Day 3 did not go well. First of all, Ma couldn't sleep last night. She didn't fall asleep till 5am. I'm guessing the Decadron she was given before the chemo caused the insomnia.
Second, Ma forgot to take her Zofran (anti-nausea drug). She blames Pa for not remembering, but she really needs to remember it herself instead of relying on Pa. When I asked her this morning, she said she had taken it. She recanted later and said she thought I was talking about another drug. I have no idea what the other drug could be since she's taking only one drug related to her chemo. Anyway, she didn't take her Zofran till 6pm. Thank goodness she didn't get nausea in the meantime.
Third and most troublesome is Ma started having pain in her knee last night. By evening tonight, the pain was severe and required Vicodin. It's not clear to me where the pain is; it might be in her entire lower legs. I asked Ma why she didn't take Vicodin earlier before the pain got bad. She said she was afraid of the nausea Vicodin gives her. I told her that Zofran will take care of her nausea IF she remembers to take it. She said she didn't know that's what the Zofran was for. When I spoke to her at 10pm, the Vicodin was just starting to relieve the pain, and she reported no nausea.
The pain, I believe, is a side effect of the Taxotere. It's supposed to be an uncommon side effect, but I see frequent mention of it on the web. The pain can last 4-5 days, but I hope it's severe for no more than a day. I also hope the pain doesn't get worse with each chemo session. I'll have to ask the oncologist about this. Ma has a follow-up appointment with him on Wednesday. In the meantime, I'm logging every side effect Ma gets so that I can report them to the doctor. Also, a lot of chemo patients see a pattern in their side effects. If this holds true, Ma will be fine on Day 1 and most of Day 2. By the evening of Day 2, she'll start having pain. On Day 3, the pain will be severe. I hope Day 4 will be better.
I almost forgot -- the fourth side effect is difficulty breathing. It's not clear to me what Ma means by this. Is it shortness of breath? Is she out of breath like when she walks at the mall? She did say she breathes better lying down, and she's able to take deep breaths. She also said she had the same problem after her surgeries. Whatever it is doesn't seem to be an emergency.
Friday, May 30, 2008
Neulasta
Because some chemo drugs can make your white blood cell count drop and affect your immune system, medication is often given to stimulate production of white blood cells. One such drug is Neulasta, given 24 hours after chemo. That's the shot Ma got yesterday.
A similar drug is Neupogen. There are two main differences between Neulasta & Neupogen:
A similar drug is Neupogen. There are two main differences between Neulasta & Neupogen:
- Number of shots required. Only one shot of Neulasta is required vs. several daily shots of Neupogen.
- Cost. Neulasta costs between $3000-7000. Neupogen is only about $300 a shot. Even with five shots required, it's still cheaper than Neulasta.
Cytoxan and Taxotere
Ma will get 4 cycles of Cytoxan and Taxotere given every 3 weeks.
Cytoxan (generic name Cyclophasphamide) is classified as an alkylating agent. It kills cells while they are in their resting phase (vs. growing or dividing phase). It is a mustard gas derivative. Clinical trials using Cytoxan began in the late '50s.
Taxotere (generic name Docetaxel) is a plant alkaloid, taxane, and antimicrotubule agent. Plant alkaloid means it's made from plants. Taxanes are made from the bark of the yew tree (taxus). The related drug Taxol was developed first using the Pacific yew tree, and clinical trials began in the mid-1980s. But large quantities of the bark are required to produce the drug. Taxotere, derived from the more-readily available European yew, was developed in response. Being antimicrotubule means it inhibits the microtubule structures of cells, the part responsible for dividing and replicating. Simply put, it kills the cells while they're dividing.
Both Cytoxan and Taxotere have a long list of side effects, among them:
Why does chemotherapy cause hair loss? Because the drugs can't distinguish between "normal" cells and cancerous cells, they end up attacking both types.
Cytoxan (generic name Cyclophasphamide) is classified as an alkylating agent. It kills cells while they are in their resting phase (vs. growing or dividing phase). It is a mustard gas derivative. Clinical trials using Cytoxan began in the late '50s.
Taxotere (generic name Docetaxel) is a plant alkaloid, taxane, and antimicrotubule agent. Plant alkaloid means it's made from plants. Taxanes are made from the bark of the yew tree (taxus). The related drug Taxol was developed first using the Pacific yew tree, and clinical trials began in the mid-1980s. But large quantities of the bark are required to produce the drug. Taxotere, derived from the more-readily available European yew, was developed in response. Being antimicrotubule means it inhibits the microtubule structures of cells, the part responsible for dividing and replicating. Simply put, it kills the cells while they're dividing.
