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.