Cancer is Back

2017 isn’t off to a stellar start.

During today’s appointment with my oncologist at Memorial Sloan-Kettering Cancer Center (MSKCC), we received disappointing news that the biopsy of my chest lymph node contained the same cancer cells (squamous cell carcinoma) as the original tumor in my tonsil. This means that the cancer has spread to distant sites and, unfortunately, cure is now no longer an option.

I enrolled in a clinical trial with Bristol-Myers Squibb’s Opdivo© (nivolumab), a type of immunotherapy called a checkpoint inhibitor, and should start treatment next week assuming I meet the study criteria. While the drug was already approved by the FDA for recurrent head and neck cancer, the study will evaluate whether or not adding targeted radiation directed at one single lung node can improve outcomes.Opdivo

I was already familiar with the synergy between radiation and other forms of therapy, especially immunotherapy. Coincidentally, we were exploring such synergies back at Cytogen Corp with the company’s skeletal targeted radiotherapy being combined with a poxvirus vaccine being developed by Dr. James Gulley at the NIH at the time. Small world.

As the trial is randomized, I may or may not be one of the patients to receive the added radiation therapy. However, both arms of the trial receive Opdivo – so I get an active drug in recurrent head and neck cancer in either case.

There has been a great deal of enthusiasm for checkpoint inhibitor products, such as Opdivo. However, in the recurrent head and neck cancer study by Bristol-Myers Squibb, the median overall survival was 7.5 months for patients that got Opdivo. The other patients that received standard therapy options (cetuximab, methotrexate, or docetaxel) had a median overall survival of 5.1 months. True, there were some ~20% patients that had durable responses with Opdivo, but the vast majority (80%) did not have a durable response.

The good news is that Opdivo is a form of immunotherapy and doesn’t have many of the severe side effects associated with both chemotherapy and radiation. Accordingly, it is expected that I will be able to continue working and not have any major issues throughout treatment, as they are rare. However, Opdivo can cause your immune system to attack normal organs and tissues in many areas of your body, and can affect the way these organs work.

I’ll be posting more updates in the coming week or so…

Biopsy Done

Very long day, so I’ll keep this post brief. Lorie and I stayed overnight in NY yesterday due to the early procedure scheduled this morning at MSKCC. My appointment was at 9:15am and I was scheduled for the operation to start around 10:40am. However, my slot got delayed and I didn’t head into surgery until around 2pm!

Michael D. Becker in the recovery room after a bronchoscopy

The good news, if there is any, is that thoracic surgeon Dr. Park was able to get sufficient tissue from the suspicious lymph node via the bronchoscopy approach and he didn’t need to do the surgical resection to go after the other nodules in my lungs.

The biopsy results will take a few days, but it is clear from the surgeon that the node they biopsied didn’t look “healthy.” Given that disease progression to the lungs is relatively common in advanced head and neck cancer, in my opinion the biopsy will most likely confirm spread of the original cancer to the lungs. Or, it could just be an unrelated new lung cancer just showing up now.

I hope to have more to report in the New Year but for now am relaxing in the passenger seat as Lorie drives us home. She’s such a trooper and I know my cancer returning isn’t easy for her.

Biopsy Consultation

Early this morning, I had my biopsy consultation with surgeon Dr. Bernard Park, deputy chief of clinical affairs, thoracic service at Memorial Sloan-Kettering Cancer Center in NYC. During the meeting, he presented the pros and cons for a couple of scenarios.

The first and most attractive option is a bronchoscopy, which is an outpatient procedure that allows a doctor to look at my airway through a thin viewing instrument called a bronchoscope. During the bronchoscopy, the doctor will remove tissue from a suspicious lymph node near my airway. If they can determine the presence of cancer during the procedure, then we are done with the biopsy portion.

The second option is a wedge resection, during which the doctor will remove a portion of my lung around one of the suspicious nodules that showed up on the PET scan. This is an inpatient procedure and may include several days in the hospital.

Dr. Park offered to combine the two options, where he will begin with the bronchoscopy and only do the wedge resection if necessary during the same procedure. This spares me from having to schedule two separate procedures and potentially delay results.

The biopsy procedure is scheduled with Dr. Park on Thursday, December 29th. Assuming the results are as expected, the next step is to meet with my oncologist Dr. David Pfister at MSKCC on Tuesday, January 10th, 2017.

As you can tell in the accompanying photo taken by my lovely wife, I’m so glad to be traveling back home on New Jersey Transit on the Friday before Christmas.

becker_train
Michael Becker

Cancer: The Grinch that Stole Christmas

Of the +30 posts on this patient blog, this has been one of the hardest to write.

Lung metsIn the prior entry, I referenced that my next PET scan was scheduled for early February 2017. However, my radiation oncologist wanted to keep the PET scans consistent at six month intervals that resulted in moving the PET scan up to December 14 (last Wednesday). My prior PET scan was in June 2016.

Unfortunately, the latest PET scan did not contain good news. Multiple new spots consistent with malignancy showed up that were not visible six months ago. This includes activity in lung nodules, subcarinal/left hilar lymph nodes (near the trachea), and mild activity around the tonsils and in the region of the oral cavity. The results were confirmed by a subsequent CT scan this past Saturday.

In the world of medicine, however, cancer doesn’t exist until the abnormal cells are viewed under a microscope. Accordingly, I will soon need to have a biopsy taken from one or more of the suspicious areas highlighted on the PET scan. However, I don’t need to wait for that procedure and the subsequent results to know the outcome.

For head and neck squamous cell carcinoma (SCC), which was my initial diagnosis, pulmonary metastases are the most frequent and account for 66% of distant metastases¹. This information, combined with the imaging results, leaves very little chance that the biopsy results will be benign.

Michael D. Becker Awaiting PET Imaging
Michael D. Becker Awaiting PET Imaging on Dec 14 at MSKCC in NYC

The consultation for the biopsy procedure has been scheduled for late this week and the actual biopsy procedure still needs to be scheduled. If the biopsy confirms that cancer has indeed spread to my lungs, the next step will be a meeting with my oncologist to discuss treatment options, which will likely include recent advances, such as biologic agents and immunotherapies (e.g., checkpoint inhibitors).

¹ ORL J Otorhinolaryngol Relat Spec. 2001 Jul-Aug;63(4):202-7.
Incidence and sites of distant metastases from head and neck cancer.

² http://www.headandneckcancerguide.org/hnc-dev/adults/introduction-to-head-and-neck-cancer/distant-metastasis/

Thankful

It’s that time of year again; where we get together with family and friends to celebrate the Thanksgiving holiday. It is also a time for reflection and appreciation, which has even greater meaning for me this year.

It was the day before the Thanksgiving holiday in 2015 when I first discovered a suspicious lump protruding from the right side of my neck. The formal diagnosis of Stage IV oropharyngeal cancer would occur several weeks later, but I knew at the time that the palpable growth just below my jaw line was anything but benign.

As a senior executive working in the field of biotechnology, and in particular the area of oncology, being diagnosed with cancer was difficult – but hearing “Stage 4” was especially disheartening. While staging systems are specific for each type of cancer, in general the cancer stage refers to the size and extent of the disease and is assigned a number from 1 to 4. If my cancer was confined to the right tonsil (where it started…) and hadn’t spread elsewhere, I would have been diagnosed with Stage 1 disease. Localized spreading would have been Stage 2 and depending on the extent of involvement of nearby lymph nodes – progress to Stage 3. When cancer has metastasized, or spread to other organs or throughout the body, it can be classified as Stage 4 and may also be called advanced or metastatic cancer. Stage 4 usually carries a grim prognosis compared to earlier stages of the disease.

