Switching Health Insurance

When I got laid off in March 2020, I was able to continue my group health insurance with Cigna due to COBRA. I had to pay the full cost ($710 for health, dental and vision; the health insurance part is $640). This year, due to the COBRA premium subsidy of the American Rescue Plan, I did not have to pay the monthly premium from April through September.

COBRA, however, is good for only 18 months. I will have to switch health insurance starting November 1. When I looked at Covered CA (AKA ACA or Obamacare), very few of the plans included Stanford and none included my oncologist. Only a few plans through Blue Shield included PAMF where my PCP is and where I was first diagnosed with cancer. The premiums (over $500/mo) and out-of-pocket maximum (over $8000) are expensive. The best I could find was through Kaiser with a monthly premium of ~$85 and max out-of-pocket (OOP) of $6500. The premium is unusually low because of a subsidy, but the OOP is still high.

My problem is that I've already paid the OOP for Cigna. But because the health plans are by calendar year and my infusions are so expensive, I will have to pay the OOP for Nov-Dec on the new plan. Then I will have to pay the OOP again in January for the 2022 calendar year. $3000 + $6500 + $6500 = $16,000. In addition, my HOA has a special assessment of $6,600 due in January for roof replacement. $16,000 + $6,600 = $22,600. The high cost has been upsetting me for a couple of months. 

The good news is that once I submitted my application to Covered CA, a new plan I'm eligible for popped up. It's still with Kaiser but the premium is subsidized and costs only $1/mo, and the OOP is only $1000! This is very welcome news. The subsidy is also through the American Rescue Plan and is supposed to be good till December next year.

Once I get my Kaiser membership card, I will have to find a new PCP and get a referral to an oncologist so that I can continue my treatment with minimal interruption. I also plan to get dental and vision insurance.

Chemo curls

Hair often grows back curly after chemo. Mine is definitely wavy. This is about five months of growth. The curliness is temporary, lasting 6-12 months, sometimes longer.

I think I have way more white hair now. Looks like I still have dandruff. It's not just my body that's experiencing dry skin but also my head. 

Jury Duty

I received a jury summons. While the court claims to enforce six feet of social distancing, their video about covid precautions shows that the seats in the jury box are not spaced far enough apart.

When I talked to my doctor last week, she said I'm moderately immunocompromised. In my response to the court online, I asked to be excused and uploaded a letter from my doctor. Now I wait to see if they accept or reject my request.

Zometa Side Effects

At my every-three-weeks infusion Friday, I was given a new drug, Zometa. It has a long list of side effects: dizziness, headache, flu-like symptoms (such as fever, chills, muscle/joint aches), cough, vision problems, diarrhea, constipation, tired feeling, joint or muscle pain.

The side effect I was most concerned about was dizziness. But my doctor was most concerned about pain. I was given Tylenol before the infusion and directed to take more when I get home. The infusion lasted only 20 minutes. I felt fine in the evening, just a little bit tired.

The next morning I went to the farmers market. After I got home, I felt very tired and had to take a nap. That's when I got the flu-like symptoms. I didn't feel well at all and was shivering even though I didn't really feel cold. I didn't bother taking my temperature because I had taken Tylenol.

In the afternoon I got up to eat and attend my support group session. After the session ended, I went back to bed and slept fitfully till the next morning. At one point I woke up and noticed muscle pain in both arms, joint pain in the fingers of my left hand, and muscle pain in both thighs. Thank goodness I took more Tylenol or the pain would have been worse. 

Most of the pain was gone by morning. I still felt tired but was fine after a few hours. The side effects lasted 48 hours. My doctor said they usually last 24-72 hours.

I will get Zometa every six months.  The dose I was given was 3 mg, which is what the endocrinologist suggested a couple of weeks ago. The good news is that the side effects usually happen at the first infusion only. But not always. For some patients it happens at every infusion. 

Endocrinologist Consult

My next phase of treatment is to take an aromatase inhibitor (AI) pill daily for 5 years. AI causes bone loss. Since I already have osteoporosis, I will be given an IV infusion of a bisphosphonate called Zometa every 6 months to minimize bone loss. However, side effects of bisphosphonates include atypical femoral fractures (AFF) and osteonecrosis of the jaw. 

The risk of AFF is higher for Asian women, and that's what I'm most concerned about. I had a visit with Dr. Deborah Kado at Stanford yesterday. She said I should be more concerned with hip fracture than AFF. She recommended the following. I'll just paste what she entered in the visit notes.

1. Agree with recommendation for IV Zometa for 3-5 years, particularly if she is to start an AI. Given patient's body size and Asian heritage (that is associated with increased AFF risk per Kaiser Southern California data as well as Canadian data), may consider a slightly decreased dose of 3mg every 6 months instead of 4 mg (though there are no trial data to support this recommendation). Asian treating MD's from Taiwan, Toronto and Japan have recommended decreased bisphosphonate doses in Asian females because of the elevated AFF risk. 
2. Vitamin D3 supplementation, 1,000-2,000 IU daily; may recheck level in about February (target is 30-50ng/mL of Vitamin D 25-hydroxy level
3. Calcium intake up to 1200 mg daily, preferable through dietary sources (see sources below)
4. Diet full of daily fresh fruits and vegetables
5. Work on balance daily, mindful of posture 3 times daily (see handout below)
6. Visit the dentist regularly, and floss daily
7. When move to Kaiser (possible plan), recommend Dr. Joan Lo to follow-up on osteoporosis clinical care. 

I will probably take a break from Zometa after 5 years. My Vitamin D level last January was 32. The balance recommendation is probably so that I don't fall and break my hip. The dentist is for avoiding osteonecrosis of the jaw. #7 mentions Kaiser because I will have to switch insurance soon. More on that later.

Ring the Bell

Today was my last day of radiation therapy. There is a tradition of ringing a bell to celebrate the end of treatment. But a survey found that those who rang the bell had more distressful memories of their treatment than those who did not.

I didn't plan to ring the bell but wanted to see if the bell sounds good. I took the clapper and tapped it very lightly against the bell, expecting a soft metallic sound. But it rang so loudly! I tried to stop the ringing, but it turns out it's true that you can't unring a bell.

Radiation Boost

I'm into the sixth week of my radiation therapy. The final week is a radiation boost targeting the area where my tumor used to be. First they do imaging (one x-ray), then they aim the machine at my breast from two different directions for about 10 seconds each. Just like before, I have to take a deep breath and hold it for those 10 seconds.

This is what my skin looks like under my arm area.

I have grade 2 radiation dermatitis. That's a fancy term for radiation burn. Grading descriptions:

Grade 1 – Faint erythema or desquamation.
Grade 2 – Moderate to brisk erythema or patchy, moist desquamation confined to skin folds and creases. Moderate swelling.
Grade 3 – Confluent, moist desquamation greater than 1.5 cm diameter, which is not confined to the skin folds. Pitting edema (severe swelling).
Grade 4 – Skin necrosis or ulceration of full-thickness dermis (middle layer of skin).

The photo doesn't show the reddest areas. My chest was very red but is starting to fade now. The bottom part of my breast is very dark (hyperpigmentation). I could be back to grade 1 now. My skin is still peeling and itches occasionally but there is very little soreness. I couldn't sleep on my left side because it was painful. I haven't checked lately if it still hurts.

Today was treatment #29 out of 30. One more day left.