Both Cytoxan and Taxotere have a long list of side effects, among them:
- Low blood counts (white, red and platelets)
- Hair loss
- Nausea & vomiting
- Diarrhea
- Mouth sores
- Neuropathy
- Fatigue
Why does chemotherapy cause hair loss? Because the drugs can't distinguish between "normal" cells and cancerous cells, they end up attacking both types.
Chemo #1 Day 2 - Back to Work
Ma went to work. Unbelievable. First she went to church, then she went to work. In the afternoon I took her back to the hospital to get a short of Neulasta to keep her white blood cell count from dropping and making her susceptible to infections. The nurses were surprised to hear that Ma went to work.
To prevent side effects from the chemo, Ma has to:
There were no patients scheduled for the afternoon so we left before 4pm and went to the movie theater to watch Indiana Jones and the Kingdom of the Crystal Skull. It was entertaining enough. The theater had the volume so high though that I had to stuff my ears.
After the movie, Ma wasn't up for a walk at the mall but consented to a short walk outside the theater. She was out of breath by the end of it. Not good. I noticed this before when walking at the mall. She used to rest only once when walking. Now it's 2-3 times. Sometimes her knees hurt, but sometimes she's out of breath. And it's a small mall.
To prevent side effects from the chemo, Ma has to:
- Take Zofran pills 3x a day for the next 3 days to prevent nausea. She also has Compazine in case the Zofran isn't enough.
- Drink 2-3 quarts of water a day to flush out the chemo.
- Rinse her mouth with baking soda and water to prevent mouth sores.
There were no patients scheduled for the afternoon so we left before 4pm and went to the movie theater to watch Indiana Jones and the Kingdom of the Crystal Skull. It was entertaining enough. The theater had the volume so high though that I had to stuff my ears.
After the movie, Ma wasn't up for a walk at the mall but consented to a short walk outside the theater. She was out of breath by the end of it. Not good. I noticed this before when walking at the mall. She used to rest only once when walking. Now it's 2-3 times. Sometimes her knees hurt, but sometimes she's out of breath. And it's a small mall.
Chemo #1 Day 1 - Infusion
Patients at Doctor's Medical Center in San Pablo get their chemo in the Infusion Room. There's an open area with six recliners side-by-side. There are three chairs for visitors across from the recliners. There really isn't room for the visitor to sit next to the patient. In addition, there are two private rooms reserved for first-timers. Ma got one of these rooms. It has a bed and extra chairs.
Ma's port had healed enough for it to be used. She put some Lidocaine cream on it an hour before her appointment. The nurse started her off with saline, then she was given her pre-meds:
Dr. Irwin, Ma's oncologist, stopped by briefly to see how she was doing. The dietitian stopped by, and I had a long chat with him mostly to learn what diabetics really can eat, not to see what chemo patients should eat. The social worker also stopped by. The nurses were mostly Filipinos (no surprise there) and very nice and friendly. And they all know Pa or had heard of him.
The only side effect Ma had was drowsiness from the Benadryl. No allergic reaction. And no chest pains, unlike one of the patients in the big room. Ma fell asleep from the Benadryl. Her door was propped open, and she was snoring so loudly that I had to jostle the bed every few minute to stop her from snoring. It didn't work. She spent the rest of the day at home resting.
Ma's port had healed enough for it to be used. She put some Lidocaine cream on it an hour before her appointment. The nurse started her off with saline, then she was given her pre-meds:
- Zofran IV for nausea
- A shot of Pepcid AC for heartburn/nausea
- Benadryl tablets to prevent allergic reaction to the chemo drug Taxotere
- A shot of Decadron for nausea and possibly for allergy to Taxotere
Dr. Irwin, Ma's oncologist, stopped by briefly to see how she was doing. The dietitian stopped by, and I had a long chat with him mostly to learn what diabetics really can eat, not to see what chemo patients should eat. The social worker also stopped by. The nurses were mostly Filipinos (no surprise there) and very nice and friendly. And they all know Pa or had heard of him.
