Mets Day 555 – slowly hiking out of the chemo hollow

Mets Day 555

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Recovery from around 2 of the chemo has taken severely longer than around 1's recuperation. It's taken me 11 days to have self belif getting ready to an an identical edge that I became pretty neatly 7 days after the 1st around. I'm at per threat 40% of traditional. Climbing a pair of flights of stairs still will get me winded. Doing  else regarding bodily observe is troublesome. At least I can read for a similtaneously, not like inside the week after chemo in which the phrases would fail to penetrate my memory.
I have not yet determined no matter if I will go forward with around three. If I do, it is every now and then my final around this year. I'm almost genuinely not to do chemo in November and December. I'd a comprehensive lot reasonably appreciate what might additionally neatly also be one in all my final trip seasons in fairly judicious neatly being and spirits.

This weekend my oldest son, Spencer, is running his 3rd Tough Mudder. If you don't recognise what which will likely be, take a take a appear at the movies or read pretty neatly it — it truely is a four-five hour learn of staying power. I shake my head in surprise. I am amazed that anyone would voluntarily state of affairs himself to one factor like that. Maybe I dropped him on his head too constantly as a infant. Next month, he's running the Philadelphia Marathon — his second — with the target of elevating cost for the Chris Atwood Foundation. Chris became Spencer's judicious loved one that died formerly this year of a drug overdose. Spencer spoke eloquently at Chris's funeral. Spencer's fundraising web page for the premise is absolute best suited here — have self belif unfastened to  and donate highly countless dollars in order for you.

I am profoundly grateful that I can spend time with my circle of household, and that they with me. Each day that my life is prolonged is a offer from God, for which I source day to day thanks. Even now, it truely is basically too readily doable for me to permit that manner of gratitude slip away. Before cancer, I had so little comprehension how the proximity to death makes me so a comprehensive lot more grateful for one and all moment of life, with all of its little joys.

Mets Day 550 mouth sores and Mt. Baldy

Mets Day 550 mouth sores and Mt. Baldy

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I've been lethargic and listless for the earlier several days. The chemo drug cures have impaired the regeneration of lining of my mouth. It looks as if my mouth has been scalded. Yesterday we had been given some "magic mouthwash" — a routinely compounded aggregate of meds to make extra effective therapy the soreness. I swish and spit, and it numbs up the raw spots and deals me brief comfort.
For the previous couple of mornings my pillow has been awash in hair. Sleep has been tricky to come back by means of triggered by means of it is, and having my sheets and pillowcase lined in hair doesn't make extra effective. Yesterday morning I took a bathtub and watched as the drain clogged with a hairball extra than an inch thick. That's it, I determined. I grabbed the hair clippers and buzzed off all of my hair. I started with the number 1 attachment, then went with the bare clippers. I then lathered up my skull and attempted to shave the remainder of the stubble off. It's no longer as amazing as I concept it'd be. Each of the circle of partner and childrens contributors had been given a wonder as they had been given proper here in and noticed my bald head. Jennifer purely proper-naturedly helped conclusion the job, shaving these tricky-to-attain puts.

So now I'm getting used to being bald. It feels traditional while laying my head towards a chair, or while my skull is perspiring. On the simplest real hand, I'm flawlessly convinced I have no longer had been given to have my hair shedding over my delicacies or garments or pillow or bathe, nonetheless on every the significant hand, wasting my hair is a tangible reminder that my easiest cancers is inescapable.

Mets Day 547 hydration and hair loss

Mets Day 547 hydration and hair loss

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Yesterday I went decrease back to the cancer middle for 2 liters of saline, an anti-nausea drug, and the Neulasta enrich hormone booster shot. I attention on that the similarly hydration is assisting — I don't rather feel choice of as deficient as I did after the first around. I'm going decrease back this afternoon for an decision couple of liters.
I haven't have been given an lousy lot of an urge for nutrients. My kind buds attention on each aspect is moldy rainy cardboard. I'm on the complete consuming protein shakes.

Meanwhile, my hair is falling out by manner of the handful. This morning the shower drain gave the influence of a gerbil was once lying on it. When I combed my hair there has been a stunning choice striking from the tines. I'm presently debating irrespective of whether to permit it fall out by manner of itself time table, or irrespective of whether to source it an news. If there ever was once a time for one in all my youngsters to do a thing dull, here's it, so I can actual tear my hair out.

Mets Day 544 mild distinction of chemo plans

Mets Day 544 mild distinction of chemo plans

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Today my wellness practitioner informed me that she can not grant my request to excursion the ddMVAC chemo infusion into two days, as the cancer core is utterly booked and can not take another all-day infusion on Thursday. As a affect, I'm going to get all 4 medicines tomorrow, with excess hydration. Then I'm going to come back on Thursday afternoon, whereas there have got to be would becould all right be some chairs obtainable, and get more hydration, anti-nausea medicines, and my boom hormone booster shot. I'm furthermore scheduled to come back on Friday afternoon for far more hydration and anti-emetics if I want them. I'm designated that, by the end of the week, I'll be thoroughly sick of the vicinity.
My wellness practitioner thinks that the varying important functions why I changed into so burnt up by one of the a lot circular changed into that I didn't care for adequately hydrated. I knew I changed into intended to be guzzling fluids, on the other hand all I would tolerate changed into a sip at a time. I knew I changed into in a foul vicinity whereas i changed into turning down Diet Coke. Hopefully the excess hydration this week will news me shop away from the worst of the blahs.

