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.

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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!

Baby Steps

It’s been a while since my last post, so I wanted to share an update on activities over the past week or two.  On Christmas Eve, I met with an oncologist at Memorial Sloan-Kettering Cancer Center (MSKCC) to discuss my case following a similar meeting at the University of Pennsylvania (UPenn) a short while before.  There appears to be little ambiguity regarding my diagnosis, which both oncologists confirmed as Stage IV oropharyngeal cancer.  However, the oncologist at MSKCC used an endoscope to view the tonsils, etc. and also commented after physical examination that the enlarged cervical lymph node seemed “tethered” in its location, which could indicate that the cancer was spreading outside of the node (extracapsular invasion).  MSKCC’s treatment approach was chemoradiation, which is the same as UPenn had recommended (UPenn discussed my case during a tumor board and surgery wasn’t recommended there either…).  At MSKCC, patients meet with each of the various specialities (medical oncologist, surgeon, and radiation oncologist) so the next step was to schedule an appointment with a surgeon to get their perspective on relevant treatment options and to schedule an appointment with a radiation oncologist, which I did.

Click to view larger

Click to view larger

Today was the meeting with the surgeon at MSKCC.  Not unlike many patients, I am growing weary of being poked, prodded, stuck with needles, etc. and I haven’t even started therapy yet.  Much to my chagrin, the surgeon wanted to perform what would be my third endoscope procedure within the past few weeks to examine my throat.  In all honesty, it isn’t a horrible procedure and I’m sure in retrospect that it will be a cakewalk compared to what is waiting around the corner – but it still isn’t what anyone would call fun. For the first time, I asked questions about the resulting images from the procedure and the physician was excellent in explaining them along with his overall perspective. For example, in the accompanying image snapped with my iPhone  I have indicated where you can find my tonsils (cancerous one circled in red = enemy), soft palate, and uvula. My cancer started in the tonsil and appears to be spreading inward towards the soft palate and also the lymph nodes (not shown).

Both surgery and chemoradiation are “potentially” curative treatment options for me.  Some of the differences between these two options relate to side effects and maintaining quality of life going forward.  In my particular case, based on the stage and extent of disease, a surgeon could theoretically remove the tonsil, lymph node, and surrounding soft tissue with the hope of getting all the cancer (clean margins).  Under that scenario, I could potentially be spared subsequent chemotherapy and its toxicities and simply go through radiation therapy as a next step.  However, if the surgical procedure didn’t result in clean margins – then chemotherapy would still need to be included along with the radiation therapy and the surgery would have been somewhat useless.  More importantly, it would expose me to potential side effects – such as difficulties in speech, swallowing, and other issues due to the spread of the cancer to the soft palate.  Armed with this insight, it was clear that surgery was an unattractive option and the plan to move forward with chemoradiation was confirmed.  Baby steps, but it was nice to rule out surgery as a treatment option and focus solely on chemoradiation.

My next appointment is Monday with the radiation oncologist at MSKCC.  I can’t tell you how many people at MSKCC have sung her praises and I very much look forward to meeting with her.  The hope is following that initial consultation I’ll be able to (finally!) start therapy the following week. I plan on posting an update after meeting with the radiation oncologist – so for now, best wishes to all of you for a happy, HEALTHY, and prosperous 2016! Speak to you in the New Year…

Initial Visit with ENT

endoscopeThe antibiotics did nothing to alter the size of the lateral neck mass, which prompted a visit to an ENT.  At this point, I was 100% convinced that I had cancer based on everything that I read.  The only question was what “type” of cancer and its stage.  After spraying my nasal cavity with a numbing agent, the physician looked at my throat using an endoscope (e.g., examining my throat using a tiny, flexible camera inserted through the nasal cavity) that didn’t seem to indicate anything out of the ordinary.  The next logical step was a CT scan to obtain additional information, which I promptly scheduled.