Accordingly, when one is diagnosed with Stage 4 cancer, the immediate concern is whether or not the individual will be able to survive the disease. For me, however, the bigger concern was surviving the treatments and their side effects. In particular, my experience licensing and launching a product to treat oral mucositis made me very familiar with this debilitating side effect from both radiation and chemotherapy.

When reviewing treatment options with Dr. David Pfister, my medical oncologist at Memorial Sloan-Kettering Cancer Center (MSKCC), I was really hoping that I would be a candidate for recent advances, such as biologic agents and immunotherapies. This was due to my familiarity with their targeted and less toxic profiles, especially when compared with chemotherapy and radiation. In fact, back in early April 2010 I published a 150-page industry report titled “Cancer Vaccine Therapies: Failures and Future Opportunities” and later that year held the inaugural “Cancer Immunotherapy: A Long-Awaited Reality” conference that took place at the New York Academy of Medicine in New York. For more information and background on immunotherapy, read “Insight: Training immune system to fight cancer comes of age” by Bill Berkrot of Reuters.

Unfortunately, approved targeted agents like Erbitux® (cetuximab) still require combination with radiation therapy and its associated side effects. Immunotherapies, such as Opdivo® (nivolumab) and Keytruda® (pembrolizumab) were only recently approved by the FDA to treat head and neck cancer, but their initial indications are limited to patients with disease progression during or after chemotherapy. I remain hopeful that use of these and other new agents will expand to newly-diagnosed patients going forward and that ultimately we no longer rely upon chemotherapy or radiation to treat this disease.

Nonetheless, it is encouraging to see two new drugs approved to treat head and neck cancer this year and know that there are options for me in the unfortunate event that my disease returns. In this regard, I was glad to help ring the Nasdaq Stock Market Opening Bell last month to celebrate cancer immunotherapy advances and the one-year listing anniversary of the Loncar Cancer Immunotherapy ETF (Ticker: CNCR). I first met Brad Loncar (@bradloncar on Twitter), Chief Executive Officer of Loncar Investments, at my inaugural cancer immunotherapy conference and he was kind enough to extend me an invitation to the Nasdaq event.

Photograph by Christopher Galluzzo / @NASDAQ
Jill O’Donnell-Tormey, Ph.D., CEO and Director of Scientific Affairs of the Cancer Research Institute, Brad Loncar, Chief Executive Officer of Loncar Investments, and Michael Becker. Photograph by Christopher Galluzzo / NASDAQ

Ultimately, I went through seven weeks of daily radiation and three cycles of chemotherapy at the start of this year, which as actor Michael Douglas was quoted “somehow seemed very accurately mapped to the seven circles of hell.” In 2010, Michael Douglas was also diagnosed with Stage 4 oropharyngeal cancer and went through the same treatment regimen at MSKCC in New York.

So, while this year started off rough (understatement), I am extremely lucky and thankful to have no evidence of cancer following treatment and to finally be free of “most” of the debilitating side effects from therapy. For example, in recent months I have noticed a dramatic improvement in both energy level and saliva output and have started to reverse a 40-pound decline in weight I experienced during and after treatment.

Aside from eternal gratitude for my wife and daughters’ love and support throughout the process, I would like to extend a special thanks to all of the healthcare providers at MSKCC for their superb care. From my “dream team” consisting of medical oncologist Dr. David Pfister, radiation oncologist Dr. Nancy Lee, and surgeon Dr. Benjamin Roman to amazing nurse practitioner Nicole Leonhart and all of the others who cared for me. I wouldn’t be here today without you!

Photo of Michael Becker and Dr. Nancy Lee
Photograph of Michael Becker with radiation oncologist Dr. Nancy Lee of Memorial Sloan-Kettering Cancer Center (MSKCC) taken November 18, 2016

For my family, friends, and colleagues – too numerous to name – thank you again to EVERYONE that helped in some way…the thoughts, emails, prayer chains, food deliveries, financial support, hospital visits, etc. were all greatly appreciated.

My next PET scan is scheduled for early February 2017 and I hope to report that all remains clear around that time.

PS – as a native of Chicago and loyal fan, I am also thankful to have witnessed the Cubs baseball team winning the World Series for the first time in 108 years in 2016! Go Cubs Go!

Looking Over Your Shoulder

CancerAs I approach the five-month mark since completing chemoradiation, I can FINALLY start to see light at the end of the tunnel. Just this month, I’ve started to notice significant improvement in both energy and ambition. A few weekends ago, I actually went out to see a movie, ran errands, did a photoshoot, and even jump-started a car. It seemed like a miracle! Prior to that, my weekend activities consisted solely of laying on the couch napping or watching television after managing to get through the exhausting work week routine.

I’m not sure if the increased energy was related to my body finally starting to heal or the fact that a few weeks ago I started taking a special type of ginseng supplement that has been shown to help with cancer treatment-related fatigue. For more information, you can read about it here. Either way, the difference is dramatic compared to a month ago.

Unfortunately, my appetite isn’t quite back to normal and my weight is now down 46 pounds from the start of therapy. Don’t get me wrong, I’m very happy to have shed those unwanted pounds – but I don’t think the chemoradiation diet fad will catch on anytime soon. Aside from not being hungry, my saliva output is still greatly diminished and that impacts on food selection and taste.

However, with the recent favorable PET scan, energy returning, and being back to what I consider my ideal weight – you’d think the word “cancer” would slowly start to fade from everyday thoughts and discussion. Not so.

Case in point: this past weekend. A series of minor gastrointestinal issues was easy to dismiss until escalating Friday evening. After vomiting for the fifth time during the evening, I briefly passed out while making my way to the bathroom and my wife had to call 911. While I couldn’t imagine any possible connection between head/neck cancer and the new gastrointestinal symptoms, it didn’t stop me from going to that “dark place” while laying face down on the bathroom floor and during the short ambulance ride to the hospital (PS – my first ambulance ride; not as exciting as it seems on television). Fortunately, this was one of the few non-cancer related trips to the emergency room and I was simply diagnosed with the norovirus, also known as the winter vomiting bug (lucky me to catch such a bug during the middle of summer…). After receiving two bags of intravenous solution to replenish my electrolytes, along with anti-nausea medication, I was released and felt much better by Monday.

What I hear from other cancer survivors is true – every little ache or anything out of the ordinary immediately causes anxiety that the disease has somehow returned. You are always looking over your shoulder.

Complete Response

Cancer - Three Arrows Hit in Red Target Hanging on the Sack on Green Background.

In my prior post, I referenced seeing my head and neck surgeon to investigate recent changes to my voice and swelling in my neck. Although there was nothing suspicious upon visual examination, he wanted to confer with both my medical oncologist and radiation oncologist to determine whether or not an imaging study was warranted. Much to my surprise, I received a call back after the Memorial Day holiday stating that they wanted to move up the date for my first post-therapy PET scan, which was originally scheduled for July 19.