Mets Day 543More chemo (reluctantly)

Mets Day 543More chemo (reluctantly)

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I quite despatched my oncologist the subsequent e-mail:
Dr. Aragon-Ching:

I've stumbled on to embody the horror and post to an added spherical of chemo this week. Let's unfold it over two days, as we discussed, and want that the added hydration will assistance ameliorate the fatigue. I'll plan on appearing up on the 2 Wed. and Thurs. at 8:30 am except for you advise but another approach. Please compare. Also, please order the Neulasta booster to be despatched to my condominium so Chelsea can inject me on Friday.

Let's additionally plan to have an added week among rounds two and three. This is the 2 for my sanity, and questioning that we've got a preferably suited deal of circle of kin amassing at our condominium each of the approach within of the middle of the last phrase week of October, and I'd ought to be feeling greater exciting than something stuck to the base of my shoe. That might perchance recommend that spherical 3 might perchance birth on Wednesday, October 30.

Many thanks,

Ken Brothers

'Nuff outlined.

Mets Day 529 Prepping for salvage chemotherapy

Mets Day 529

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Tomorrow morning I leap dose dense MVAC (or ddMVAC) chemotherapy. The objective of this chemo circular purely is hardly ever very to cure me of my optimum cancers. The doctors have made clear that they lack the capacity or skills to "cure" (because of this to location into remission for more than five years) metastatic bladder optimum cancers. There has on no account been a proven healing remedy for my kind of optimum cancers that may also be replicated with any reliability. It is wanted to appreciate the bounds of a treatment ahead of embarking on it. I get it.
Instead, the target of this job chemo is palliative, because of this to deal with and hopefully diminish indications, yet with out a healing intent. This kind of chemo additionally is pointed out as "salvage chemotherapy." The indications that this chemo is in quest of to keep up is the unfold of my optimum cancers to remote components — chiefly the so many lymph nodes in my torso, yet additionally to gradual the boom of tumors in different organs, extraordinarily my liver, lungs, bone marrow, and brain.

As I've recounted in my prior blog entries, doing this ddMVAC regimen at this factor is an competitive treatment, for three reasons. First, we're proceeding with out problems. We are not waiting till I have lymph nodes which are over 1.5 cm in measurement, that's the ancient threshold for measurable metastatic disorder. Doctors consistently want to wait till they see nodes or tumors of that measurement, so they'll be able to later measure them to see if the treatment labored. But it made no sense to me to seem ahead to the disorder to improvement ahead of we leap making an try and gradual its boom. It's like making an attempt ahead to weeds to solely take over a garden ahead of you apply a herbicide. Better to assault the weeds ahead of the roots get too deep.

Second, the recommendations that ddMVAC actually works purely is hardly ever very as robust as many doctors would like. There is some info that it may possibly gradual the construction of the disorder in up to 50% of patients, yet the literature additionally unearths that once the consequence (if any) wears off, the optimum cancers progresses quicker. Returning to my gardening metaphor, the ddMVAC herbicide may also gradual the boom of the cancerous weeds, yet whereas the herbicide wears off, the weeds grow quicker than ahead of. But if it slows the boom of the weeds for some length of time, then the chemo will have labored.

Third, ddMVAC carries with it the likelihood of a few imperative aspect effects. It is inclined to hurt my GI tract, sooner or later causing blisters to the mucosa layer on the internal of my lips, mouth, and throat. I'll potentially have the 2 constipation or diarrhea, or the 2, to boot as nausea and vomiting. I'll have fatigue and malaise. I'll be at danger for infections and fever. I'll potentially lose my hair. During this regimen I'll be walking on the ragged edge of toxicity, taking slightly not up to the dosage that would so weaken my body that an illness would be fatal. I can't guard taking the ddMVAC for more than six doses at a time, and 12 doses well-liked, in view that over time the chemo drug ideas are so poisonous that it may also kill me. The hope is that the chemo will have major of a prophylactic consequence that it be miles going to delay the added boom of the optimum cancers, yet not so an awful lot as to bring about a systemic crumble. My doctors have told me that they reflect onconsideration on that I will "tolerate the chemo well" and that they they'll be able to tackle these aspect effects, yet I'll be the simplest barfing and writhing on the ground in chilly sweats.

I'm going into this with my eyes vast open, opting for to space myself to the aspect effects in view that this treatment provides the surest danger for extending my existence. I have made clear to my doctors and beloved ones that I don't are making an attempt out to torture myself to purchase a pair of additional weeks of existence. In weighing the aptitude benefits in festival to the negative aspects, even supposing, I have concluded that ddMVAC does not rise to the level of torture. Maybe in a pair of weeks I'll modification my thoughts, yet for now, we're transferring ahead.