The only side effect Ma had was drowsiness from the Benadryl. No allergic reaction. And no chest pains, unlike one of the patients in the big room. Ma fell asleep from the Benadryl. Her door was propped open, and she was snoring so loudly that I had to jostle the bed every few minute to stop her from snoring. It didn't work. She spent the rest of the day at home resting.
Thursday, May 29, 2008
Graduation Party
Kuya George's elder daughter Melissa got her BS in Nursing. They threw a party at a Chinese restaurant. Lots of food -- pork in lettuce leaves, soup, shrimp with walnuts, chow mein, fried rice, spicy beef, Peking duck with buns, etc. There was also a whole lechon that people munched on before dinner. And there was a table with marshmallows and pretzel sticks that you could dip into the chocolate fountain.
Tito Pepe & Tita Belen with their granddaughter Melissa.
Tito Pepe, Tita Belen, Ma & Pa
Ate Vicky, Kuya George & Tito Lum
Tita Belen, Beta & Ma
Raymond & Maia. Maia is due in July.
Ate Beth, Totie & Ryan
Marianne & Lizza Mae
Raymond & Dennis
Ryan, Lawrence & John
Richard, Ate Beth & Totie
Ma & Pa
Beta & son
Kuya George, Melissa, Anjelica & Dorothy
Lechon head that Ate Beth took home.
Tito Pepe & Tita Belen with their granddaughter Melissa.
Tito Pepe, Tita Belen, Ma & Pa
Ate Vicky, Kuya George & Tito Lum
Tita Belen, Beta & Ma
Raymond & Maia. Maia is due in July.
Ate Beth, Totie & Ryan
Marianne & Lizza Mae
Raymond & Dennis
Ryan, Lawrence & John
Richard, Ate Beth & Totie
Ma & Pa
Beta & son
Kuya George, Melissa, Anjelica & Dorothy
Lechon head that Ate Beth took home.
Saturday, May 24, 2008
Stage III
The tests came out clear -- brain MRI, bone scan, CT scan. So it's official -- Ma is Stage III, not Stage IV. More specifically, she's Stage IIIB.
We met with the tumor board at the hospital Wednesday. I was expecting only about six people there. But no, there must have been about 20 -- surgeons, oncologists, radiologists, pathologists, two medical residents, a dietitian, a social worker, the director of the cancer center, and who knows who else. They basically agreed with the chemo treatment recommended by Stanford and that no further surgery is needed at this point. They also said that the liver doesn't look cancerous in the PET scan. This contradicts what Dr. Guardino at Stanford said. The radiologist said that "a liver with cancer doesn't look like that." So I was pretty confident going into Friday that Ma would be "only" Stage III.
Chemo will start on Wednesday.
We met with the tumor board at the hospital Wednesday. I was expecting only about six people there. But no, there must have been about 20 -- surgeons, oncologists, radiologists, pathologists, two medical residents, a dietitian, a social worker, the director of the cancer center, and who knows who else. They basically agreed with the chemo treatment recommended by Stanford and that no further surgery is needed at this point. They also said that the liver doesn't look cancerous in the PET scan. This contradicts what Dr. Guardino at Stanford said. The radiologist said that "a liver with cancer doesn't look like that." So I was pretty confident going into Friday that Ma would be "only" Stage III.
Chemo will start on Wednesday.
Friday, May 23, 2008
News: Vitamin D Deficiency
A study shows that women with Vitamin D deficiency are more likely to have their breast cancer metastasize. Another study shows that the countries closest to the equator have the lowest rates of breast cancer. However, experts caution against increasing sun exposure as a way to decrease breast cancer risk. It would be best to maintain a healthy weight, get regular exercise, drink moderately, and eat a healthy and balanced diet.
Update 05/30/08: The Canadian Cancer Society recommends taking 1,000 IU of Vit. D daily.
Update 05/30/08: The Canadian Cancer Society recommends taking 1,000 IU of Vit. D daily.
News: Mammograms & Ultrasound
A recent study shows that mammograms and ultrasound are better in detecting breast cancer in women with dense breasts than mammograms alone. However, ultrasound results in higher false-positive readings that lead to unneeded biopsies.
News: Anti-Discrimination Bill
President Bush signed a bill that protects people from losing their jobs when genetic testing reveals they're susceptible to cancer, heart disease, or other costly diseases.