For head and neck cancer, this first PET scan following chemoradiation therapy is a big deal. A “complete response” to therapy based on PET assessment is associated with a high probability of regional control (only 2.3% regional failure rate) and a five year overall survival rate of 79.8% based on long-term follow-up in a large uniform cohort at Memorial Sloan-Kettering Cancer Center (MSKCC, see reference below). With a suspected incomplete response on the first PET scan, the 5-year overall survival rate dropped to 57.0% in the same study.

My PET scan was rescheduled for late in the day last Friday (June 3), which meant that I wouldn’t receive a phone call with the results until today (Monday). It was worth the wait, however, as the report from my PET scan couldn’t have been better. There was no accumulation of the radio tracer in my tonsil, the previously enlarged lymph node, vocal cords or any other area of concern. Sometimes there is inflammation and other artifacts from treatment that radiologists can’t rule out as residual disease and therefore cautious language can be used in the radiology report, which wasn’t the case for me. Additionally, there was a marked decrease in the size of the infected lymph node.

Personally, I’m not a fan of the terms “cure” or “cancer free” – since right now there’s no way for doctors to know with certainty that all of the cancer cells in my body are gone. In fact, some cancer cells can remain unnoticed in the body for years after treatment. So for now I prefer to embrace the phrase “complete response,” which references the disappearance of all signs of cancer in response to treatment.

If cancer cells do come back, it often happens within the 5 years following the first diagnosis and treatment. In this regard, I’m optimistic about the expected 80% 5-year survival rate  – especially when compared to some other aggressive cancers, such as pancreatic cancer, which is associated with a 5-year survival rate of only 8% (American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016).

I meet with my radiation oncologist in a few weeks and will learn more about how frequently I will need to have follow-up PET scans and other visits. Until then, I’m trying to digest the positive news, looking forward to slowly regaining some control over my life, and appreciating the coincidence that yesterday cancer survivors and supporters in communities around the world gathered to celebrate the 29th annual National Cancer Survivors Day® (June has been designated National Cancer Survivors Month).

Thank you to everyone (far too many to name…) who supported me during this difficult period – but especially my wife Lorie who has been absolutely amazing through all the ups and downs (luvya!).

References:

Int J Cancer. 2013 Sep 1;133(5):1214-21. doi: 10.1002/ijc.28120. Epub 2013 Mar 29.
Long-term regional control in the observed neck following definitive chemoradiation for node-positive oropharyngeal squamous cell cancer.
Goenka A, Morris LG, Rao SS, Wolden SL, Wong RJ, Kraus DH, Ohri N, Setton J, Lok BH, Riaz N, Mychalczak BR, Schoder H, Ganly I, Shah JP, Pfister DG, Zelefsky MJ, Lee NY.

Three Month Mark

Hard to believe, but later this week will be the three-month anniversary since I finished chemoradiation. Unfortunately, it’s also been nearly that long since my last blog post, although I did write a brief article for Cure Magazine published in April 2016 that can be viewed here.

I haven’t been writing much lately because I wanted this blog to be somewhat uplifting and inspirational. Frankly, the past few months have been extremely frustrating and difficult. It occurred to me, however, that sharing the bad along with the good may be equally important to others facing head and neck cancer. So here it goes…

In my last post from March 2016 I noted that my weight declined by 20 pounds since the start of chemoradiation. I’m now down a total of about 30 pounds (which I still think is okay since I was overweight to start). The additional weight loss comes from a combination of taste disturbances, reduced salivary output, and general loss of appetite during the period.

I’m pleased to report that my taste buds are now ~90% back to normal and that “most” foods taste the same as before therapy. Unfortunately, my saliva output is still greatly diminished and eating dry foods, such as bread, is very challenging. I have managed to eat a hamburger by taking off the top bun and eating the rest with a fork and knife along with a fair amount of ketchup. The biggest issue relates to a general lack of interest in eating, which I originally thought was due to the taste disturbances. Most days I have a high protein, nutritional shake for both breakfast and lunch and then a “normal” dinner and dessert. I haven’t been out to a restaurant since the start of therapy, as I am self-conscious about my eating habits.

Fatigue is still an issue, although it has improved over the past month or so. I returned to work full-time around mid-March, which meant getting up early and commuting to New York. Until recently, I would come home and literally pass out on the couch from exhaustion at the end of the day. Now I am able to stay awake through dinner, watch some television, and go to bed at a reasonable hour. I do still sleep on the morning train ride to New York and look forward to the weekends where I normally sleep until noon or later to catchup on rest.

The one major issue I haven’t discussed at length in this blog is the psychological impact of being a cancer survivor – namely depression. Societal expectations have taught men not to display any emotions. We are trained from an early age to be confident, stoic and strong. It is extremely difficult to fulfill this role or expectation as a male cancer survivor. On more than one occasion I have burst into an emotional crying session lasting a good 15-minutes. I’m not talking about the quiet episode of crying with sniffles and a tear or two down the side of your cheek. I mean full-fledged bawling your eyes out accompanied by nasal discharge and the near inability to speak normally – “I…I…I…nuh…na…nah…need…ah…uh…t…t…tis…tissue.”

The first such breakdown occurred around the start of chemoradiation when my wife and oldest daughter first came to my temporary apartment in New York. In retrospect, I had bottled up all of the emotion from first discovering the growth on my neck, to receiving a formal cancer diagnosis, to my first infusion of chemotherapy, etc. and let it all out at once. More recently, however, I broke down after showering the morning of my oldest daughter’s prom. I started to think about how happy I was to get home from New York during therapy to see my youngest daughter for her freshman formal and recalled the photographs from that evening with my neck visibly red from the radiation therapy. Then I started to think – are these going to be the last “big” events I will be around to see for each of my daughters? That spiraled into a series of awful “what if” questions that left me in a giant puddle.

Most of the time I am able to maintain a positive outlook and not let cancer “win” by occupying my every thought (insert ZOLOFT® ad here…). This is made harder by the requirement for periodic tests and imaging studies to determine whether or not the cancer has returned. Aside from those periodic tests, it feels like I am constantly watching over my shoulder for signs or symptoms of cancer’s return.

For example, in early May my wife noticed my voice had changed. At first she dismissed it as that froggy, lower tone you sometimes get first thing in the morning or when you have a head cold. But it didn’t go away and eventually even I noticed it. Subsequently, I found that the neck area under my chin was swollen. My first thought was “#@$&!” – the original cancer had now spread to the vocal cords, larynx (voice box), or other areas of the throat, as these would all be relevant symptoms. I saw my head and neck surgeon last week and he didn’t see anything suspicious upon visual examination. His initial diagnosis was that the voice change and neck swelling were simply the after-effects of radiation therapy, which can manifest even months after treatment. Nonetheless, he wanted to confer with both my medical oncologist and radiation oncologist to determine whether or not an imaging study is warranted. In the meantime, I’m trying to adjust to my new bass-baritone “Barry White” voice…which may or may not return to normal.

So that’s about it…you are now caught up on my life over the past few months. The next major event will be my PET scan on July 19, which will be the first such imaging test following treatment. Still hoping for a positive outcome from that study and will update as appropriate.

 

Home Sweet Home

This week I was able to move out of my temporary apartment in New York and return home to Bucks County, PA. I don’t know whether it was being away from the loud traffic noises or just finally sleeping in my own bed, but the first night home was the best night’s sleep I’ve had in weeks.

