Go Back Three Spaces

Remember the setbacks intrinsic to board games. Players are sent back three spaces, or maybe they forfeit a turn simply because they landed on the wrong square or drew the wrong card. In the overall rhythm of the game, these impediments are never really catastrophic, but they trigger a keen sense of frustration nonetheless.

I had a similar setback earlier this week. My radiation treatments, scheduled to begin during the last week of April, were taken off calendar, and I was sent back to the breast surgeon to discuss re-excision. Before I explain further, let me assure those who are quick to worry that my health status has not changed in the slightest. No new or bad facts have presented themselves. This week's shift in treatment reflects nothing more than a change in thinking about the next step.

If you've followed this blog for awhile, you may remember that, based on the pathology report following my surgery, the breast surgeon achieved a "clean" margin around my invasive cancer, but only a "close" margin around the pre-cancerous condition (known as DCIS). While achieving a "close" margin is not as bad as a "dirty" margin, the downside is that close margins leave lingering doubt -- maybe all of the DCIS was removed, but maybe it wasn't. Close margins call for additional medical intervention. Depending on each patient's circumstances, they are either rectified by the surgeon, who removes a little more tissue during a re-excision, or by the radiation oncologist, who increases the radiation dosage to kill off any unwanted cells that the surgeon missed.

In my case, the breast surgeon instructed me to discuss the margin problem with Dr. Rad, which is my nickname for the radiation oncologist I'm seeing. At the time, which was back in December, Dr. Rad was confident that by increasing the radiation levels, he could eliminate any remaining bits of DCIS. My reaction to this idea was tepid at best. From a holistic viewpoint, I was a little hesitant to let Dr. Rad dial up the dosage, but I was the only one who balked. The rest of my team -- the medical oncologist and the breast surgeon -- all concurred with Dr. Rad and green-lighted this plan. Since I lack an M.D. after my name, arguing with three medical experts seemed pointless. I acquiesced and agreed to return to Dr. Rad after I concluded chemotherapy in order to begin super-charged radiation treatments.

But this week, when I showed up for a pre-radiation planning session, Dr. Rad looked at my chart again and changed his mind, although not for medical reasons. He cited my age and said that he was reluctant to proceed because he didn't want me to be unhappy with the cosmetic results of extra radiation. To be honest, the picture he painted was not a pretty one. Given that I was never fully invested in the extra dose idea anyway, he didn't have to say much before I agreed to inquire further about re-excision. Two days later I was consulting with a breast surgeon, although not the same one who performed my original procedure since that doctor has since relocated, but everything still fell easily into place. The new surgeon believes that by re-excising, he can both rectify the margin problem and give me a better cosmetic outcome than radiation would impart.

Even though I think I'll be happier in the long run by following this course, the delay is still frustrating. I want to reach the finish line, and I don't relish being sent back 3 spaces. The re-excision is scheduled for next week, and radiation is set to begin at the end of May.

As a kid, I always enjoyed board games, and I good-naturedly weathered the inevitable lost turns or directives to retreat a few squares. At least that's how I remember the long summer days I spent playing Trouble or Parcheesi. This experience, however, is testing even my patience. I want to get to Candyland. Now.

Three Seasons Later

Done. Done. Done with that!

Chemo is finished, thankfully, and I owe some words of appreciation to those who so kindly extended their help. To my husband Dennis, to BK, and to TB, thanks so much for chauffeuring me on chemo days. Also, many thanks to EQ for stopping by to visit during my treatments.

I'm also very grateful to my lunch/coffee buddies -- JB, BE, LR, MB and BP. You've brightened my mood over many meals and continued to assure me that my bandanna was fine. Really.

Thanks, Mom, for the meals. And thanks to everyone for your extended support over these long months since I was first diagnosed. Your kind thoughts have arrived in many forms -- e-mails, blogposts, telephone calls, greeting cards, floral deliveries, prayers and, yes, even mental telepathy. I know that you're thinking of me, and that knowledge has helped to propel me forward with my good spirits mostly intact.

My first radiation planning session is scheduled for later this week, when I will get some better information about the final phase of treatment. This breast cancer ordeal, which began last September with a peanut-sized mass palpable under my skin, will wind down in the not-too-distant future, and I will shift into a maintenance mode. Since embarking on my detour, a Halloween, a Thanksgiving, a Christmas, and an Easter have all been celebrated. A once obscure politician, Barack Obama, now has instant name recognition.

This past weekend in Los Angeles, the weather was more akin to July than April, the tomato plants were beginning to flower, and people's conversations were drifting toward graduations and vacations. Summer will circle around again soon, and I will return to days without cancer treatments.

The life I resume, however, will not exactly be the same as the one that I led a summer ago. I'm no longer the same. How could I be?

In the Name of Science

Fourteen days have passed since my final round of chemo. For the first time in 11 weeks, I feel that I'm at a point where I can begin to rejuvenate from the treatments.

While my energy level is far from normal, I'm also not as fatigued as I have been. That said, at the end of April, I'm scheduled to begin radiation, which also imparts a cumulative weariness in patients. Knock you down, let you build back up, and knock you down again. Add to the fatigue level varying amounts of hair loss, nausea and low blood counts. Indeed, the cancer treatment cycle is vicious, but so are those nasty cancer cells. Doctors are only trying to match the correct level of firepower to the perceived level of threat. The side effects are so much collateral damage.