Port
Ma had her port inserted on Tuesday. Her appointment with the surgeon was canceled the day before, but we had a hurried consultation with her the next day before the surgery. It took less than an hour. Ma had a MAC, somewhere between general anesthesia and conscious sedation. She was given three different anti-nausea medications when surgery ended, but she still got nausea. The nurse gave her another drug, and that seemed to help, but all those drugs made her very drowsy. We had to wait several hours before taking her home. The good news is she had no pain at all the next day.
Monday, May 19, 2008
Full Week This Week
Ma has a full week this week.
Mon - Consult with a surgeon about inserting a port in her chest for receiving IV chemo.
Tue - Have the port installed. It's an outpatient procedure.
Wed - Tumor board and brain MRI.
Thu - Bone scan and CT scan.
Fri - Follow-up with the oncologist. Pa is also having a growth removed from his underarm.
Mon - Consult with a surgeon about inserting a port in her chest for receiving IV chemo.
Tue - Have the port installed. It's an outpatient procedure.
Wed - Tumor board and brain MRI.
Thu - Bone scan and CT scan.
Fri - Follow-up with the oncologist. Pa is also having a growth removed from his underarm.
Friday, May 16, 2008
Photos 5/11-5/15
We went for a walk at the mall on Mother's Day (5/11) after spending several hours cleaning up the office.
After we got the second opinion Wednesday (5/14), we had lunch at Stanford Mall.
Ma talking on the phone with Kit on 5/15. This was taken at the office. Yes, Ma still works.
Wednesday, May 14, 2008
Triple Negative
Triple negative means the tumor is ER- (estrogen receptor negative), PR- (progesterone receptor negative) and HER2- (HER2/neu negative). If you're ER- and PR-, you can't be treated with tamoxifen (for premenopausal women) nor aromatase inhibitors (for post-menopausal women), two types of hormonal therapy. If you're HER2-, you can't be treated with Herceptin, a biological therapy. Triple negative cancers are very aggressive and typically found in younger women.
Triple negative also means you could have the BRCA1 gene mutation. I need to follow up on this.
Triple negative also means you could have the BRCA1 gene mutation. I need to follow up on this.
Pleural effusion
A pleural effusion is an abnormal collection of fluid between the thin layers of tissue (pleura) lining the lung and the wall of the chest cavity. Malignant pleural effusions are very, very bad. Ma's PE showed up in her x-ray and PET scan. 600ml was drained from her lung. I don't know if it means anything, but the affected lung is contralateral (on the opposite side of the body) to her tumor. She also was asymptomatic. She felt no difference after the fluid was drained.
Tumor Board
I mentioned tumor board in my first post. Basically, a bunch of doctors get together and review a case. The doctors may include medical oncologists (chemo doctors), radiation oncologists, and surgeons. When we got our second opinion from Stanford, Dr. G consulted with other breast cancer oncologists in the office; it wasn't a formal tumor board. Stanford does have a more formal tumor board where patients can request that their cases be reviewed, but they have to pay for it. At Doctor's Medical Center in San Pablo where Ma is being treated, they have a tumor board every week. Her case will be presented next Wednesday, May 21. There is no fee for this.
The Background
Ma felt a lump in her left breast a few days before Easter. (Easter was March 21st this year). She immediately had a mammogram, but the lump was hard to see because she has dense breasts. It was clearer in the ultrasound that followed. A biopsy showed that it was cancer. The surgeon ordered an MRI which showed more suspicious areas in the same breast. Another biopsy was done on one of the areas, but it turned out to be negative. So the surgeon recommended a lumpectomy and an axilla dissection. That was done on April 29. The results:
2.2 cm tumor
Invasive ductal carcinoma
Poorly differentiated
Grade 3
Triple negative (ER-, PR-, HER2-)
16 out of 16 lymph nodes positive for cancer
That means it's aggressive and advanced. In addition, Ma had a pleural effusion in her right lung. That was drained on
May 2nd. Tests results showed it was negative for cancer. But see the previous post. At the moment she's considered stage IIIB. Further tests will determine if she's stage IV.
Update 05/23/08: Ma is officially stage IIIB.
2.2 cm tumor
Invasive ductal carcinoma
Poorly differentiated
Grade 3
Triple negative (ER-, PR-, HER2-)
16 out of 16 lymph nodes positive for cancer
That means it's aggressive and advanced. In addition, Ma had a pleural effusion in her right lung. That was drained on
May 2nd. Tests results showed it was negative for cancer. But see the previous post. At the moment she's considered stage IIIB. Further tests will determine if she's stage IV.