As predicted by my physicians and nurses, the weeks following chemoradiation were the most difficult in terms of toxicities due to the delayed effects of therapy. For me, week #8 was the worst and I required additional hydration pretty much every other day during that week. This was due to the fact that my electrolyte levels, in particular magnesium, were low. Fatigue was probably the greatest side effect, but in general I just felt like I had a really bad case of the flu.

By week #9 the physicians indicated that my electrolyte levels had stabilized and/or improved, meaning that I didn’t require as frequent hydration. That gave me the freedom to return home since I didn’t need to be near MSKCC.

My salivary output and taste buds are still off as a lingering effect from the chemoradiation therapy, although I understand they should return over time. This makes it difficult to eat – or at least find food that is appealing. I’ve lost more than 20 pounds since the start of treatment, which doesn’t disappoint me as much as my doctors.

I’m hoping to return to my daily commute to NY for work later this week and get back to a relatively normal life. The radiation burn marks on my neck are nearly gone and you’d hardly know by looking at me that I just went through seven weeks of pure hell.

My post-treatment visit with Dr. Nancy Lee has been scheduled for mid-May 2016 which is when I’ll get my first update on the treatment efficacy. She did order a PET scan on my last day of treatment, which looked encouraging although you cannot draw any definitive conclusions at this early stage. Nonetheless, there was decreased fluorodeoxyglucose (FDG) uptake in the right tonsil and in the rim corresponding with the neck nodal mass. Interestingly, the neck nodal mass also originally measured 4.0 x 2.6 centimeters and now measures 2.3 x 1.6 centimeters, which is a dramatic decrease in size.

Week #7 – Done and Done

Friday marked the last day of my seven week chemoradiation therapy journey. Aside from some routine follow-up appointments and recovering from lingering toxicities, I will now wait several months for the repeat PET scan that will provide some insight as to whether or not the treatment was a success. Of course, I’m trying to stay optimistic that the combination of radiation and chemotherapy treatments that I endured over the past seven weeks successfully eliminated all of the cancer – but there is always that nagging thought that it did not and that leaves a pit in my stomach.

Michael Becker's Radiation Mask
Michael Becker’s Radiation Mask

Fortunately, on Friday I was able to take home with me the dreaded radiation mask (see enclosed image). No longer will I need to wear this mask for daily radiation therapy, which makes me VERY happy. The nuclear technicians offered humorous insight as to what other patients do with their masks after radiation treatment is done.  Some make decorative items, such as flower pots. Others simply burn them in a sadistic revenge ceremony, which I must admit holds a certain type of appeal. Although it somehow conjures up thoughts of Darth Vader’s helmet, last seen burning in a funeral pyre in ‘The Return of the Jedi,’ winding up in the hands of Kylo Ren in the ‘Star Wars: The Force Awakens’ movie…

Regardless of what I do with my mask, I am enjoying a certain freedom knowing that I’m no longer beholden to a daily treatment schedule and that I have received the very best treatment possible for my disease by the entire team at Memorial Sloan-Kettering Cancer Center (MSKCC). It is amazing how quickly the seven week treatment cycle passed and it all seems like a blur right now. While I did not look forward to the daily radiation treatment, the appointments were at least a reminder that I was doing something to treat the disease. Now I have that same empty feeling that plagued me when I was first diagnosed and searching for the best treatment – the feeling that I should be doing something but cannot.

Final Day of Chemotherapy

Today was my last chemotherapy appointment. It was bittersweet watching the final drops of cisplatin fall from the bag, stream down the winding tubes, and finally enter the intravenous line into my vein.

On the positive side, I was able to complete all of the three cycles of chemotherapy that are associated with the encouraging survival rates published by the physicians at MSKCC. Some patients don’t make it through all three cycles due to side effects, and I was nervous earlier this week when I started running a fever that they may skip the last cycle.

On the negative side, the week following chemotherapy has been difficult for me in terms of nausea and a general sense of feeling crappy. On top of that, the doctors keep reminding me that the coming few weeks will be the toughest. This is due to the cumulative effects of both radiation and chemotherapy, as the two therapies continue to exert their toxic effects even after they are discontinued.

Michael Becker and Daughter Megan in the Chemotherapy Suite at MSKCC
Michael Becker and Daughter Megan in the Chemotherapy Suite at MSKCC

Fortunately, I was joined not only by Lorie but also my youngest daughter Megan. Megan was able to come to NYC thanks to Lorie’s best friend since 3rd grade of elementary school – Debby Novack. She came into town to help out after Lorie’s sister went back to Illinois after her three week tour of duty. Not an overly exciting day for Megan sitting around the chemotherapy suite and shuffling between various appointments, but it was great having her there.

The following two days (Thursday and Friday) are also my final days of radiation therapy. It will be so nice to have at least part of my life back next week – not having to be a slave to the daily treatments and the three chemotherapy cycles. Any remaining doctor appointments will simply be routine checkups leading up to a PET scan in approximately 3-4 months to determine in part whether or not the treatment was successful or if further intervention is needed.

Most important, my lower back pain has greatly subsided and I can get up and down much better than even a few days ago. Either the muscle spasm went away on its own or the myriad of pain medicines and muscle relaxers finally started working. Regardless, I’m happy and better positioned to deal with the coming weeks with one less ailment to worry about.

Snake Eyes

It seems as though each time I make an optimistic blog post, something goes wrong. Since my last post was titled “Lucky Seven,” it seemed appropriate to keep with the gambling theme and title this one “Snake Eyes.” For those unfamiliar with the term, a throw of two ones with a pair of dice results in the lowest possible score, and by extension the term is also used to reference bad luck¹.

image
Snake Eyes

Today was supposed to be the start of my final round of chemotherapy, with the second and final day on Tuesday. Sunday night, however, I started running a temperature of 102 degrees Fahrenheit that prompted my second trip to the urgent care center at MSKCC over the weekend. The obvious concerns being influenza, bacterial infection, etc. that would delay receiving chemotherapy.

After a variety of tests, influenza and infection were ruled out. While it is possible to run a low grade temperature from daily radiation, a high temperature such as mine is unexpected. This left all of us wondering what was causing my fever and why it was so high. Since there was no immediate cause for concern, they decided not to admit me overnight and said that I could use Tylenol for the fever. They acknowledged that it was unlikely I’d be receiving chemotherapy on Monday.

The next day (Monday) I saw Nicole – the nurse practitioner. I could tell she was on the fence proceeding with chemotherapy that day given that my temperature was again above 100 degree Fahrenheit. She conferred with Dr. David Pfister my medical oncologist and they opted to be cautious and postpone chemotherapy by one day. The only good news is that this shouldn’t change my final day of chemoradiation therapy which is this Friday.

Around the time of my daily radiation treatment, my temperature had dropped to low grade and I’m hopeful that we can continue with chemotherapy tomorrow morning. Separate from having cancer or receiving treatment, my lower back pain continues to be a problem so they switched me to some stronger opioid medications. I’m not talking minor pain or discomfort – but rather debilitating pain making it tough to get out of bed or getting up from a sitting position. I’ve experienced lower back pain issues in the past, but they usually only last a day or two and aren’t this severe.

It’s the final stretch and I “should” be done with therapy this Friday, so I’m trying not to complain. Hopefully these are just minor speed bumps on the road to Friday and then recovery. Until then, keep those thoughts, prayers, and good vibes coming!

