“Yes there are two paths you can go by, but in the long run…”

Tuesday, 11/30/10

The radiation oncologist called me back that evening and I asked him why the sudden change in treatment. He explained that where my cancer was located it could be treated either way, i.e. with or without neoadjuvant therapy. He said that he had spoken with my surgeon and that the surgeon was strongly in favor of doing radiation and chemo prior to surgery. There was a 20% chance that neoadjuvant therapy would be overkill in a case like mine. However, if I opted to have surgery first without neoadjuvant therapy and something was found during the surgical procedure that didn’t show up on any of the scans, they would be kicking themselves for having lost that treatment window of opportunity. In a tough case like this it would be best to err on the side of caution. Ultimately, the burden of responsibility rests on the shoulders of the surgeon and if he feels that pursuing neoadjuvant therapy will make it easier for him to resect the tumor and reduce the risk of recurrence then he was willing to back him up 100%.  He said that he was meeting with my oncologist that evening and they would be discussing my case. The next step would be radiation mapping and a port placement.

“More cowbell”

Tuesday, 11/30/10

The day after Thanksgiving I contacted the surgeon’s office to see about scheduling my colectomy, but the person in charge of scheduling was busy and I had to end up leaving a voice mail. I called again on Monday and it was like déjà vu all over again. I left another voice mail, but no call back. When I called on Tuesday I told the receptionist I had been calling for three days and had yet to speak to a warm body. She apologized, took my contact info and told me that I should receive a call within the next hour. When the phone rang I was expecting the scheduler to be on the other end, but was surprised to find that it was my surgeon. He told me that I needed to have neoadjuvant therapy prior to surgery. When I mentioned that the radiation oncologist I saw the week before stated I didn’t need to have neoadjuvant therapy he response was that he had just spoken to the radiation oncologist that afternoon and he agreed that I should have radiation and chemo prior to surgery.

He went on to explain that he and the gastroenterologist believed that my tumor was of rectal origin and the standard protocol for treating rectal cancer is neoadjuvant therapy. It would help shrink the tumor, making it easier to resect and the risk of recurrence would be lower. While I understood his rationale for wanting to pursue neoadjuvant therapy I couldn’t help wonder why the radiation oncologist had changed his tune. After talking with the surgeon I put in a call to my radiation oncologist. My mind was still trying to process the conversation I had with the surgeon. The more I thought about it, the more frustrated and agitated I became. I wanted some answers and a concrete game plan…no more surprises.

“Now I’m verklempt”

My side of the family came to our place for Thanksgiving this year. A few days before my sister, Margaret had called and asked if would be okay if she brought some music, said a few words and did a laying on of hands after dinner. She and her husband are very spiritual people and I agreed.

After Thanksgiving dinner that evening my sister Margaret played a CD with the chant “Veni, Sancte Spiritus – Come Holy Spirit”. My brother-in-law stood, placed his hand on my shoulder, read a short passage from scripture and said a few words. One by one, each person at the table came over, placed their hand on my shoulder and said a few more words. In the beginning I felt nothing, but as each one of sisters spoke I could feel the lump in my throat growing and before long I was starting to tear up. My wife came over and wrapped her arms around me. It was a profound spiritual moment and one I will never forget.

 

“Now I'm verklempt. Talk amongst yourselves. I'll give you a topic. The chick pea is neither a chick nor a pea. Discuss! There I feel better.” 

Linda Richman - Coffee Talk

“Doctor, my eyes, tell me what you see…”

Monday, 11/22/10

I met with the radiation oncologist to discuss my case. He reviewed all of the scans including the MRI that was performed on Saturday. We talked about the differences between colon and rectal cancer. He mentioned the same things that my oncologist had told me and added that the lymphatic drainage is different for the two types of cancer. The lymph fluid from the colon drains into the mesenteric lymph nodes while the lymph fluid from the rectum drains into the pelvic lymph nodes. He went on to say that there would only be two reasons for performing radiation prior to surgery.

1.     If the tumor was low in the rectum, i.e. closer to the anus it would be more difficult for the surgeon to remove and radiation would help shrink the size of the mass making it easier to resect. The same would also apply to cases where the tumor exhibited extension into the pelvic area, which can be seen in advanced stages of the disease.

2.     If the lymph nodes appeared to be involved.

He said that based on the MRI, the majority of my tumor appeared to be in the distal end of the sigmoid colon with a slight dip downward into the rectum and there didn’t appear to be any extension of the tumor into the pelvis. The lymph nodes were clear on the CT & PET scans and measurements taken from the MRI determined the lymph nodes were about 6 mm in diameter, which was within normal limits. Therefore, I didn’t need radiation and chemo prior to surgery. This was great news!

I told him that I was worried about the long-term effects of radiation exposure, e.g. chronic gastroenteritis, bladder or prostate cancer. In years past, radiation was administered using a relatively broad path and other organs could be affected. He said that radiation treatment had changed quite a bit just in the last five years and new technologies had been developed like intensity-modulated radiation therapy (IMRT), which uses a much smaller beam. Target areas can be painted with surgical-like precision, thus avoiding other organs. He went on to say that while I didn’t need radiation or chemo before surgery we would have to wait for the pathology report on the lymph nodes harvested from surgery to see if I needed post-surgical treatment. If any nodes were positive I might need to have IMRT, but we would cross that bridge after surgery.

He said he imagined the past few weeks must have been frustrating since there seemed to be no answers, just more questions. He assured me that all of the tests were necessary to piece together a picture of what was really going on and the MRI was the last piece in the puzzle. It felt great to finally have some concrete answers and a game plan for treatment. My fears regarding radiation had been alleviated and things were looking up. Thanksgiving was just a few days away and I had much to be thankful for this year.

