Treatments 19 - 22

Last week was very similar to the one before, with the exception of having Wednesday off for Christmas. I did have a treatment on Christmas Eve. My radiation oncologist, Dr. Langer, was off last week, so I saw Dr. McMullen on Tuesday. I told him about the irritation at the radiation site. He checked me and wasn’t concerned with what he saw. I also told him about the bladder irritation and he prescribed a medication for that. The bladder irritation wasn’t as bad at that time as it had been the previous weekend. I delayed taking the medication until yesterday. The rash got worse during the week and I have alternated between hand lotion and petroleum jelly on the site, but neither seems to help. I will tell Dr. Langer when I see him this week.

Since I only had one day off from the radiation treatments, Mom came here for Christmas. It was good to visit with her – our first time together since Thanksgiving. She got to see that I really was doing as well as I had told her.

I expect this week to be more of the same with respect to the treatments. I will meet my new medical oncologist today and will probably see Dr. Langer on Tuesday. New Year’s Day provides another mid-week break from treatment, although at this point I would like to have that treatment and be one day closer to the end.

Treatments 14 - 18

This is starting to get boring – the blog, that is. The third full week of treatment was like the second. I feel about the same. Over this past weekend I noticed a little irritation at the site where the radiation is given. That’s normal. I alternated between lotion and petroleum jelly on the area. There is a medicated gel that can be prescribed. It also seems my bladder is irritated. This is common for organs near the radiation site. The sensation is similar to a bladder infection. I check my temperature daily, as directed by one of my doctors, and it has stayed between 98.0 and 99.0. I don’t think there is an infection since my temperature is normal and irritation of the bladder in particular is common during radiation for rectal tumors. I’ll let my radiation oncologist know about both issues during my next visit.

There was a bit a bad news during the week when I was told my medical oncologist, Dr. Clark, had broken her arm and would require surgery. Then I was told she had previously informed everyone she would be leaving. Work had already begun to assign her patients to other doctors, but her broken arm has accelerated the transition. Dr. Clark is my favorite doctor among those I have encountered this year. An appointment with her is much like a visit with a friend. She is genuinely interested in all aspects of my health and asks lots of questions. I will certainly miss her. A lot of the people I met with during the week knew her and had similar feelings.

Treatments 9 - 13

The second full week was much like the first with respect to side effects. Over the weekend I felt as well as I did last weekend, if not a little better. I’m starting to get self-conscious because of the lack of problems.

I saw my medical oncologist, who I see once every two weeks, on Monday. She is happy with my current condition. One especially encouraging note is that she said patients who experience serious side effects during their treatment show initial signs by the point at which I was then. I realize that doesn’t mean I won’t have any problems, just that the probability of serious problems is small. I assume that as I progress further without problems, that probability decreases more. At least I have convinced myself of that.

On Wednesday I had my weekly appointment with my radiation oncologist. He also is happy with my condition. He has the results of my blood tests each week and informed me that my hemoglobin count rose again. It’s still short of the normal range, but is well above its level in July when my anemia was diagnosed. The radiation will cause it to decrease at some point. I hope it is no time soon.

It’s great to have nearly reached the halfway point of my treatment and feel this good. I don’t expect the second half to go this well, but I have hope that it will not be too difficult.

Treatments 4 - 8

The first full week of treatment was incident-free. Wednesday night I felt sleepy earlier than usual and went to bed about thirty minutes early. I did the same on Thursday night. Late in the week I also experienced an increase in stomach gas, which probably is unrelated to either of the treatments. However, with the possibility of nausea, it made me feel a bit uneasy. I have since read that the mere anticipation of nausea and vomiting is a common problem during chemotherapy and can cause it.

The radiation treatments were a mixed bag. Monday I was greeted by a different team than usual. It shouldn’t be a big deal, but even after only two days with the other two technicians I had started to learn their routine. On Tuesday I was a few minutes early and had to wait about ten minutes after changing into a gown. I was finally greeted by yet a different pair of technicians. Unlike my previous visits, they had not set up the table in advance so I had to wait a couple more minutes after getting into the treatment room. That’s when I really missed my usual team.