¹ http://wordsmith.org/words/snake_eyes.html

 

Lucky Seven

This Monday is the start of Week #7 of my chemoradiation treatment. It is also the last week of treatment! It consists of two (2) days of chemotherapy on Monday and Tuesday and five (5) days of radiation Monday through Friday (5+2=7). With the prominence of lucky number seven, I’m hoping that the final week is uneventful and my recovery can slowly begin over the following weeks.

Why is “lucky seven” the world’s favorite number? There are seven days of the week, seven colors of the rainbow, seven notes on a musical scale, seven seas and seven continents¹.

Week #6 was relatively uneventful – at least as it relates to my cancer treatment. The frequent hydration during the week lowered my creatinine levels, which correlates with improving kidney function.

Michael Becker asleep with iPhone in hand at the urgent care center at MSKCC.
Michael Becker asleep with iPhone in hand.

In fact, the biggest issue for me this past week was throwing out my back. This isn’t cancer or treatment related, which was confirmed when I stopped by the urgent care center at MSKCC. I was a bit nervous since back pain can also be a sign of kidney issues, but all the tests came back fine. They prescribed some good pain medications and a muscle relaxer, which caused me to fall asleep while on my iPhone as you can see in the funny photo in this post captured by Lorie.

The likely culprit for my back pain was the mattress in our temporary apartment which is a good deal softer than the one we have at home. The folks at Furnished Quarters have been really great during our stay and they promptly replaced the mattress when we asked.

Thanks again to everyone taking the time to read this blog and for all the thoughts, prayers, and good vibes.

¹ Read more: Why ‘lucky 7’ really is the world’s magic number at: http://www.dailymail.co.uk/news/article-2601281/Why-lucky-7-really-magic-number.html

Visit Home Cut Short

A repeat of my bloodwork confirmed that the elevated serum creatinine levels were a concern regarding my kidney function, so the physicians ordered more intravenous hydration with saline and potassium to flush them out. As mentioned in my prior post, this is a common issue with chemotherapy (cisplatin).

They originally wanted to do the hydration Friday late afternoon. Unfortunately, that would have interfered with my getting back to Pennsylvania in time to see Megan before her Freshman formal dance. After explaining the situation, they came up with the solution of hydrating Saturday instead. While this would allow me to see Meg, it made for a short trip to Pennsylvania before heading back to NYC.

Michael And Megan Becker photographed by Saron Mastrosimone
Michael And Megan Becker photographed by Sharon Mastrosimone

It was definitely worth the short trip. Our friend and fellow photographer Sharon Mastrosimone was kind enough to come over and take pictures before the dance. The image in this blog post is one of my favorites and alone made the night worthwhile. Many thanks Sharon!

So, here I sit at MSKCC with Lorie getting hydration on a Saturday afternoon instead of being back home in Pennsylvania. But I’m doing it with a smile on my face looking at pictures from last night. Megan looked beautiful and I’m so glad I was able to be there.

Radiation Dermatitis

During Week #5, another common side effect from chemoradiation treatment emerged – radiation dermatitis. Just like oral mucositis discussed in a prior post, radiation dermatitis is graded on a scale – with Grade 1 being mild and Grade 4 being severe. In most patients, radiation dermatitis is mild to moderate (grades 1 and 2), but ∼20%–25% of patients experience severe reactions¹.

Photo of Michael Becker's neck with mild/moderate radiation dermatitis.
Photo of Michael Becker’s neck with mild/moderate radiation dermatitis.

Right now, I have mild to moderate radiation dermatitis on my neck in the area that is being targeted. This is characterized by mild erythema (red rash), which you can see in the accompanying image. The more severe forms of radiation dermatitis are associated with itchy, peeling skin and ultimately open wounds and ulceration. I’m hoping that my condition doesn’t advance to those stages.

The treatment for radiation dermatitis is basically keeping the skin moist by applying Aquaphor ointment. No creams or ointments have shown superior efficacy over another in randomized clinical trials.  This includes topical steroids and other agents.

Other than that, there is some indication that my kidney function might be impaired due to elevated serum creatinine levels. They are still running more tests, but worse case would be more frequent intravenous hydration to flush out the kidneys. Kidney function can be negatively impacted by the chemotherapy (cisplatin).

I did have intravenous hydration today and have been feeling pretty good overall. Fatigue is still my major complaint, but also par for the course.

¹ Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck. Ann Oncol (2008) 19 (1): 142-149. doi: 10.1093/annonc/mdm400. First published online: September 4, 2007

Steady As It Goes

The second round of chemotherapy and end of Week #4 was relatively uneventful – especially when compared with the first cycle when I came down with the flu. The biggest changes are increased taste alteration and fatigue.

Michael Becker Receiving IV Hydration
Michael Becker Receiving IV Hydration

My heart rate and blood pressure were elevated this week, so my physician ordered an extra 2-hour intravenous hydration session. Frankly, I was happy to do so – as I planned on coming home to Pennsylvania for the extended weekend.

I took the train home on Friday afternoon, but spent most of the day on Saturday sleeping which isn’t like me at all. I’m not normally one to take naps, but the fatigue from radiation and chemotherapy makes it hard to even keep my eyes open at times. I feel like I’m sleeping the entire weekend away!

Lorie’s sister Maureen is in town for a few weeks and has been a tremendous help around the house. She’s also a great cook and has been making some fabulous meals, although I just haven’t been up to eating them and have very little appetite. However, Lorie and the kids are enjoying them.

Sunday (today) is Lorie’s birthday in addition to being Valentine’s Day, which is another reason why I really wanted to make it home this weekend. I definitely owe her a proper celebration after we are past the cancer treatment, but in the meantime it will be nice to have a small celebration at home.

Monday starts Week #5 and it looks like March 4th will be my last radiation session. From what the doctors tell me, this is where things start to get rough with the treatment. Accordingly, I’m a bit nervous about what the coming days/weeks will bring…

Second Round of Chemotherapy

Today was the start of week #4 for my chemoradiation treatment. It was also the second time that I was scheduled to receive chemotherapy (cisplatin) in addition to my daily radiation treatment. I receive a total of three chemotherapy treatments – one at the beginning, one in the middle, and then one at the end of my therapy.

Fortunately, I felt well enough last Friday to come home to Pennsylvania for the weekend. It was great to see my wife and kids, pets, and sleep in my own bed for the second weekend in a row. I was really glad I could make it, since I missed being with Rosie for her 18th birthday during the week while I was in NYC. I can’t remember the last time I wasn’t with her to celebrate her birthday in person, although I was able to FaceTime and sing happy birthday.

This morning, my wife and I took the morning train from Bucks County, PA into NYC for my chemotherapy appointment. I was feeling a lot of pain this morning from the mouth sores and for the first time in my throat as well. I was miserable the entire train ride, but made it to New York and we headed to Memorial Sloan-Kettering Cancer Center (MSKCC) for treatment.

The day started with radiation therapy and then an appointment for blood work and then a meeting with Nicole – the nurse practitioner before starting chemotherapy. Last week when I met with her, she prescribed gabapentin and a lidocaine gel to help manage the pain. Today when I communicated my current pain level to her, she also prescribed Oxycodone. After about 30-minutes, the pain was improving and continued to do so throughout the next few hours with the Oxycodone. Nicole also mentioned that the steroids administered as part of the chemotherapy could also help with inflammation and might help alleviate the mouth and throat pain.