Update 05/23/08: Ma is officially stage IIIB.
Second Opinion
Ma, Pa & I went to Stanford today to get a second opinion on Ma's chemo treatment. We had to wait a few hours before we got to see Dr. Guardino. She did consult with other oncologists at the cancer center before seeing us, so it's almost like getting the benefit of a tumor board. The news was not good.
First of all, she finds the pleural effusion "worrisome." She thinks we got a false negative on Ma's PE. If the PE comes back, it should be tapped again. Her guess is if the fluid is processed without delay, cancer cells will be found.
Second, she feels there are suspicious areas in the left breast (the same breast that had the tumor). I believe she was talking about the areas that lit up in the MRI. One of them was biopsied and was negative. Another is described in the MRI report as this: It is possible this represents an intramammary lymph node. Dr. Guardino thinks it's a cancerous lymph node in the chest wall. There is also a very high risk of recurrence of the cancer in the same breast or the remaining lymph nodes. Now I'm regretting not pushing for a second opinion on the surgery. I really felt that Ma would have had a difficult time recovering from a mastectomy vs. a lumpectomy, so I was relieved when the surgeon recommended a lumpectomy. It doesn't matter now. Dr. Guardino said at this point, additional surgery would do more harm than good.
Third, if I heard correctly, the PET scan showed that the liver has "a nodular border consistent with cirrhosis." This is the first I've heard of it. Dr. Guardino thinks it's suspicious and may be cancerous.
What's the next step? Additional tests to determine staging -- a CAT scan with IV contrast and a bone scan.
If Ma is Stage III, Dr. G recommends 4 cycles of TC (Taxotere & Cytoxan) every 3 weeks followed by radiation.
If Ma is Stage IV, she recommends 4 cycles of Taxotere & Xeloda, followed by radiation, then low dose Xeloda as maintenance therapy for the rest of her life. Xeloda is an oral chemo taken twice a day for two weeks, then one week off. It's well-tolerated by the elderly and doesn't cause hair loss.
This is in contrast to what Ma's oncologist recommended - Taxol weekly for 12 weeks and 4 cycles of Avastin every 3 weeks. Dr. Guardino thinks Avastin is too high-risk for Ma because of its side effects.
Also, because of Ma's numerous health issues (diabetes, hypertension, etc.), she needs to be monitored very closely.
First of all, she finds the pleural effusion "worrisome." She thinks we got a false negative on Ma's PE. If the PE comes back, it should be tapped again. Her guess is if the fluid is processed without delay, cancer cells will be found.
Second, she feels there are suspicious areas in the left breast (the same breast that had the tumor). I believe she was talking about the areas that lit up in the MRI. One of them was biopsied and was negative. Another is described in the MRI report as this: It is possible this represents an intramammary lymph node. Dr. Guardino thinks it's a cancerous lymph node in the chest wall. There is also a very high risk of recurrence of the cancer in the same breast or the remaining lymph nodes. Now I'm regretting not pushing for a second opinion on the surgery. I really felt that Ma would have had a difficult time recovering from a mastectomy vs. a lumpectomy, so I was relieved when the surgeon recommended a lumpectomy. It doesn't matter now. Dr. Guardino said at this point, additional surgery would do more harm than good.
Third, if I heard correctly, the PET scan showed that the liver has "a nodular border consistent with cirrhosis." This is the first I've heard of it. Dr. Guardino thinks it's suspicious and may be cancerous.
What's the next step? Additional tests to determine staging -- a CAT scan with IV contrast and a bone scan.
If Ma is Stage III, Dr. G recommends 4 cycles of TC (Taxotere & Cytoxan) every 3 weeks followed by radiation.
If Ma is Stage IV, she recommends 4 cycles of Taxotere & Xeloda, followed by radiation, then low dose Xeloda as maintenance therapy for the rest of her life. Xeloda is an oral chemo taken twice a day for two weeks, then one week off. It's well-tolerated by the elderly and doesn't cause hair loss.
This is in contrast to what Ma's oncologist recommended - Taxol weekly for 12 weeks and 4 cycles of Avastin every 3 weeks. Dr. Guardino thinks Avastin is too high-risk for Ma because of its side effects.
Also, because of Ma's numerous health issues (diabetes, hypertension, etc.), she needs to be monitored very closely.
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