On Wednesday the regular crew was back and I was happy to see them. Unfortunately, there were problems getting me positioned correctly on the table. About half the time after getting me positioned with the laser lines and then taking an image, someone will come back in the room and make a slight adjustment. Wednesday, someone came in twice to make adjustments. Then both techs came back in and said they couldn’t get it right and had me get up while they checked and repositioned the molds. We started over and it worked after that. They said sometimes something is off and the only way to remedy it is to start over. The sessions on Thursday and Friday went much better.

I am relieved to get through a full week with no significant problems. Having finished eight out of twenty-eight treatments means I am past the one-quarter mark. I know the last quarter will be harder than the first, but it’s that much in the rear-view mirror.

First week of treatment

Okay, so it was only three days of treatment and I didn’t start the chemo drug until Monday night (doctor’s order), but it’s a milestone. I didn’t have any negative side effects. There were a few stomach growls and odd feelings or twitches during those three days that made me wonder. However, it was just my mind searching for something to happen.

As expected, the first radiation session took a while. The same two technicians who handled the simulation were there along with two other people. I wasn’t sure if they were the same as the last time. They spent what seemed like a lot of time getting me in the proper position. I never felt I was properly in either the upper or lower molds. Since I was face down, I couldn’t know for sure, only that it didn’t feel right. They did get me in the position they wanted and said everything lined up correctly. After that they gave me my first treatment. I think I was in the treatment room a little over a half hour.

For my second treatment I only had two technicians and they were not the two I had worked with previously. Also, we were in a different room. I really like the two “new” technicians. The woman who seems to be in charge explained the process and told me I would see them and be in that room for the rest of my treatments unless a problem occurs. The second and third treatments went much faster than the first and I felt I was properly in the molds. Once in the proper position a treatment still takes around ten minutes or so. I think the actual radiation takes just two or three minutes, but they have to get some images first.

The chemotherapy isn’t a big deal since I am taking tablets rather than having to get it through an IV. I take three 500 mg Xeloda tablets after breakfast and three more after dinner on the days I have radiation treatments. At this point, it’s like taking any other medication.

I am happy with the way the first three days of treatment went and the fact that I felt fine afterward. That gives me confidence going into my first full week. I believe I have a very good chance of getting through it with no, or few, problems.

Treatment begins

Treatment starts tomorrow. I am happy to get started. It seems strange to feel that way, given all the possible side effects that can occur. However, it’s the real beginning of the process to being cancer free. I do feel some apprehension because so much ahead is unknown. The list of possible side effects from the chemo drug (Xeloda) is long. Instead of the list, someone could have just written “Anything you can think of and a few things you never would have”. In addition, different people experience different side effects at different times with varying severity. Some even make it through will very few problems. I don’t expect any problems tomorrow or any day this week. I do expect something sometime. I don’t know what it will be or when it will happen. That is what is causing my apprehension. But for now, let’s just get it going.

Simulation

After dealing with everything involved in the ultrasound, it was nice to have a relatively simple procedure. I arrived at the radiology department before 1:00 on Thursday of last week to begin the prep. One of the technicians came to the waiting room and gave me two medicine bottles filled with an iodine-based contrast solution for my GI tract. I had to drink one then and the other thirty minutes later. It had a sort of fruit flavor – not too bad, but not too good either – and it made my tongue bright red.

The technician came back for me just before 2:00 and took me to the CT room. After I partially undressed, he, another technician, and two other people who I assume were students came into the room to help get me situated on the table. Dr. Langer, my radiation oncologist, came in a few minutes later. One technician inserted an IV catheter in my right arm for an IV contrast solution that would be given during the procedure. Next I had to lie on the table, face down, with my upper body on a hard, square doughnut sort of thing. The purpose was to let my stomach hang down through the opening, which would pull the organs in that direction and away from where the radiation would be aimed. It wasn’t comfortable, but it was bearable.

