Course Change Recommended

On Monday, I was able to complete the remainder of my magnetic resonance imaging (MRI) scan without further issue. Not surprising given that MRI imaging is an exceedingly safe technique with more than 30 million scans being performed every year in the United States. Nonetheless, my bizarre experience during Saturday’s initial attempt still left me a bit apprehensive.

MRI machines use strong magnetic fields and radio waves (radiofrequency energy) to produce images. In fact, the most considerable safety concern in the MRI environment is the effect of the magnetic field on medical devices, implants, and any ferromagnetic objects in the room (clips, coins, body piercings, steel oxygen tanks, etc.) that can become very dangerous projectiles. This is why patients are carefully screened by a qualified healthcare professional even before entering the MRI environment.

Before Saturday, I was familiar with the potential magnetic field concerns of an MRI but unaware of the bio-effects of radiofrequency fields (RF) that can cause tissue heating in the human body. All of my prior MRI imaging took place on the tried-and-true 1.5 Tesla (1.5T) machines versus the 3.0 Tesla (3.0T) used on Saturday (note: Tesla is the unit of measurement quantifying the strength of a magnetic field). A 3.0T MRI provides higher clarity and better detail because the magnetic field is twice as strong as 1.5T. Based on my recent experience, however, the stronger 3.0T MRI may have been just enough for me to sense the increased temperature in my chest and abdomen towards the end of the scan.

Regardless, given the differences between the 3.0T and 1.5T machines and not knowing what to expect in terms of a potential internal warming sensation likely resulted in my having a rather decent panic attack. Stuck in a tube and unexpectedly feeling like you could be boiled from the inside is a bit disconcerting. Technicians already inform patients about what to expect once a contrast agent is injected as part of the MRI procedure. Going forward, additional disclosure to patients about other differences between T3.0 versus T1.5 might help patients avoid unnecessary anxiety.

While there wasn’t a dramatic progression of my cancer based on Saturday’s CT scan of my abdomen/pelvis, the overall picture looked different when combined with the results from the MRI of my spine and the increasing level of pain. Bottom line: a relatively rapid advancement of cancer in the bone occurred. Taxol alone isn’t cutting it; a change in course is recommended.

Accordingly, we are forgoing the last dose of Taxol this week (should have been dosed today…) and moving forward with plans for radiation therapy (RT) to the new tumors next to my T8 and L3 vertebrae. The goal of this round of RT is to alleviate my pain and potentially reduce dependence on steroids, opioids, gabapentin, etc.

In the background, arrangements are being made for me to be seen in the Early Drug Development clinic at Memorial Sloan-Kettering Cancer Center (MSKCC) to discuss clinical trial options after I’m discharged from the hospital. Hopefully, this occurs on Friday, which represents the one week mark for my current hospital stay.

Note: I finished this post and went to walk a lap or two around the hospital floor. Turning one of the corners and who do I literally bump into? My wife came to visit me by surprise! I’m just SO darn lucky and blessed to have her by my side now.

Michael and Lorie Becker at Memorial Sloan-Kettering Cancer Center’s (MSKCC’s) recreation room, March 13, 2019.

Out Like a Lamb?

The proverb that March comes “in like a lion, out like a lamb” implies that the month is a bridge between seasons, beginning with wild, bitter and blusterous winds and rough weather until winding up with mild breezes and gentler weather by April. So, as we turn the calendar to March, I’m hoping that my recent bouts of severe pain due to cancer progression in my spine diminish and go out like a lamb as the month progresses.

My situation is far from unique. Unfortunately, despite significant advances in oncology, cancer patients still often suffer pain. Also, pain in cancer is not one single entity and often doesn’t respond to one drug (or any drug). Interventional pain management techniques, such as a nerve block, are alternative options that can provide effective pain relief when conventional drugs fail or aren’t well-tolerated.

In addition to my weekly chemotherapy infusion, I had an appointment with Amitabh Gulati, M.D., a board-certified anesthesiologist and chronic pain specialist at Memorial Sloan-Kettering Cancer Center (MSKCC) this past Tuesday. Following a physical exam, and based on the suspicion that the new tumor located to the left of my T8 vertebrae is responsible for the referred pain in my left lower chest wall area, Dr. Gulati recommended an ultrasound-guided, paravertebral nerve block. Dealing with severe pain for weeks, I was ecstatic to learn that he could perform the nerve block immediately.

A nerve block is a procedure where a local anesthetic (a numbing drug), often combined with a steroid (an anti-inflammatory agent), is injected into or around a nerve or into the space around the spinal cord to block pain. After the injection, the nerve is no longer able to relay pain—so the discomfort is relieved for some time.

The spinal cord nerves branch out through openings between your 24 vertebrae and connect to internal organs, muscles, joints, ligaments, tendons and other areas and parts of the body (see Figure 1). For example, the nerves emanating from the T8 vertebrae map to the spleen, which is located near my painful left lower chest wall area. Accordingly, it makes sense that a tumor at T8 could send referred pain to that area.

Figure 1. Spinal Nerve Chart. Source: Gray’s Anatomy, 29th Edition, Page 4

During the nerve block procedure, the numbing effects of the local anesthetic can be felt almost immediately. This is diagnostic, as it helps the physician determine whether or not they are targeting the right nerves in “real time”. Being in the prone position for the entire procedure; however, it was difficult to reach under my body and confirm exactly which areas of my chest were numb.

Due to the immediate numbing effects of the local anesthetic, I was relatively pain-free after the nerve block procedure. Unfortunately, the impact of the local anesthetic can wear off after 24-hours. It can also take up to two weeks to feel the full results of the steroid. Sure enough, I started experiencing episodes of break-through pain by later the next day. Towards bedtime, I was in severe discomfort again despite taking pain medications.

While monitoring the effects of the nerve block, I am also scheduling an appointment with Dr. Nancy Lee, my radiation oncologist at MSKCC. Recall that back in October 2018, I finished the fifth and final session of radiation therapy to both my L5 and T7 vertebrae. I received a total dose of about 30 gray (Gy) to each site, which has provided significant pain relief in my affected hip/buttock area. Shortly, I’m meeting with Dr. Lee to determine whether or not the tumor near T8 could also be a candidate for radiation therapy—especially in the event that the nerve block fails to provide adequate relief.

Aside from managing my pain, I have two more weekly chemotherapy infusions before the next CT scan around mid-March. Depending on the outcome, I can consider continuing with the paclitaxel monotherapy or getting more aggressive by adding a second agent, such as carboplatin. There are also clinical trials to evaluate.

As always, I hope that taking the time to tell my story will help raise awareness about HPV-related cancers and the importance of vaccinating both young women and men to prevent certain cancers. You can learn more about HPV from the Centers for Disease Control (CDC) by clicking here and join the conversation this Monday, March 4th for the second annual International Human Papillomavirus (HPV) Awareness Day by using hashtags like #HPV and #HPVaware on Twitter.