I've done a pair of subjects to arrange for my chemo. On Sunday, I began taking 500 mg. of ginger twice an afternoon to reduction lower nausea. My sister introduced to my interest an NIH-sponsored learn published very last year (link here), which concluded that ginger reduces acute chemotherapy-induced nausea whereas taken for six days together with each unmarried chemo cycle, commencing three days ahead of and going till three days after. There's no cringe to taking the ginger tablets, and I'll additionally be taking the anti-emetics. I'll additionally be taking Miralax on a on a daily basis foundation. I've been to this rodeo ahead of, and feature a purely a little greater theory on how to guard my GI formula in balance.

I had a baseline CT scan at NIH the day past. As I lay on the desk and felt the iodine sizzling my body and accumulate in my neobladder, I realized that this was my ninth CT scan in 20 months. It's historical hat now. One of purposes of the day past's CT was to see if it is going to detect a tumor in my liver. If so, we're going to potentially pull the plug on the chemo, as ddMVAC does not work well with liver tumors. Assuming the scan does not disclose a liver tumor, we're going to proceed. [After I at the leap posted this blog entry, Dr. Apolo emailed me the CT report, which did not detect any liver metastases or different enlarged nodes.] I'll have an commerce CT scan in December or whenever I cease this regimen, to see if my optimum cancers has unfold. If not, and dependent on how I tolerate the chemo, I may also have an commerce six rounds of ddMVAC early subsequent year. If it the disorder has progressed, then we're going to know that the chemo didn't work.

Dr. Aragon-Ching's nurse purely also referred to as to tell me that she wanted to do all 4 drug infusions tomorrow. This is choice from what she had told me formerly(the M drug on day one, and the VAC drug ideas on day 2), with no explanation as to why. I'll stumble on that out tomorrow morning. Tomorrow will be a protracted day, lasting 9 hours or more for the infusions, plus the blood work and port placement. I'll potentially absorb the laptop non-public computer and blog, and even I'll leap having a look at a glossy day miniseries. People have recommended Breaking Bad (teacher with optimum cancers does horrible subjects) or Mad Men (ad executives do horrible subjects) or House of Cards (politicians do horrible subjects). On 2d thought, maybe I don't are making an attempt out to watch oldsters doing horrible subjects. Yesterday I held my new granddaughter for purely about three hours. There are only a few subjects greater than that.

Mets Day 525I’ve made a decision to have ddMVAC chemo

For the beyond ten days I've collected wide latitude of an implemented lot of statistics about the treatment substitute probabilities for my spreading melanoma. I've spoken with three specially several oncologists about whether or not I need to have salvage chemotherapy, they customarily have in turn consulted with four other docs. Yesterday Dr. Apolo pronounced that she had consulted with two added docs, who agreed that ddMVAC was like minded, so the ultimate tally is 5 docs help dose dense MVAC, and two advise in festival to it. In addition, I have largely pointed out whether or not to proceed with Jennifer and Chelsea. I have prayed for solutions in, or at least convenience with, my resolution. Yesterday afternoon I determined to head forward with ddMVAC.
The themes that swung my resolution to head forward with treatment have been as follows: First, I trust the judgment of Drs. Apolo and Aragon-Ching. Although I additionally trust the judgment of Drs. Plimack and Steinberg, who've been advising in festival to treatment, I was as a cease result persuaded by overview of the literature, and in final outcomes of my cell conference with Dr. Apolo the former day.

Second, the reality that Dr. Apolo pronounced that she had examined the melanoma cells take from me right all by way of the biopsy a large wide latitude of weeks within of the beyond, and concluded that my metastatic melanoma was undifferentiated and greater competitive, delivered about me scale down payment the hope expressed by Dr. Plimack that my melanoma would in all likelihood circulate slowly by way of my physique. It appears to be love to be the classification of melanoma that, if unchecked, will circulate very rapidly by way of my physique. Doing nothing in all likelihood would make selected that I would latitude secondary tumors in a bunch of months.

Third, Drs. Apolo and Aragon-Ching strongly trust that they could furnish attention to ddMVAC with out the toxicities that have been standard 10 years within of the beyond, when 70% of victims ended up being hospitalized right by way of chemo. Dr. Apolo pronounced how she had been treating a bunch of victims who persisted to paintings, or garden, or in a the many method retain ambulatory. This helped persuade me that the 3 months of chemo in all likelihood doesn't be lost months, however that I would have the threat to retain a moderately typical agenda. Whiel I do now not predict the ddMVAC to be a cakewalk, I'm persuaded that I need to have the threat to retain away from hospitalization in final outcomes of the chemo.