"I get by with a little help from my friends"

They call me Yoda at work. I would have preferred Obi-Juan, but now I’m starting to look more like Yoda, e.g. bent over, thinning hair and I’ll probably be looking a little green once chemo starts. I’m so fortunate to have great coworkers who are also my friends…you guys rock! I quote the great master regarding my battle against cancer; “Try not! Do or do not. There is no try.”

“Do you hear what I hear?”

Saturday, 11/20/10

I went to the hospital and checked in at 8:00 AM so that I could fill out another stack of redundant paperwork before my MRI. The tech came and escorted me down the hall to a dressing room near the machine. I was able to keep my tee shirt on, but the jeans had to come off because of all the metal, e.g. button, zipper and rivets. They gave me two of the one size fits none hospital gowns, one to cover the front and other to cover the back. I walked into the adjacent room and laid down on the table connected to the MRI, shading my eyes from the bright lights above and listening to the chirping of the machine in its resting state.

The room was quite chilly and the technician draped a warm blanket over me.  The equipment is very noisy while in operation and she gave me a pair of headphones that played Christmas music for the duration of the scan. I placed my arms above my head as the table moved into the machine. I thought the chamber for the PET scan was confining, but that was nothing compared to the MRI chamber. My face was about four or five inches from the opening and my arms were held tight against the sides of the chamber. My oncologist had ordered a scan with and without contrast so I figured the whole process might take a hour. The technician did a couple of quick scans and then pulled me out of the chamber for about 15 minutes while a radiologist across town read the images and decided what protocol should be used for the remaining scans. I could be wrong, but “reviewing protocols” sounded like code for a Starbucks run.

The table moved back inside the chamber and three more scans were performed. I hadn’t taken any Aleve that morning and my back was really starting to hurt from lying on the hard table so long. In retrospect, I should have taken a muscle relaxer and maybe some Vicodin…paging Dr. House. Toward the end of the third scan I couldn’t feel my right arm because the gown was tight through my shoulders and it was also pressed up against the machine.  I hadn’t eaten anything that morning and just had a little water to drink, yet another mistake. I still can’t feel my arm and now my heart starts beating faster and my chest is feeling tighter with each breath. I was having a hard time catching my breath. I’m usually not claustrophobic, but I could feel the anxiety building and I knew if something didn’t change soon I was going to panic. I kept trying to tell the technician, I can’t breathe, I can’t catch my breath. Of course the response I got was a patronizing voice saying “yeeeaaaaah, we know...” and I’m like, no you don’t know, I really can’t breathe!

They pulled me out of the machine and my right arm fell to the side. It took a few minutes before feeling came back and I could move it. I was able to take a few sips of water before going back in for the last scan without contrast. They did the scan, pulled me out and tried to run an IV, but I was so dehydrated by this time that the techs weren’t able to it. They had to call in the “IV Team”, which is like the A-Team only for IVs…they pitied the fool (me) and got the contrast solution pumped in right away.

Back in I went and I was doing okay for the first three scans, but I couldn’t make it through the last one without being pulled out for just a few minutes so I could relax my arms and back, which was really hurting now. They put me in for the last round of Wheel of Misfortune, which was only a few minutes, but seemed like an eternity. After two hours of lying on that table my back was pretty tweaked and close to being in spasm. The table is so narrow there was no way to turn on my side and nothing to grab a hold of so I could pull myself up. It took three people to help get me up off the table. I made some definite mistakes by not eating, not drinking enough and not taking any pain meds ahead of time. If I need to have an MRI in the future I’ll ask to be shot with a tranquilizer dart.

Heads it’s colon, tails it’s rectal

Friday, 11/19/10

I met with my oncologist and we talked about the results from the PET scan. There did not appear to be any increased metabolic activity in the liver, lungs or elsewhere, which was good. However, the origin of the tumor was still in question. He thought that it may be a colon tumor that had a slight extension down into the rectum rather than a true rectal tumor.  The distinction was important because colon and rectal cancers are treated differently.

Typical treatment for rectal cancer

1.     Neoadjuvant therapy consisting of radiation & chemo using 5-Fluorouracil (5-FU)

2.     Surgical removal of the tumor

3.     Follow up chemo using FOLFOX (Folinic acid, 5-FU & Oxaliplatin)

Radiation is used in rectal cancer to help shrink the size of the tumor making it easier for the surgeon to remove. This is especially true in advanced cases of the disease where the tumor has penetrated the rectum and extended into the pelvis. In addition, clear margins (unaffected areas of normal tissue lying adjacent to the tumor) can be difficult to obtain if the tumor is low in the rectum near the anus.

Typical treatment for colon cancer

1.     Surgical removal of the tumor

2.     Follow up chemo using FOLFOX (Folinic acid, 5-FU & Oxaliplatin)

Radiation carried with it a certain amount of risk depending upon how the treatment was performed and the size of the area being treated, e.g. chronic gastroenteritis if portions of small bowel were in the path of the beam and increased risk of bladder or prostate cancer in the future. Rectal tumors not treated with radiation had a higher chance of recurrence.

The CT scan had provided basic anatomical detail and the PET scan had characterized metabolic activity, but more information was needed to pinpoint the location. There were two options, endoscopic ultrasound, which isn’t currently available in Fort Collins or MRI. He scheduled an MRI for the next morning and was referring me to a radiation oncologist who would interpret the results and determine if radiation treatment was necessary.