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 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.

The Impatient Patient

One of the hardest aspects of having my particular type of cancer is the fact that it has spread to a cervical lymph node on my neck that is both visible and palpable.  I am reminded of the disease every time I look in the mirror or place my hand on the area. As a result, I am quite anxious to get started with treatment despite the associated side effects. I just want it gone – now!  Christmas day will be exactly one month since I first discovered the growth and I cannot help but feel that the cancer is being given too much time to grow and spread.

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I mistakenly envisioned that following a “formal” cancer diagnoses (which itself takes some time waiting for biopsy and imaging results…), a SWAT team of physicians rushed in to promptly start therapy.  In reality, however, it can take weeks to schedule appointments with some doctors.  For some procedures, such as radiation therapy with IMRT, the process also involves complex treatment planning to deliver dose to the tumor and spare normal tissue and getting fitted for a special reinforced thermoplastic mask to hold the patient within a few millimeters for consistency each day of therapy.

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Upon starting daily radiation and chemotherapy, I plan on doing a series of self-portraits to document the associated changes in physical appearance over the 7-week treatment cycle.  In preparation, I took a self-portrait today so that you can see the difference in size between the right side of my neck (blue lighting; site of the cancerous lymph node) and the left side (red lighting; normal side).

To help put this in perspective, I also included a comparable image from my recent PET scan that shows the relevant lymph node as a highlighted/glowing mass in the same general area. In case you were wondering or alarmed – no, I don’t have brain cancer.  The brain also lights up on a PET scan in extremely intelligent individuals.  Just kidding – the brain always lights up as glucose is the predominant substrate for brain metabolism and PET imaging utilizes radiolabeled glucose.