The technicians took some time to get me positioned properly and create molds so I will be in the same position each time I have a treatment. The molds were large plastic bags with some sort of material inside. One of the guys called them bean bags. When I was in the position they wanted and that I could live with, they removed the air from the bags and depressions were formed where my arms and legs were. After that, they sent me through the CT scanner twice; the second time with the IV contrast solution to show my circulatory system.

Small marks were made on my body for reference points. There is an X on each hip and a vertical line below the base of my spine. Round, clear bandages were placed on each mark to help preserve them. With those marks, the body molds, and the fiducial markers inside me, it seems there shouldn't be a problem getting everything aligned.

My treatment schedule should be set in a week or so.

A bit of good news

It’s not often that stage II cancer is good news, but when there is a chance you have stage III, it is. The CT scan conducted in early September indicated five or six lymph nodes were inflamed. Dr. Arshad, my gastroenterologist in Bowling Green, said the CT scan didn’t provide the detail necessary to determine if the lymph nodes were inflamed because of the presence of cancer, an infection, or something else. Last Thursday’s endoscopic ultrasound indicated there is only one, 2 millimeter lymph node considered to be abnormal. There is a small chance it is malignant. One rectal cancer study found that lymph nodes of 1 to 2 mm had a 9% malignancy rate and lymph nodes of 2 to 5 mm had a malignancy rate of 17%. The odds seem more in my favor than I thought two months ago.

The procedure included the placement of six, gold fiducial markers as mentioned in my previous post. They are very small – the diameter of a small mechanical pencil lead and less than one-quarter inch long – so the monetary value of my body did not increase significantly. My hope is they will greatly increase the accuracy and efficacy of the radiation treatments.

The prep prior to the procedure went well. I got through Wednesday’s fast on sweet tea and Pepsi. There were only a few times my stomach made noise. Mid-afternoon I took four Dulcolax tablets and around 5:00 started drinking the MiraLax solution. The worst of it was over before 8:00 and I slept well that night. Thursday morning I started the other half of the solution shortly after getting out of bed, even though the directions said I didn’t have to start until 10:00. I wanted to get it over with well before going to the hospital. I never felt especially hungry or weak. I did drink some Gatorade, which may or may not have helped.

After the Propofol wore off, about the time Mom and I got to Denny’s for an early dinner, I felt fine. I ate too much, but the double cheeseburger I ordered looked and tasted very good. My stomach grumbled afterwards for a while probably due to the shock of all that beef after having nothing for about 45 hours. However, I made it through the night with no problems as a result of the dinner or the procedure.

Fasting again

On tap tomorrow is the endoscopic ultrasound. The prep and the procedure are much like a colonoscopy. The procedure will be in the afternoon, which means I have to fast all day Wednesday (liquids only), take four Dulcolax tablets mid-afternoon, and do half the prep (MiraLax) late in the afternoon and into the early evening. Thursday morning I will do the other half of the prep. My colonoscopy in September was early in the morning and fasting and doing the prep the day before wasn’t a problem. I expect this will be a bit more difficult from the standpoint of having to fast for more than a day and a half. Doing without even one meal is not something I like to do.

This ultrasound is being done to get a better look at the rectal cancer. By using an endoscope with a transducer on the end and placing it adjacent to the lesion and the wall of the colon, a more accurate picture can be obtained than is provided by a CT scan. It is also possible to view adjacent organs and, especially important in my case, nearby lymph nodes. The resulting images will be used with next week’s CT scan (the simulation) to design the radiation treatment.

