Mixed Bag

After completing two cycles of chemotherapy with Taxol® (paclitaxel) monotherapy, I had my periodic CT scan last week to determine the outcome. Recall that one full cycle of this therapy is defined as once-weekly infusions of paclitaxel for three consecutive weeks followed by a one week break typically reserved for imaging and/or rest and recovery.

The CT scan results were a mixed bag. On the positive side, the image showed minor decreases in the size of my lung metastases, mediastinal lymph nodes (the mediastinum contains the heart, thymus gland, portions of the esophagus and trachea, and other structures), and the tumor on my spleen since my prior CT scan on November 6, 2018. One lesion in my right kidney increased in size, while others remained stable or decreased.

With regard to cancer that has spread to my spine/bone, it is difficult to distinguish between cancer progression (bad) or treatment effect/healing from prior radiation treatment (good) on a CT image. Cancer that spreads to the bone is often characterized as osteolytic (causing the breakdown of bone), osteoblastic (causing increased bone production), or in some cases a mix of both. My latest scan showed increased bone formation activity with several new sites visualized, which could either reflect a healing response from radiation therapy or cancer progression. On a positive note, the compression fracture at my L5 vertebrae looks unchanged/stable from the prior scan.

Based on the latest CT scan, my medical oncologist, Dr. David Pfister, and Nicole Leonhart, ANP, RN, with Memorial Sloan-Kettering Cancer Center (MSKCC) feel that there is a very real component of my disease that remains sensitive to paclitaxel. As such, they are not inclined to add carboplatin back into the mix not knowing if it will contribute anything other than more side effects. And they certainly don’t want to abandon paclitaxel now, since I am still objectively responding. For example, having me switch to a clinical trial with a lot of unknowns and potential negative impact on quality of life.

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Figure 1: Michael Becker receiving chemotherapy at MSKCC on 1/29/19.

So, I’m currently scheduled for two more cycles of paclitaxel monotherapy (3 weeks on, 1 week off x 2) and then reimage. My first dose was infused during yesterday’s appointment without issue (Figure 1).

As mentioned in my prior post, bone pain and radiation pneumonitis that emerged in late 2018 remain my biggest challenge. The bone pain is manageable with a combination of steroids and oxycodone, each with their own side effects. It’s no wonder that skeletal metastases remain one of the more debilitating problems for cancer patients. After experimenting with different treatments, my radiation pneumonitis is currently manageable through a combination of steroids and levalbuterol inhalation solution via a nebulizer.

The latest new issue to surface is a sharp, stabbing pain near the inferior border of my left lung (Figure 2). This has been accompanied by mild swelling and numbness near the skin surface, which is coincidentally where radiation tattoos used to guide my prior spleen therapy can be seen. The pain started just over a week ago and has been getting progressively worse.

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Figure 2: Michael Becker’s radiation tattoos shown in small, solid red circles. Dashed circle with “A” represents the area of pain, while “B” represents the numb and swollen area.

Diagnosing the source of this strange new pain occupied the majority of my time at MSKCC during yesterday’s appointment. Normally I would have jumped to the conclusion that cancer had simply spread to that rib area, but my prior CT scan from a mere week ago didn’t show any anomalies. Nonetheless, an X-ray of my chest was taken to rule out a possible rib fracture that could have been caused by any one of my severe coughing attacks associated with the radiation pneumonitis. However, the X-ray came back clean with no sign of fracture.

In the absence of a fracture or cancer progression, other conditions could explain this new pain. One example is costochondritis, an inflammation of the junctions where the upper ribs join with the cartilage that holds them to the breastbone. Or the pain, numbness, and swelling could be late effects from prior radiation to the spleen.

To further support that the new pain is related to an inflammatory condition, we monitored the response to increased steroids (anti-inflammatory agents). I’m already taking 20mg of prednisone daily to help with the spinal metastases and radiation pneumonitis, but I always receive an additional dose of steroids via IV as part of the premedication course for chemotherapy. Additionally, I was prescribed 300mg gabapentin twice daily, as it can help treat neuropathic pain. I took my first pill last night.

When I got out of bed today, I noticed that the rib pain was gone. The big question remains—what caused the pain in the first place? And did the double steroid dose eliminate the pain, or did the gabapentin play a role? As the additional steroids wear off over the coming days, it will be interesting to see how this plays out.

Lastly, I addressed the increased depression referenced in my prior post. Following an appointment with my psychiatrist at MSKCC, Dr. Jeffrey B. Freedman, my daily dose of Zoloft® (sertraline HCl) was increased and already seems to be helping. PSA—more cancer patients, especially men, should seek professional help for treating depression.

7 thoughts on “Mixed Bag

  1. Are you able to exercise at all Michael? I wouldn’t be surprised if you couldn’t but know it can have positive effects on mood?
    Please don’t think I am implying you should.. Stretching gently helped me retain mobility and balance.

    I sing, and found singing and listening to music during my chemo particularly helpful.
    I had combined chemo radiotherapy for cervical cancer stage 2b. Now clear of cancer but late effects of treatment have been severe.

    I sing for my local Hospice and other choirs. I found that helpful with depression but still needed additional support because loss of lifestyle, income and health require major adjustment of expectations.
    I hope you are settling into your new home.
    Best wishes
    Jane .

  2. Appreciate the update as I wonder how you’re doing. Gabapentin is a great resource as it’s a part of our preop orders before and after abdominal surgery for pain and patients seem to benefit. Hope the rest of your treatment cycle goes well.
    My husband’s scan this time showed the SCC has metastasized to his left external iliac nodes and to his lung. The “remission” after Cetuximab and radiation lasted six months. His response to Cetuximab was 30%. He starts new FDA approved drug Libtayo (Cemiplimab). An IV once every 3 weeks. Surgery and radiation being considered today at MDA. We are grateful the drug was approved and trying to stay positive. However, response rate in two clinical trials was 50%, and of the 50% only 4% had full response and rest partial. He’s fighting, but agree depression is a serious problem. Trying to manage that.
    Best,
    Fiona

  3. The former cancer biologist in me finds the level of detail you provide intellectually compelling, while the medical writer I now am appreciates the clear and concise language you use, even during the bleakest of times.

    And my humanity hopes you and your loved ones find moments of joy each and every day.

  4. Hi Michael,
    I’m hoping your depression eases with the arrival of spring and daylight change (March 10)
    I have been battling depression for about 15 years and I am on the highest doses of Wellbutrin and Efexor, but still I noticed a positive change in my condition in the spring time at the end of daylight savings time.
    And somewhat related I am attending my first head and neck cancer support group at Penn this morning. Apparently it’s a well attended group that meets the first Wednesday of every month.
    I’ll let you know how that goes in case it’s something you’re interested in.
    Also, I was thinking this/your blog itself might be beneficial to some of the patients.
    Well I am off, But here’s my last comment. I certainly agree with Alice about the writing of this blog. And when I read it each month I think to myself what a remarkable person you are – for a number of reasons.
    Warmest regards
    Evan

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