Fourth, the upside of ddMVAC outweighs the downsides. The classic time for progression to full-blown tumors with out a treatment is 4-5 months. With ddMVAC, this could be over nine months, and 35% hit the 2-yr mark. While there could be no technique to prove whether or not ddMVAC sold greater time, need to that happen, it in all likelihood would now not relatively motive long run harm, principally since I'm moderately younger and in a the many method wholesome.

I've let Drs. Aragon-Ching and Apolo realise of my resolution. Dr. Aragon-Ching has got the approval of my policy cowl industrial website guests to proceed. I'll have a baseline CT scan by way of NIH on Monday afternoon, for the explanation that policy cowl industrial website guests balked at approving that. I am scheduled to have my first dose (the "M") starting on Wednesday, September 25. On Thursday, Sept. 26, I'll have the "VAC" doses. On Friday, Sept. 27, I'll have the Neulasta development hormone booster shot. Then I'll repeat the cycle for six times, or until eventually I have too many facet resultseasily (in reality mouth sores that retailer you me from swallowing). After I conclusion the cycle, I'll have an substitute CT scan to exercise routine what ameliorations there are from my baseline CT scan.

For now, I trust as I am headed back into the poisonous mire, poisoning myself to retailer myself. To (mis)quote younger Henry:

Once greater unto the breach, dear chums, in each single sector again;
Or near the cells up, make our melanoma lifeless!
In peace, there s nothing so becomes a grownup,
As modest stillness and humility:
But when the blast of chemo blows in our ears,
Then imitate the movement of the tiger;
Stiffen the sinews, summon up the blood
Disguise sincere nature with hard-favour'd rage;
Then lend the eye a awful detail;
Let pry all by way of the portage of the pinnacle
Like a brass cannon; let the foreheado'erwhelm it
As fearfully as doth a galled rock
O'erhang and jutty his confounded base
Swill'd with the wild and wasteful ocean
Now set the tooth and stretch the nostril wide
Hold hard the breath and bend up each spirit
To his full peak.

Mets Day 524Dose Dense MVAC Q&A

Mets Day 524Dose Dense MVAC Q&A

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In the past few days I have exchanged a pair of emails with Drs. Apolo and Aragon-Ching, and this morning I had a follow-up cell consultation with Dr. Apolo, on whether to proceed with dose dense (dd) MVAC chemotherapy. Following are my questions and their answers:
Q&A with Dr. Aragon-Ching of George Washington University:

Aragon-Ching Question 1: Dr. Apolo said that she changed into going to have my cancer sequenced. Could that proof supply any conception into whether dose dense MVAC (or probably a fate clinical trial) is most likely compatible for me?
Aragon-Ching Answer 1: I would defer to Dr. Apolo.

Aragon-Ching Question 2: You told me that you couldn't determine any proof comparing median overall survival of sufferers with mets BC who should not ever have dose dense chemo to those that do. Where may well I favor proof on those that are meant to not ever have any cure?
Aragon-Ching Answer 2: One part III trial comparing a salvage chemotherapy drug is understood as vinflunine (now not accredited throughout the US, this changed into primarily a European trial) changed into compared to what we call most unparalleled supportive care (no chemo) and the median overall survival changed into a bit over 4 months (hyperlink the following)

Aragon-Ching Question 3: The PET experiment confirmed there changed into questionable focal uptake throughout the right medial hepatic lobe. Does the risk of metastatic pastime throughout the liver support going ahead with dose dense chemo, or is it irrelevant as it is indeterminate?
Aragon-Ching Answer 3: The presence of recognised visceral disease is an antagonistic prognostic limitation, compared to just adenopathy alone … it'd support cure with chemotherapy.

Aragon-Ching Question 4: The 2001 glance at that you gave me ( ironically confirmed that sufferers receiving dose dense MVAC had a somewhat extra ideal response significance (sixty two% to 50%) and two yr survival significance (35% vs. 25%) than sufferers receiving fixed MVAC, nonetheless that there changed into no statistical difference in either the final survival significance, or time to progression of additional metastases. I'm having a troublesome time understanding these proof. Can you shed some conception on it? Also, that glance at changed into of sufferers who had now not formerly got platinum-primarily based therapy, so it appears much less applicable to me. Am I misreading it?
Aragon-Ching Answer 4: You are most achievable right in reading this…this changed into a neoadjuvant trial in sufferers on no account been taken care of with chemo (so this is now not technically applicable to you) nonetheless I wanted to offer you an idea-about what the regimen contained & its schedule (dose dense)and it changed into being compared tothe useful dose MVAC. Having said this, sufferers who cross via dose dense MVAC who have been formerly taken care of also can as a matter of truth present a expand to extra toxicities than what this paper is discussing.

Aragon-Ching Question 5: The 2012 glance at ( noticed throughout the industry changed into a sixty one% response significance, with 10% having a total response. Digging deeper into the proof, it appears that the confident prices are skewed by the inclusion of sufferers who didn't have far-off metastatic disease: three of the four sufferers who had a total response didn't have metastatic disease. For men and women folk with far-off metastases, the median time to progression changed into 4.4 months, and median overall survival changed into 5.7 months. These do now not sound very encouraging to me. Am I lacking it doesn't matter what?
Aragon-Ching Answer 5: This trial covered all sufferers with metastatic websites of diseasebut made no distinctionwhether they were far-off websites or now not.

