like about SBRT.

SBRT involves the use of sophisticated image guidance that pinpoints the exact three-dimensional location of a tumor so that the radiation can be more precisely delivered to cancer cells. Adverse events associated with SBRT can include pneumonitis, cough, pain, esophagitis, and dermatitis. However, severe toxicities (Grade 3 and 4) are fairly uncommon, occurring in 5% to 10% of patients after SBRT.

Possibly due to my background working with radiopharmaceuticals, I’ve long been interested in the role of radiation therapy beyond its cytotoxic effects. Radiation therapy interacts with cancer and immune system through a variety of mechanisms. It promotes the release of tumor neoantigens during cancer cell death in addition to stimulating immune adjuvant effects, engaging the two key arms of the immune system and functioning like an in situ vaccine, generating tumor-specific T cells.

In fact, localized radiation can infrequently trigger systemic antitumor effects, called the “abscopal effect.” Recent studies presented at ASCO 2018 have explored SBRT in combination with checkpoint inhibitors to potentially improve the abscopal effect with mixed results.

In one study, cancer patients were treated with SBRT and at least 1 cycle of pembrolizumab. Results of the study showed an abscopal response defined by 30% reduction in any single non-irradiated measurable lesion was present in 27% of patients, but only 13% of patients when defined by a 30% reduction in aggregate diameter of non-irradiated measurable lesions. It is difficult from these data to separate out whether the effects seen were because of the combination or from SBRT alone.

In another study, head/neck cancer patients with at least two measurable lesions were randomized to either nivolumab alone for 2 cycles or nivolumab with SBRT to a single lesion (9 Gy x 3) between the 1st and 2nd doses of nivolumab. While safe, the addition of SBRT to nivolumab failed to improve objective response rate (ORR), progression-free survival (PFS), or overall survival (OS).

For now, a treatment plan was developed using SBRT to target tumor sites in each of my lungs. Starting with my left lung, the treatment takes place Monday, Wednesday, and Friday of this week. The same schedule will be used next week for my right lung. For reasons still unclear, questions remain regarding the use of SBRT to also target the lesion on my spleen.

Yesterday was my first SBRT session. Lorie stopped me for a quick kiss before I disappeared into the men’s locker room at MSKCC to change clothes. It was traumatic to see the same rooms and equipment from my prior chemoradiation experience. And while my body needs to be kept in the same position for each treatment, thankfully this is accomplished through the use of a mold of my back instead of being pinned to the table by a face/shoulder mask like last time.

The SBRT session was quick and painless. I thought readers might enjoy seeing what the process is like, so embedded in this post is a brief time-lapse video of me holding still on the table in my shorts and shoes as the linear accelerator components twirl around me.

I’ll update the blog with any significant updates on my SBRT experience. For now, I’m simply hoping to get some relief from coughing.

18 thoughts on “Radioactive

  1. Best of luck to you Michael! I had a the same treatment on a nodule in my lung and it was successful. No side effects to speak of.

  2. Is that a Varian machine?

    Oh, and while your thought was “Radioactive” by The Firm, mine was “Radioactive” by Gene Simmons (his KISS solo album). So, you know, different strokes for different folks and all that… lol

  3. I continue to pray for you mike even though we do not know each other. I pray this treatment extends life and grants relief.

  4. Michael, Thank you again for the update. I cannot express enough how much your blog means to me. I have learned more about the cancer we share than if I had gone to the Harvard Medical School. – Kevin

  5. Much more palatable than the head mask! That for me was horrific. I’m somewhat claustrophobic and I’m still not sure how I got through it. Sending good wishes and energy!

  6. We may not know each other but you and your family are always in my prayers. God works in mysterious ways. Thank you for your update and will continue to pray for you.

  7. Now we do know each other! I’m very proud and inspired by your strengthens determination.
    I feel positive you will get relief from the cough. Praying that those damn T-cells kick in! Stranger things have happened my friend. Drink lots of fluids.
    Sending hugs.

    Your new friend,
    Lisa

  8. Thank you for updating your journey! This sounds promising! I continue to keep you, Lorie, and the girls in my prayers!!

  9. Fingers crossed for immediate relief and more time to spend with Lorie, Rosie, and Meg🤞🏻

  10. You DO walk with a purpose! We live in your world and personally know what you are facing. There is always hope and sometimes it’s tempered by reality. What’s amazing about this disease is that reality constantly changes over time, as does the rest of our lives. Up and down, around, level, and every which way, we face life’s ever changing direction. We have never lost hope though. Never. Hugging you over technological space and wishing you the best always.

  11. We got the news last night. Spreading via the lymph nodes. Incurable. Chemo then Immunotherapy. From a clear scan to new sites in six months. Not sure how to process this news. Doctors seem happier it’s spreading through lymphatic system rather than blood stream. How do families process this terrible disease? Frustration, anger, anxiety…so many emotions pouring in. Patient and family in turmoil.

    • Dee – very sorry to hear the news. My scan also went from clear to metastatic disease in six months. While HPV-positive cancers generally respond well to treatment, there are those cases where the disease is aggressive. My cancer spread via the bloodstream, but it is “better” if it spreads via the lymphatic system. Process the news, but know that treatment (chemo, immunotherapy, etc.) can prolong life. Thoughts and prayers…

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