Chemotherapy (cisplatin) infusion pump

My chemotherapy was scheduled for 1pm, but the routine blood test came back with some bizarre readings in the metabolic panel. In fact, had the results been correct – the nurse said my heart would likely have stopped! Needless to say, they also couldn’t proceed with chemotherapy if the results were accurate. They needed to take another blood test to determine whether or not the readings were true. Not surprisingly, the first results were wrong and the second set was perfectly normal. As a result, the chemotherapy treatment proceeded – but not until around 2:30pm.

I finally finished chemotherapy at 7:45pm and Lorie and I went to a nearby restaurant for a late dinner before heading to the apartment. The second dose of Oxycodone left me feeling little pain and I actually had an appetite. It was the first time I felt comfortable going out to eat in more than three weeks. The French toast sounded like a good bet for some much needed calories and I ate the entire portion except for some of the crust. It was a fantastic end to a day that started off a little rough.

Tomorrow is the second day of chemotherapy and then I’m back to just daily radiation for the next few weeks. It will be interesting to see how I handle this round of chemotherapy as opposed to the first round when I came down with the flu.

Progress Report

Yesterday marked the beginning of Week #3 for my chemoradiation treatment. By now, the cummulative effects of daily radiation have started to appear.  This includes oral mucositis (where the mucosal lining of the mouth breaks down forming ulcers) and xerostomia (dry mouth). The World Health Organization (WHO) Oral Toxicity Scale measures anatomical, symptomatic, and functional components of oral mucositis¹. The scale ranges from Grade 0 (no oral mucositis) to Grade 4 (unable to eat solid food or liquids). The majority of head and neck cancer patients (83%) who are receiving radiation therapy develop oral mucositis and 29% develop severe oral mucositis².

IMG_7111
Oral mucositis ulcer on side of my tongue

My current assessment would be WHO Grade 2, which means that I can still eat solid foods despite the presence of ulcers (see photo of the single ulcer on the side of my tongue). Recall that I started taking Caphosol® at the start of my chemoradiation treatment. This oral rinse has been shown to reduce the severity and duration of oral mucositis in a clinical study. The study design used a different oral mucositis scale devised by the National Institute of Dental and Craniofacial Research (NIDCR), which ranks oral mucositis on a 0-5 scale where I would presently be at Grade 2 (single ulcer <1 cm). Results from the study demonstrated a peak Grade 1.38 for patients using Caphosol compared to Grade 2.41 for the placebo group. Accordingly, it will be interesting to see whether or not I develop additional ulcers or more severe oral mucositis to help determine the benefit of using Caphosol.

I received a progress report during my appointment with Dr. Nancy Lee, my radiation oncologist at Memorial Sloan-Kettering Cancer Center (MSKCC). The results are encouraging, as the tumor has markedly decreased in size over the first two weeks of therapy – characteristic for my type of cancer. The better news was that the PET imaging study looking at levels of oxygen deficiency (hypoxia) in the tumor tissue showed dramatic improvement. In particular, the pre-treatment scan showed “mild” radiotracer uptake in the primary tumor (right tonsil) and “intense” radiotracer uptake in the neck lymph node, indicating a significant amount of hypoxic tumor cells that are generally more resistant to radiation and many anticancer drugs. However, the most recent PET scan showed “no” radiotracer uptake in the primary tumor and only “mild” persistent uptake in the neck lymph node. Unfortunately, the fact that there is still some hypoxia means that they won’t be able to reduce the amount of radiation to the neck node, which could have reduced some of the side effects.

This morning I had my follow-up hearing test, which showed no change from pre-treatment.  This is also good news, as the chemotherapy (cisplatin) can sometimes cause hearing loss. Next week will be my second round of chemotherapy on both Monday and Tuesday. I’m hoping that this cycle will be less eventful than the first and that I don’t contract the flu or have any other surprises.

¹ World Health Organization. WHO Handbook for Reporting Results of Cancer Treatment. Geneva, Switzerland: World Health Organization; 1979:15-22.

² Vera-Llonch M, Oster G, Hagiwara M, Sonis S. Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Cancer. 2006;106:329–36.

Coming Home

In contrast to the first week, the second week of treatment was relatively uneventful. I had daily radiation therapy Monday-Friday and the effects of the flu seemed to dissipate with each passing day. Still not what I would consider back to 100%, but a heck of a lot better than how I felt last Friday!

I’m writing this blog post on the New Jersey Transit evening train heading home to Bucks County, PA for the first time since I started treatment on Monday, January 18. I normally commute to NYC daily for work, so it is a very familiar ride. But the prospect of seeing my wife and kids, family pets, and sleeping in my own bed is making the trip seem a lot longer – almost like time is standing still. I’ll spend the weekend home and then return to NYC for week three of treatment. It’s a calculated risk coming home and being far from MSKCC, especially in view of what happened last weekend. However, I fear this will be one of the last times I’ll feel up to commuting back-and-forth and I really need a distraction at the moment.

By now, I’ve started to see the same familiar faces in the men’s locker room to change before getting daily radiation. The first few times, there wasn’t a lot of discussion or interaction. Slowly, you strike up conversation that is oddly reminiscent of a prison scene from the movies. “What are you in for?” “How long is your sentence?” Stuff like that.

It’s a strange cast of characters and most of them are much older. Almost everyone I’ve spoken with seems to have some cancer involvement in the lungs that required surgical removal of at least a portion of them in addition to subsequent radiation. Then there are the real strange diseases, like the older guy who had cancer in some tissue left behind from his umbilical cord when he was an infant that spread to both his bladder and lungs. Another guy who has cancer of the eye, with visible impact. They all remark that they are at peace with their fate; ready to go if this is their time but not minding a longer stay on this earth if the opportunity is provided by the treatment. Maybe because I’m the younger one in the crowd, but not me…I’m not at all at peace with the situation and ready to fight like hell.

That Escalated Quickly…

Truth be told, all this week I felt worse than I had originally expected. I was told the “tougher” part of therapy would be around week three or four, so it was disheartening that I felt so awful after only the first round of chemoradiation.

Moments after my brief victory lap for completing the first week of treatment, I started running a fever and felt rundown. A quick call to my oncologist and I was instructed to head over to the urgent care facility Friday night. Fortunately Lorie and Rosie were already in town to spend the weekend with me (Megan was sick and stayed back in Pennsylvania with a friend).

Michael Becker at Urgent Care Center at Memorial Sloan-Kettering

The snow storm hadn’t hit NYC yet, but the hospital lobby was fairly crowded. When I was seen, they took a nasal swab to test for the flu. Everything was fine until the blood test. During the blood draw, I felt lightheaded and nauseous (which never happens to me…). Immediately afterward the room started getting dark and the next thing I knew I was in another room with nurses standing around me suctioning vomit from my mouth. I had what is called a vasovagal response, which caused me to pass out and vomit.

Long story short, and despite getting the flu shot this season, the nasal swab came back positive for the flu. The flu effects are magnified in patients undergoing chemoradiation, which is why I felt so crappy this first week. The good news is that they started me on an antiviral agent (tamiflu) and hopefully I’ll be feeling much better during week two of therapy.