Q&A with Dr. Apolo of NIH's National Cancer Institute:

Apolo Question 1: Dr. Aragon-Ching said that, if I changed into to proceed with dose dense MVAC, it is going to disqualify me from later clinical trials. You and I had discussed a ramification of feasible trials; would any of those be closed off if I proceeded?
Apolo Answer 1: You would nonetheless be eligible for my clinical trials if in case you have proceed with MVAC.

Apolo Question 2: Even if those trial were foreclosed to me, would you nonetheless put forward my proceeding with dose dense MVAC?
Apolo Answer 2: Yes, nonetheless they are now not

Apolo Question 3: You said that you were going to have my cancer sequenced. Has that passed off but, and in that case, does that proof supply any insights of what reasonably therapy or trial is some of the compatible for me?
Apolo Answer 3: I will follow up on the sequencing on Thursday when I meet with our pathologist. This also may well make a adjustments what you acquire after chemo nonetheless the panel is merely 50 genes, so the findings are constrained. Foundation medicine has a panel with 200 genes and I think policy cowl
covers this. I am not sure if I can send this out from the NCI with out a hassle because we dont handle policy cowl nonetheless most likely Dr. Aragon-Ching can, I will ask her.

Apolo Question 4: Can you aspect me to proof appearing median overall survival of sufferers with mets BC who should not ever have dose dense chemo?
Apolo Answer 4: I have connected some pivotal papers on first line chemotherapy for metastatic disease. Including the part 3 of (gemcitabine and cisplatin) GC vs MVAC (hyperlink the following) and the PCG (paclitaxel/gem/cis) vs GC (hyperlink the following). I have additionally including a retrospective report from France on sufferers that got ddMVAC after GC (hyperlink the following).

Apolo Question 5: The PET experiment confirmed there changed into questionable focal uptake throughout the right medial hepatic lobe. Does the risk of metastatic pastime throughout the liver support going ahead with dose dense chemo, or is it irrelevant as it is indeterminate?
Apolo Answer 5: If you do have disease throughout the liver then ddMVAC would now not be essentially the most unparalleled option of therapy with out a hassle because my objective is to have you in achieving a total response (CR) with the ddMVAC. The possibilities that you in achieving a CR are best with lymph node disease and occasional with liver disease. Chemotherapy for your environment is given for palliation nonetheless you dont have signs, this is Dr. Plimack's reservation. My objective is to a in achieving a CR which is basically full in 5% of sufferers with GC and 20% with ddMVAC when it is given as the primary chemotherapy to sufferers with metastatic disease. You will be given ddMVAC as your 2d chemotherapy BUT first throughout the metastatic environment. The French studied confirmed a CR significance of 10% with ddMVAC (for your environment). Patients that during achieving a total response have longer survivals. That being said ddMVAC has a main quantity of facet results and is troublesome to get via. I ultra acknowledge Dr. Steinberg nonetheless he is a urologist now not a medical oncologist. I consulted your case with Dr. Cora Sternberg the oncologist who constructed ddMVAC (I connected her customary handbook from 2001) (hyperlink the following) and she wholly is of the identical opinion with me.

Apolo Question 6. Your email notes that ddMVAC would now not be essentially the most unparalleled option if I have liver disease. Given the ambiguous results from the PET experiment, does it make sense to are making an effort to rule that out earlier than embarking on ddMVAC? How would I go about doing that?
Apolo Answer 6: The PET experiment is inconclusive. It's very had to tell from a PET experiment whether there is metastatic pastime throughout the liver, with out a hassle since the complete liver is scorching. We use CT scans to tell whether there is node enlargement or tumors throughout the liver. The PET experiment suggests that, if there changed into metastatic pastime for your liver, it is now not throughout the lymph nodes, nonetheless inside your liver. If a next CT experiment confirmed a tumor throughout the liver, then make express you now not proceed with ddMVAC, or make express you cease it if it changed into begun.

Apolo Question 7: Thank you for consulting with Dr. Cora Sternberg, who constructed the 2001 glance at. As I examine it, that glance at has a paradox. On the one hand, it confirmed that sufferers receiving ddMVAC had a somewhat extra ideal response significance (sixty two% to 50%) and two yr survival significance (35% vs. 25%) than sufferers receiving fixed MVAC, nonetheless nevertheless, it confirmed that there changed into no statistically essential difference in either the final survival significance, or time to progression of additional metastases. I'm having a troublesome time reconciling these proof, specially as additionally they can follow to my situation. Does this imply that there is a extra robust risk that ddMVAC also can supply a total response (CR) or partial response (PR) similtaneously I have the chemo, nonetheless once the far-off tumors present a expand to, the disease moves quicker, so my OS will be identical? Also, that glance at changed into of sufferers who had now not formerly got platinum-primarily based therapy; as we know, I failed GemCis, so I'm occupied with how applicable that proof is to me.
Apolo Answer 7: The glance at does have that paradox, and we wrestle with the proof. The studies imply that the costs of CR are enormously extra ideal with ddMVAC than with fixed MVAC or GC chemo, specially perioperatively. These proof support ddMVAC as a 2d line therapy. There hasn't ever been a part III clinical trial comparing GC to ddMVAC. We are commencing that now. The proof imply that median progression-unfastened survival for ddMVAC is 9.1 months, with fixed MVAC it is 8.2 months, with GC it is 7.4 months, and with out a therapy, about 5.5 months. Extrapolating from the studies, ddMVAC presents you your most unparalleled risk of CR or PR.

