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.

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.

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Oral mucositis ulcer on side of 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 andCraniofacial 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.

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!

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.