I was put in isolation so as not to get other fragile cancer patients sick, hence the mask and outfit shown in the accompanying image. I need to stay in the hospital for the full weekend to get IV fluids and rest, but will move forward with starting week two of radiation therapy on Monday with no interruption.

Never a dull moment!

Week One and Done

Following this evening’s (Friday) radiation treatment, I will have completed week one of my 6-7 week chemoradiation treatment schedule. No therapy is given on the weekends and I’m very much looking forward to the upcoming two-day break despite the dire winter weather forecast.

Monday and Tuesday’s chemotherapy sessions took a toll by Wednesday of this week as the nausea side effect started to really kick into gear. After switching to a different anti-nausea medication (ondansetron) later that day, things improved a bit. By Thursday, I was “mildly” interested in food again – although meals don’t quite taste the same now. Known as dysgeusia, this alteration in taste is a common complaint of patients undergoing chemotherapy and research indicates that 46-77% of patients receiving chemotherapy report changes in taste (Bernhardson, Tishelman, & Rutqvist, 2008).

I was able to move into an apartment in New York this week, which makes a huge difference in terms of commuting to both work and daily radiation therapy appointments. It’s walking distance to both my oncologist and radiation oncologist, which is quite convenient. The biggest downside is not being able to see my wife and kids daily, but I’m trying to stay focused on the relatively short duration of treatment and looking forward to being back home in a few months.

In addition to daily radiation therapy, next week’s appointment schedule includes some PET imaging studies, which will provide some insight into how treatment is impacting the cancer.

Treatment – Day One and Two

Yesterday (Jan 18) was my first day of therapy. As expected, it was bittersweet. On one hand, it felt great to finally get started with attacking the disease. The flip side is knowing what lurks around the corner in terms of side effects.

Michael Becker in chemotherapy lounge at MSKCC
Michael Becker in chemotherapy lounge at MSKCC (click to enlarge)

The day started at 8:45am with bloodwork and consultation with a nurse to answer any remaining questions. Next was two hours of intravenous fluids, an hour of intravenous anti-nausea medications and kidney protection medication, an hour of intravenous chemotherapy, and then two more hours of intravenous fluids. Of the six hour total infusion time, the four hours of fluids cover flushing out the kidneys, which are at risk for damage from the chemotherapy.

The time actually passed quickly. My wife and I chatted throughout, had a small lunch, checked emails, etc. Not quite a day at the spa, but no unpleasant surprises. It’s so great having her by my side! Luvya babe.

The fun wasn’t over yet. Next was a shuttle bus to the radiation center for that component of the therapy. The radiation treatment is only about ten minutes, but there is setup time, changing clothes, etc. that take up about an hour total.

You do not feel anything during the radiation treatment.  The side effects come later, so literally you leave day one feeling emotionally drained but physically fine. The worst part of radiation treatment is that darn mask! The confining nature of the mask and being pinned to the table is more of a mental challenge than anything else.

Today (Tue), I woke up early at 5am feeling wide awake, which can be a side effect from the steroids they gave me. However, a short while later I started to get a bit nauseous. It was disturbing to see the chemotherapy side effect so soon after treatment, but I took a pill for nausea they prescribed and felt better after about 30-minutes.

My wife and I stopped for breakfast and I was able to order my favorite banana toast meal from Bluestone Lane and had some coffee as well. We then headed over to MSKCC for day two of chemoradiation.

For the next few weeks, I won’t have to do the 5-6 hour chemotherapy. During that period, I “simply” have daily radiation Monday-Friday. Then, around week three I go through the same two-day chemotherapy with radiation and the process repeats. The total treatment cycle is 6-7 weeks.

The biggest epiphany so far is that commuting to New York daily for both treatment and work is likely going to be too much. As a result, I’m getting a temporary apartment in NY for the next few months. Not a cheap solution, but a necessary one – especially when side effects start to appear around week three or four. Fortunately, family has been there to help offset the added and unforseen expenses (thanks again!).

Lastly, to everyone that posts on my Facebook page, comments on this blog, emails, texts me on my phone, etc. – I can’t tell you how much it means to me. The kind notes and supportive words really do keep my spirits high. Thank you!

Reunited

When I first licensed the North American marketing rights to Caphosol® in October 2006 (see press release), I had no idea that nearly a decade later I would be a customer. The product is intended to treat some of the common side effects from cancer chemotherapy and radiation – both oral mucositis (inflammation of the mucous membranes in the mouth with symptoms ranging from redness to severe ulcerations) and xerostomia (dry mouth). While these side effects can occur as a result of various treatments, they are particularly prevalent in head and neck cancer patients undergoing chemoradiation like me.

Michael Becker and the oral mucositis and xerostomia treatment Caphosol
Michael Becker reunited with the oral mucositis and xerostomia treatment Caphosol (click to enlarge)

It was disheartening that so many years after its commercial introduction, no physician I spoke with had heard of Caphosol. After a fair amount of nagging and discussion, I was finally able to secure a prescription this week and locate a pharmacy that carried the product in advance of starting treatment this Monday (special shout out to my wife, former colleague June, and her colleague Ken for their assistance in this regard!). This is important, as one the key clinical studies supporting Caphosol’s efficacy incorporated the product at the start of therapy.  In other words, Caphosol was used before the incidence of oral mucositis or xerostomia – as a preventative therapy. The trial demonstrated that Caphosol was able to reduce the severity of oral mucositis, decrease pain and associated use of opioid analgesics, and reduce the days of neutropenia (abnormally low concentration of white blood cells in the blood) – see journal abstract from the study.

To be perfectly clear – I have absolutely no financial interest in Caphosol. However, I am a believer in the product and did extensive due diligence as part of the licensing process. As a result, I hope that this blog post can help other patients at risk for oral mucositis and/or xerostomia learn about Caphosol. While there are other agents used in the treatment of oral mucositis and xerostomia, Caphosol is unique in that the product’s efficacy was demonstrated in a randomized, placebo-controlled clinical study. Perhaps the most significant distinguishing feature of Caphosol is the high concentrations of calcium and phosphate ions. Why is this important? Calcium ions play a crucial role in several aspects of the inflammatory process, the blood clotting cascade, and tissue repair, and phosphate ions may be a valuable supplemental source of phosphates for damaged mucosal surfaces. No other product on the U.S. market is formulated this way or has the proven clinical benefit that Caphosol does.

As you can see in the accompanying image, Caphosol is supplied in a carton with 30 doses.  A dose is comprised of two ampules of aqueous solutions, one containing a phosphate solution and the other containing the calcium solution.  The two solutions are combined in a glass and patients are instructed to swish the resulting mixture in the mouth thoroughly and then expectorate (spit out).  This process can be repeated 2-10 times per day, although four doses per day is what was used in the clinical trial.

I will report on my experience with Caphosol (good, bad, or indifferent) throughout my chemoradiation treatment over the next 6-7 weeks.  My first round of chemotherapy and radiation therapy starts this Monday and Tuesday.  As the treatments occupy most the day, it may not be until later this week that I post any blog updates.

Crossroads

It’s coincidental that after spending so many years leading a few small, oncology-focused biotechnology companies developing immunotherapies, radiopharmaceutical agents, and supportive care oncology products, I am now utilizing that experience, knowledge and network to make informed treatment decisions following my cancer diagnosis. Like driving down a familiar road, I am constantly seeing landmarks and signs that I know quite well from my time in the industry.