Apolo Question 8: The 2012 French retrospective glance at appears to divide sufferers into two organizations: adjuvant chemo and metastatic disease. While it noticed throughout the industry changed into a sixty one% response significance with ddMVAC, with 10% having a total response, it appears that essentially the most unparalleled results were obtained by sufferers who had adjuvant chemo nonetheless didn't didn't have far-off metastatic disease. For men and women folk with far-off metastases, the median time to progression changed into 4.4 months, and median overall survival changed into 5.7 months. Am I physical to positioned myself into the mets network, and expect a diminish likelihood of CR or PR?
Apolo Answer 8: You are one of many two organizations. You had confident nodes after your surgical therapy, nonetheless has now not spread systemically, and you had no far-off tumors. Looking at your cancer from the lymph node that we biopsied lower than the microscope, it changed into poorly differentiated, and as a matter of truth aggressive. It didn't have much of the tendencies of micropappillary bladder cancer. Instead, it looked like a tumor that we could in you to present a expand to right this moment. It doesn't appearance like a cancer that we could in you to be indolent, which implies that that it is going to present a expand to slowly.

Apolo Question 9: The 2012 taxanes glance at is provocative. Is adding a taxane into ddMVAC an option? Is there any downside to trying it?
Apolo Answer 9: Taxanes with ddMVAC is merely too poisonous and is now not an option.

Apolo Question 10: Boiling the entirety down, I'm attempting to favor whether 3 months of
feeling lousy similtaneously having ddMVAC goes to be worth it. If it presents 3 months of life to the returned finish, nonetheless I lose three months similtaneously handling the chemo, then it appears to be a wash, and without doubt now not worth it. If there is a economical prospect of having a total response and radically adding time beyond regulation, then it becomes extra pleasing. But if it is going to permanently weaken my immune machine and compromise my remaining time with little likelihood of fulfillment, then I'd fairly now not do it. Do you handle how I've boiled it down?
Apolo Answer 10: It's an only manner of in need of at it. You also can get 3 months or extra on the returned finish, or you also cannot. Don't pay too much realization to the French retrospective glance at on toxicities, with out a hassle because we have now discovered so much on the right manner to decrease the toxicities. I present 3 liters of hydration with the MVAC, so it may well take as much as 9 hours to procure the full chemo dose — 6 hours for hydration, 3 hours for the tablets. I the complete time stay away from sufferers overnight unless they live very vicinity. Many of my sufferers tolerate ddMVAC o.k.. Most nowadays, I gave 5 rounds of ddMVAC to a nurse who works on the NCI hospital. She saved working similtaneously having each circular, along side for circular 5, when she constructed mouth sores and couldn't consume. Another refreshing affected consumer lived on a farm and endured to paintings as a farmer similtaneously having the chemo. Each affected consumer is the varied. The simplest facet results are mouth sores, fatigue, and fever. You are relatively younger and in a the varied manner suit, so make express you have the aptitude to tolerate the ddMVAC well.

Apolo Question eleven: I remember that, on steadiness, you handle that the professionals radically outweigh the cons, that I'll get via ddMVAC, and have an only risk at either CR or PR for some amount of time. I'm unclear from the literature how long the CR or PR oftentimes lasts. It appears that, for some, it is only similtaneously the chemo is being administered, and once it stops, the disease comes returned like gangbusters. For a minority of other sufferers, it appears that the response extends beyond the period of cure. Is it sincere to claim that, in my case, there is now not any manner of understanding whether I'll have any favorable response, nonetheless that you handle that having ddMVAC is essentially the most unparalleled manner to expand my life similtaneously nonetheless preserving a favorable high quality of life?
Apolo Answer eleven: I would imply proceeding with ddMVAC with Dr. Aragon-Ching. You do
now not want to get restaged with Dr. Plimack, I can do it or Dr. Aragon-Ching can do it. Treating you with ddMVAC is essentially the most aggressive option. If it were me in you footwear, I'd do ddMVAC. If you favor now not proceed with the chemotherapy that's OK too, it as a matter of truth it's a non-public range.

