Mets Day 529: Prepping for salvage chemotherapy

Tomorrow morning I start dose dense MVAC (or ddMVAC) chemotherapy.  The goal of this chemo round is not to cure me of my cancer.  The doctors have made clear that they lack the ability or knowledge to "cure" (meaning to place into remission for more than five years) metastatic bladder cancer.  There has never been a proven curative therapy for my type of cancer that can be replicated with any reliability.  It is important to understand the limitations of a treatment before embarking on it.  I get it.

Instead, the goal of this course of chemo is palliative, meaning to treat and hopefully lessen symptoms, but without a curative intent.  This type of chemo also is referred to as "salvage chemotherapy." The symptoms that this chemo is attempting to address is the spread of my cancer to distant locations -- mainly the hundreds of lymph nodes in my torso, but also to slow the growth of tumors in other organs, especially my liver, lungs, bone marrow, and brain.

As I've recounted in my prior blog entries, doing this ddMVAC regimen at this point is an aggressive treatment, for three reasons.  First, we're proceeding quickly.  We are not waiting until I have lymph nodes that are over 1.5 cm in size, which is the traditional threshold for measurable metastatic disease.  Doctors usually like to wait until they see nodes or tumors of that size, so they can later measure them to see if the treatment worked.  But it made no sense to me to wait for the disease to progress before we start trying to slow its growth.  It's like waiting for weeds to completely take over a lawn before you apply a herbicide.  Better to attack the weeds before the roots get too deep.

Second, the evidence that ddMVAC actually works is not as strong as many doctors would like.  There is some evidence that it can slow the progression of the disease in up to 50% of patients, but the literature also indicates that when the effect (if any) wears off, the cancer progresses faster.  Returning to my gardening metaphor, the ddMVAC herbicide may slow the growth of the cancerous weeds, but when the herbicide wears off, the weeds grow faster than before.  But if it slows the growth of the weeds for some period of time, then the chemo will have worked.   

Third, ddMVAC carries with it the risk of some severe side effects.  It is likely to damage my GI tract, eventually causing blisters to the mucosa layer on the inside of my lips, mouth, and throat.  I'll probably have either constipation or diarrhea, or both, as well as nausea and vomiting.  I'll have fatigue and malaise. I'll be at risk for infections and fever.  I'll probably lose my hair.  During this regimen I'll be walking on the ragged edge of toxicity, taking just under the dosage that would so weaken my body that an infection would be fatal.  I can't keep taking the ddMVAC for more than six doses at a time, and 12 doses total, because over time the chemo drugs are so toxic that it would kill me.  The hope is that the chemo will have enough of a prophylactic effect that it will delay the further growth of the cancer, but not so much as to cause a systemic collapse.  My doctors have told me that they think that I will "tolerate the chemo well" and they they can manage these side effects, but I'll be the one barfing and writhing on the floor in cold sweats.

I'm going into this with my eyes wide open, choosing to subject myself to the side effects because this treatment offers the best possibility for extending my life.  I have made clear to my doctors and family that I don't want to torture myself to buy a few extra weeks of life.  In weighing the potential benefits against the risks, however, I have concluded that ddMVAC does not rise to the level of torture.  Maybe in a few weeks I'll change my mind, but for now, we're moving forward.

I've done a few things to prepare for my chemo.  On Sunday, I started taking 500 mg. of ginger twice a day to help reduce nausea.  My sister brought to my attention an NIH-sponsored study published last year (link here), which concluded that ginger reduces acute chemotherapy-induced nausea when taken for six days in conjunction with each chemo cycle, starting three days before and going until three days after.  There's no downside to taking the ginger pills, and I'll also be taking the anti-emetics.  I'll also be taking Miralax daily.  I've been to this rodeo before, and have a slightly better idea on how to keep my GI system in balance. 

I had a baseline CT scan at NIH yesterday.  As I lay on the table and felt the iodine warm my body and collect in my neobladder, I realized that this was my ninth CT scan in 20 months.  It's old hat now.  One of purposes of yesterday's CT was to see if it could detect a tumor in my liver.  If so, we'll probably pull the plug on the chemo, as ddMVAC does not work well with liver tumors.  Assuming the scan does not show a liver tumor, we'll proceed.  [After I initially posted this blog entry, Dr. Apolo emailed me the CT report, which did not detect any liver metastases or other enlarged nodes.]  I'll have another CT scan in December or whenever I end this regimen, to see if my cancer has spread.  If not, and depending on how I tolerate the chemo, I may have another six rounds of ddMVAC early next year.  If it the disease has progressed, then we'll know that the chemo didn't work. 

Dr. Aragon-Ching's nurse just called to tell me that she wanted to do all four drug infusions tomorrow.  This is different from what she had told me earlier(the M drug on day one, and the VAC drugs on day 2), with no explanation as to why.  I'll find that out tomorrow morning.  Tomorrow will be a long day, lasting nine hours or more for the infusions, plus the blood work and port placement.  I'll probably take in the laptop and blog, or maybe I'll start watching a new miniseries.  People have recommended Breaking Bad (teacher with cancer does bad things) or Mad Men (ad executives do bad things) or House of Cards (politicians do bad things).  On second thought, maybe I don't want to watch people doing bad things.  Yesterday I held my new granddaughter for about three hours.  There are very few things better than that.