For example, some of the common side effects from chemotherapy and radiation therapy include oral mucositis (painful ulcers in the mucosa) and xerostomia (dry mouth). I studied these two side effects extensively as part of the due diligence process when I licensed and launched an advanced electrolyte solution called Caphosol® back in 2006. Based on this experience, I know what to expect from my chemoradiation treatment and hope to incorporate Caphosol into my arsenal against these debilitating side effects.

295077-smallWhile the streets may be familiar at times, I am still faced with difficult decisions at some of the crossroads. The latest example arose during yesterday’s follow-up visit with Dr. David Pfister, my medical oncologist at Memorial Sloan-Kettering Cancer Center (MSKCC). Separate from my upcoming daily radiation treatments, the appointment largely focused on scheduling my three chemotherapy infusions and discussing what to expect in terms of side effects from the treatment. The chemotherapy I will receive is called cisplatin, which was first approved for use in testicular and ovarian cancers back in 1978.  The list of potential toxicities includes nausea, constipation, kidney issues, hearing issues, and others.  The conversation shifted to potential clinical trials and Dr. Pfister mentioned one that is exploring an alternative to chemotherapy that may have less side effects. In the study, the chemotherapy agent (cisplatin) is replaced by Erbitux® (cetuximab) – another FDA approved agent for treating head and neck cancer. Erbitux is an inhibitor of the epidermal growth factor receptor (EGFR), a receptor found on both normal and tumor cells that is important for cell growth. But the study also adds an investigational agent BYL719, which is an inhibitor of PI3K, an enzyme which fuels the growth of several types of cancer. Having worked at several companies developing inhibitors of the PI3K pathway, this was more familiar territory. However, trading the proven results with cisplatin for “potentially” similar efficacy with lower side effects from the investigational combination is a difficult crossroad.

On the one hand, the aforementioned clinical trial includes an approved agent for treating head and neck cancer (Erbitux).  This is different from some other clinical trial designs that include a placebo arm or an arm with only an investigational agent. However, Erbitux has its own side effects and there are unanswered questions in the medical community regarding whether or not Erbitux is “as good” as cisplatin. As a result some physicians only use Erbitux as a replacement for cisplatin when the patient cannot tolerate cisplatin’s toxicities. In my mind, forgoing cisplatin and its proven efficacy could jeopardize the potential for cure. Partially offsetting this risk is the inclusion of a promising new investigational agent – the PI3K inhibitor BYL719 being developed by Novartis. The PI3K pathway is widely known in the oncology community as a potential target for cancer therapy – and in particular head and neck cancer. Preclinical data suggest that simultaneous inhibition of PI3K and EGFR leads to synergistic antitumor activity in head and neck cancer, but future randomized trials are required to answer the question of whether or not the combination is equal to (or better than) cisplatin. Lastly, BYL719 is an investigational agent and although it appears well-tolerated in studies to date, side effects may arise as more and more patients are exposed to the drug.

Ultimately, I decided to stick with the more established cisplatin for a variety of reasons. First, it is my understanding that the radiation therapy, which would be included regardless of whether I opted for cisplatin or the investigational Erbitux/BYL719 combination, is the driving force for both cure AND debilitating side effects.  Most of cisplatin’s side effects, such as nausea, constipation, and other issues, can be partially offset with medication and hydration. Second, cisplatin has been around for decades and appears to be the gold standard in combination with radiation for Stage IV head and neck cancer and it is hard to argue with the clinical data supporting its use to date. Lastly, in the unfortunate event that my chemoradiation therapy isn’t effective – I can always explore investigational treatments as a next step.

 

Pointillism

One of my wife’s favorite artists is Georges Seurat, a French post-Impressionist painter known for his role in devising the painting technique called “pointillism.” This technique uses small, distinct dots of color that are applied in patterns to form an image. Looking at such a painting from afar, our eyes and brains blend all of the dots of color into a fuller range of tones that then form an image.

Yesterday’s meeting with the radiation oncology team at Memorial Sloan-Kettering reminded me of pointillism. Prior to the visit, I saw the complete picture from afar – it would be 6-7 weeks of treatment and the associated side effects, but there was the prospect of being cured by the end.  After the meeting, however, I started seeing the hundreds or thousands of individual dots of color that represented my treatment.

IMRT mask
Example of the type of mask used during radiation therapy for head & neck cancer

For example, during the day they created the “mask” that will be used to keep my head and shoulders in the exact same place for my daily (Mon-Fri) radiation treatment. The mask is secured where you lay and prevents any movement of the head and shoulders (see example image). Unlike the older masks, there is a cutout for your eyes, nose, and mouth but coverage of the jaw largely prevents you from speaking. Frankly, it is terrifying! They did three imaging procedures in the afternoon (MRI, CT, and PET) and each one involved the mask being worn for about 30-minutes. Each time I was rolled into the imaging tube, I couldn’t help but think – what happens if I start coughing or choking? With my jaw immobilized I wouldn’t be able to do much. Trying to get past that fear, I quickly realized – wearing the mask would become a daily routine for the next 6-7 weeks.

The side effects of radiation therapy were another one of the individual dots of color that came into focus as I looked more closely at my treatment “image.” I’ve lost count of how many physicians and nurses have told me to “bulk up” now before starting therapy. Gain 10 pounds or more they say. This is due to the fact that in a few weeks it will be difficult to chew, swallow, etc. as a result of oral mucositis and dry mouth from the radiation therapy. As a result, weight loss and fatigue are to be expected.

During the day, I enrolled in two clinical trials – one for imaging and another for blood tests.  The imaging study looks at levels of oxygen deficiency (hypoxia) in the tumor tissue. Hypoxic tumor cells are resistant to radiation and to many anticancer drugs and therefore tumor hypoxia influences the outcome of treatment with radiotherapy, chemotherapy and even surgery.  The hope is that ruling out hypoxia in the area of the tumor could reduce the amount of radiation therapy needed to cure the disease – and thus reduce side effects. The blood test can be viewed as a type of “liquid biopsy” that detects circulating tumor cells and fragments of tumor DNA that are shed into the blood from the primary tumor and from metastatic sites. Changes in these markers may be able to predict the likelihood of disease recurrence after therapy.

FullSizeRender
The doctor uses a flexible, lighted tube called an endoscope to examine areas of the head and neck that are less accessible. The tube is inserted through the nose after applying a topical anesthetic (lidocaine – applied directly to the nose and throat) to make the examination more comfortable.

It was a very long day with my first appointment starting at 9am and not finishing until around 6pm, but aside from the aforementioned and putting aside more poking and prodding (including my fourth endoscope procedure – see tiny camera getting stuck up my nose in the embedded image…), by the end of the day I felt somewhat better knowing the timeframe for starting radiation treatment, which looks like it will be Monday, January 18. In addition, I felt much better after meeting my radiation oncologist Dr. Nancy Lee (you can watch a video interview with her under the “Videos” menu tab at the top of my blog). She is fantastic! I have a follow-up appointment with my medical oncologist this Thursday, where I will learn more about the timing for starting chemotherapy.

Since I couldn’t eat all day due to potential interference with the imaging tests, the best part of the day was grabbing a quick dinner in NYC with my wife before taking the train back to Pennsylvania. It is so great having her by my side during this ordeal!