Mets Day 522My GW Oncologist says do ddMVAC chemo

This morning Jennifer and I met with Dr. Aragon-Ching, my medical oncologist who supervised my GemCis chemotherapy between January and April 2012. She had received the total main factors about ultimate month's CT scan from Fox Chase, and my PET scan and biopsy from NIH. She furthermore had exchanged a chain of emails referring to my cure with Dr. Apolo (NIH), Dr. Plimack (Fox Chase), and Dr. Steinberg (U. Chicago). She furthermore had a telephone convention with Dr. Apolo, and had accrued the enter from an additional three doctors.
Dr. Aragon-Ching reviewed what we already knew: my neoadjuvant GemCis chemo had failed; I had pathologically confirmed metastatic online game as of May 2, 2012; it had taken 15 months for a scan to detect distant metastatic online game, which had been demonstrated by my biopsy. However, since the node turned into no longer bigger than 1.5 cm on its transient axis, I failed to presently have "clinically magnificent" distant metastatic online game that could qualify me for optimum medical trials. She noted that, the early detection and confirmation of my distant metastatic online game turned into on condition that I had been so proactive in my cure.

At this level, the question is no matter if or to no longer have any medical therapy. Dr. Aragon-Ching reiterated what I already knew: there may be not any recognized option to cure metastatic bladder melanoma. Unlike assorted the one of a kind cancers, harking back to breast melanoma or lymphoma, there may be not any proof that any therapy can put mets BC into remission. Thus, any cure for mets BC can no longer be considered therapeutic, yet palliative (e.g., relieving or soothing the signs of the melanoma without effecting a cure). The crisis is no matter if or no longer the reward of the proposed therapy are definitely well worth the risks.

She noted that, at this facet, on condition that I don't have sufficiently significant metastatic nodes, or distant solid tumors, the ideas boiled the total way down to both having "2nd line" chemotherapy, or doing nothing for now. Second line chemo refers to a 2nd effort at a amazing chemo routine after the favourite chemo turned into attempted and failed. It furthermore is is named salvage chemotherapy. In her opinion, if I turned into going to have any therapy at this facet, the optimum logical exchange turned into dose dense MVAC. This is a 4 drug chemo which is given each two weeks, with fewer dose delays and fewer toxicity. The "M" drug (methotrexate) is given on Monday, the "VAC" drug cures (vinblastine, doxorubicin, and cisplatin) on Tuesday, on Wednesday I'd get a Neulastia shot (a boom hormone), then I'd have 10 days to get nicely before I do it some other time. If I turned into to attempt this, she'd put forward beginning with 6 cycles over 12 weeks, and spot how I'd tolerate it.

She said that the arguments for proceeding with dose dense MVAC chemo at this facet have been as follows: 1) there turned into assorted proof that dose dense MVAC had a successful outcome on patients who earlier had failed GemCis chemo; 2) my distant mets melanoma turned into small, and my melanoma burden low, making it more most in all chance that it would possibly presumably presumably respond to chemo than later, whilst my melanoma burden turned into better; 3) I turned into particularly sturdy, had no the one of a kind co-morbidities, and should always have the strength to tolerate the chemo. She correctly said that there turned into no established proof that dose dense MVAC would work in my instances, and said that she turned into making her advice truthfully founded upon her personal philosophy and adventure. She furthermore said that Dr. Apolo had come down on the side of proceeding with dose dense MVAC, although her advice turned into a comfortable "yes", no longer an emphatic one. Dr. Aragon-Ching likewise said that her personal advice turned into in some approach to weighing the totality of the instances. I turned into reminded of my criminal practice and burdens of proof, and acquired the impression that, for her, having me proceed with chemo exceeded the preponderance of the proof principal, yet in all chance didn't meet the refreshing and convincing proof, and definitely didn't meet the beyond an can fee-green doubt principal.

Knowing that I appreciated to dig into the literature, Dr. Aragon-Ching gave me two articles to study approximately dose dense MVAC. The first article, titled Randomized phase III trial of immoderate-dose-depth methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) chemotherapy and recombinant human granulocyte colony-stimulating element versus classic MVAC in advanced urothelial tract tumors: European Organization for Research and Treatment of Cancer Protocol no. 30924, is the first leading examine about that whilst put next typical MVAC to dose dense MVAC. It's a European examine about printed in 2001 in the Journal of Clinical Oncology. The examine about paradoxically confirmed that patients receiving dose dense MVAC had a a chunk of better response fee (sixty two% to 50%) and two year survival fee (35% vs. 25%) than patients receiving typical MVAC, yet interestingly, there turned into no statistical difference in both the general survival fee, or time to progression of additional metastases. The examine about extrapolated that patients receiving does dense MVAC have been 25% much less most in all chance to relapse or die than MVAC patients.

The 2nd examine about a 2012 retrospective examine about printed in the European Journal of Cancer titled Accelerated MVAC chemotherapy in patients with advanced bladder melanoma earlier handled with a platinum-gemcitabine routine. It checked out information of forty 5 patients who had received dose dense MVAC. It discovered there turned into a 61% response fee, with 10% having a entire response, yet also appearing that 69% of patients had vitally important toxicities, and 10% died due to the chemotherapy. Digging deeper into the primary factors, it appears to be like that the successful charges are skewed by the inclusion of patients who failed to have distant metastatic ailment: three of the 4 patients who had a entire response failed to have metastatic ailment. For men and women with distant median time to progression turned into 4.4 months, and median overall survival turned into 5.7 months. Ugh.