Thanks to the sacrifices of a group of laboratory mice, however, some of chemo's negative impacts may be a thing of the past. A joint study, conducted by USC/Norris and the Giannina Gaslini Institute in Genoa, recently showed that by starving mice for a few days before their chemo treatments, the rodents avoided some of chemo's debilitating side effects. The researchers believe that healthy cells, when deprived of nourishment, stop dividing in order to withstand the stress. Cancer cells, however, respond differently and continue to divide, even when they are not getting proper sustenance. Since chemo only attacks dividing cells, the researchers believe that patients may be able to ward off chemo's ill effects if they forego food for a few days before treatment.

In this particular experiment, 28 mice received only water for 48 to 60 hours preceding treatment. Only one mouse out of the 28 who fasted did not survive the experiment. Meanwhile, another group of 37 mice ate normally before their chemo treatments, yet 20 mice in this group perished. Interestingly, the survivors in the group who fasted showed no visible side effects, while the remaining mice in the group who ate became sluggish and had ruffled fur. All of the mice were given the drug Etoposide, at levels three times the maximum human dose.

The results appear promising, and a clinical trial is expected to begin later this year to test this theory further. Until more is known, however, Valter Longo of USC, the director of the study, warns chemo patients not to fast before their treatments without instruction from their doctors.

While Longo and the others behind this study will undoubtedly get all the praise, the mice are the true unsung heroes. Out of the 65 mice who began the experiment, 21 are no longer with us. Now that's a hazardous job, and it brings to mind all of the laboratory rodents who work to further our understanding in so many fields of study. If I had hair, I'd tip my hat to those furry little creatures. Instead, I'll raise my glass. Here's to lab rats and research mice everywhere. Your efforts go largely unnoticed, but your contributions are immeasurable.

Dem Bones, Dem Bones, Dem Dry Bones

I wanted to share some of the feedback I've received on my clinical trial question.

Generally, people have asked whether I can replicate the benefits of taking the osteoporosis drugs by improved diet and exercise. My sense is that a targeted diet and exercise regimen would help to prevent osteoporosis, but I'm not sure it would be as beneficial as the drugs in warding off a recurrence of breast cancer.

Our bones are constantly regenerating. Old bone is broken down by cells called osteoclasts (the demolition teams), and new bone is created in its place by another group of cells, the osteoblasts (the construction teams). This process keeps bones strong and flexible. As we age, and lose estrogen, however, the demolition teams outpace the construction crews, resulting in bone loss. Genetics, diet and exercise all influence this balance.

This process is further complicated when breast cancer cells show up at the construction sites. Once they enter the bone marrow, breast cancer cells indulge their destructive natures and habitually sign on to the demolition parties, which just can't be a good thing. As I understand it, osteoporosis drugs, or bisphosphonates, work by interrupting the relationship between breast cancer cells and the osteoclasts. Doctors already use these drugs to treat metastatic bone cancer. The two-fold question being investigated in the clinical trial is, first, whether bisphosphonates will help to prevent breast cancer recurrence, as the European study showed, and, second, which drugs and dosages are most effective.

Elizabeth Edwards's story is a good case to consider. After her initial diagnosis in 2004, she underwent surgery, chemo, and radiation, although not necessarily in that order. Most women who follow this treatment remain cancer free. Three years later, however, she learned that her breast cancer had metastasized to the bone. The question for the researchers sponsoring the clinical trial is could she have avoided the involvement of her bones had she taken bisphosphonates in 2004 as an on-going part of her treatment?

Although I'm not completely sure of this, let's assume that diet and exercise can generate bones that are strong enough to inhibit cancer cells from entering them. That would be a real plus. However, in the event that a few cancer cells survived the chemo/radiation and did find their way into the bone marrow, it seems too late for diet and exercise to have any benefit. Since bone is the most common site for breast cancer metastasis, researchers are hoping that bisphosphonates will deter cancer cells already in the skeletal system from making it their second home.

Another point that you've raised in e-mails is the type of bone that bisphosphonates create. Because these drugs work by inhibiting the osteoclasts from breaking old bone down, the resulting bone may be denser, but it's also old and brittle. Bisphosphonates don't generate the new, flexible bones that osteoblasts build naturally, which may explain the problems that some women have experienced with their jaws.

Finally, I've been asked to consider the holistic effect of all of the forms of treatment I've completed or will eventually complete -- surgery, chemotherapy, radiation, estrogen suppressant -- plus the possible addition of bisphosphonates. What is the cumulative impact of all of this? This is a good question for the oncologist, but I'm not scheduled to see him again until the end of April. We will also do the bone scan, or DEXA study, then. Meanwhile, I'm moving ahead with the planning sessions to get radiation underway.

I still have a little time to think about the clinical trial, and I'm finding your e-mails and comments very helpful. Your questions are pointing me in new directions and giving me new angles to consider. It's no secret that I thoroughly enjoy delving into a topic, so keep the feedback coming.