To her immense credit, Dr. Aragon-Ching explained that proceeding with dose dense MVAC at this facet turned into an competitive cure, and that ready turned into the optimum conservative option. The arguments for ready, she said, have been that 1) my ailment had progressed particularly slowly (15 months from regional mets to distant mets), and that it would possibly presumably presumably proceed to pattern slowly; 2) there turned into no established proof that any 2nd-line chemo would both cure, or postpone, the progression of the melanoma; 3) the side effects and risks of the chemo have been immoderate; and 4) proceeding with a 2nd chemo routine would possibly also later disqualify me from medical trials. She said that Dr. Plimack and Dr. Steinberg both had definitely priceless conserving off on chemo.

Dr. Aragon-Ching addressed each single of these arguments worldwide our discussion. She said that the sluggish progression of the ailment cut down both methods, noting her reports re relative melanoma burden. On the no established proof, she said that the sole main factors she had turned into from the two research that she gave me, and her personal personal bias and adventure. On the side effects, she turned into self-assured that they is in all chance controlled and tolerated. On the probable disqualification of medical trials, she said which are in optimum cases no longer be a deciding element, since medical trials wee more for the analysis than actually supporting the victim.

I requested her of the general survival for patients receiving dose dense MVAC vs. no cure. She said that there not at all had been a Phase III medical trial evaluating the two, and would possibly also no longer give that main factors. I furthermore noted that we had a new kid in he rental, and no matter if both her or I could be at multiplied danger due to the chemo. She said that there turned into no danger for the child, yet since they is in all chance little germ magnets, after i turned into doing chemo, I should always love to dodge the child if she turned into sick.

So the bidding stands at two doctors for dose dense MVAC, and two doctors in the direction of. I told Dr. Aragon-Ching that I compulsory to study the literature, and go ahead with my appointment at Fox Chase on October 1. She understood my warning and supported my determination to have a smarter scan. She said she would confirm that my policy cowl would pay for the dose dense MVAC, yet does no longer time table me for cure until I gave the go ahead.

When I acquired here domestic, I discussed these conflicting methods with my daughter, a fourth-year medical college pupil. She acquired here up with the next questions: 1) Are there any main factors evaluating the median overall survival charges of these receiving dose dense MVAC vs. no cure? 2) Could NIH's DNA sequencing of my melanoma give any insights referring to strength cure alternate possibilities? For example, if the sequencing suggests that designated cures of medical trials is in all chance constructive, does it make highly feel to go ahead with dose dense MVAC if that would also later preclude participation in the ones trials? Good questions; I'll look at up. I'm furthermore going to do assorted more finding out and spot what else I can locate.

I'm no longer going to decide until after I meet with Dr. Plimack on October 1. For now, I'm no longer persuaded that dose dense chemo will provide a better cash in. If it buys me three more months at the again conclude, yet causes me to be sick for 3 more months now, is that well worth it? Probably no longer.

Mets Day 520 – Officially a Grandpa

Mets Day 520 - Officially a Grandpa

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Yesterday afternoon my 25 year historic daughter, Chelsea, gave start to her first newborn, and my first grandchild. My granddaughter is has a acceptable head (of route), a strange cry, and a piercing stare. All is nicely with every frame fascinated.
Chelsea and I had agreed that all over the worldwide the accurate shipping, much productive the health and wellbeing care expert, her husband, and Jennifer would possibly desire to be existing. I sat throughout the room having pointed out that on on every frame the one of a kind portion of curtain, and listened, as the health and wellbeing care expert was once giving commands, Jennifer was once counting, Josh was once reassuring his spouse, and Chelsea was once alternating between pushing and catching her breath. I had a quiet dialog with God as this went on for about an hour. I released that, in some strategies, the curtain was once like a veil conserving apart me from my relations. I could maybe just presumably sense their presence, send my prayers and faded and love to my daughter, and documents the celebration, having pointed out that I was once now not physical existing.

Death is presumably like this, I accept as authentic with. My soul, and all that I am, will proceed on. I is barely now not physical existing, having pointed out that still is presumably of their presence, is presumably waiting to send my prayers and faded and love to my relations, and documents their delight and sorrows. As Sullivan Ballou wrote to his spouse the week beforehand he died throughout the first clash of Bull Run, "I shall basically be close you; throughout the gladdest days and throughout the darkest nights . . . basically, basically, and if there be a cushy breeze upon your cheek, it will likely be my breath, as the cool air followers your throbbing temple, it will likely be my spirit passing as a result of. [D]o now not mourn me dead; glance at I am gone and watch for thee, for we'll meet over again."

Holding my granddaughter, I felt exquisite delight and rejoicing in my posterity. The subsequent generation of my relations has started. Life keeps on.