In addition to the normal endoscopic ultrasound, I agreed to participate in a clinical trial that entails placing small, gold markers (fiducials) near the tumor during the procedure. The expectation is that the markers will help the radiologist better aim the radiation treatments. Traditionally, small marks are made on the body with permanent ink to serve as reference points. Those marks can move relative to the tumor, especially as the body changes over the course of treatments, so they aren’t exact. I will still get those external marks, but the fiducials will provide additional references. I thought that if it helps aim the treatment, it’s a benefit to me. Also, since it is being done as part of the ultrasound I was having anyway, it doesn’t add another procedure or any inconvenience on my part. It only adds about ten minutes to a procedure that was forty-five minutes to an hour long.

I started my pre-prep Monday night by eating a sweet potato for dinner – no meat. Throughout Tuesday I ate low fiber foods; again, no meat. My hope is that will make the prep easier. Being limited to clear liquids all day Wednesday with the prep not starting until late afternoon will be especially challenging. It is interesting that the list of “clear” liquids includes broth (which I do not like), coffee and tea without cream, and Coke and Pepsi products. Tea and Pepsi will be most popular with me. Gatorade is highly encouraged. I can tolerate it and will make myself drink some to get the electrolytes, but it isn’t especially appealing.

My next post will report on how the prep and procedure went. At least the likelihood of some sort of surprise during the procedure, like finding cancer during the colonoscopy, is very small.

First radiation oncologist's visit

After a much-too-lengthy delay, I was able to see a radiation oncologist last Tuesday. I had started a blog post about the ordeal to get to that point, but it was too long and turned into a rant about unreturned calls and other problems experienced during the process of finding a doctor and getting an appointment.

I first saw a resident, Dr. Hansen, who went through my history and performed a general exam. She used notes, but she undoubtedly was familiar with my history. After finishing, she left for a few minutes and came back with Dr. Mark Langer. He seems a bit quirky. He didn’t offer to shake my hand. Just after he came in, he said he knew who I was, but wanted me to say my name to him. It’s not a strange name, so that seemed weird. He also went through some of my history and seemed familiar with it. I then had to get into a gown so he could feel my lymph nodes and perform a rectal exam. In the last two months I have had a colonoscopy and CT scan of my entire colon and a sigmoidoscopy of my rectum – records of which he had. Dr. Langer had also stated prior to this that he wanted an endoscopic ultrasound to get a better look at the tumor and to better map it for the radiation treatment. With all of that, why would an old-fashioned digital exam be necessary?

Another thing that bothered me was Dr. Langer’s negative attitude. He heavily stressed the side effects of the chemo and radiation. I know he has an obligation to be sure I am aware of them, but he provided little hope of getting through treatment with minimal problems, unlike Dr. Geiger at Vanderbilt. He prefaced his comments with the fact that everyone reacts differently and he didn’t know the type of chemo or amount of radiation I would receive. However, when going through the side effects told me I would likely not be able to work a full day by the third week of treatment. He also asked if Dr. Geiger had told me his plan for the surgery. I told him the plan and said I had been given the option of leaving a portion of the colon in place or removing it completely. Dr. Langer said he was surprised Dr. Geiger would be able to offer that option. Again, the majority of his comments were negative.

Dr. Langer also said I would have to see a medical oncologist to supervise my treatment. Since Dr. Geiger specifically told me to see a radiation oncologist, I thought he could also oversee the chemo or could consult with Dr. Geiger and his associates on their treatment plan. Obviously I was wrong. So, today I see a medical oncologist. Hopefully I am getting closer to beginning treatment.

First specialist's visit

I met my surgeon, Dr. Timothy Geiger, at Vanderbilt University Medical Center last Thursday (September 19). Technically, he is not an oncologist. However, his practice is in Vanderbilt's Ingram Cancer Center and, since he limits his practice to colon and rectal surgery, much of his work is with cancer. Mom and Dan went along to provide support and help take in all the information. I like Dr. Geiger a lot and feel very comfortable with him guiding my treatment. Mom and Dan feel the same.

The visit provided some new details and his recommended course of action over the next few months. The rectal cancer is near the mid-point of the rectum; thankfully, not the worst location. The colon cancer is at the opposite end of the colon. Dr. Geiger did not provide an indication of the size of the growths or their severity. I didn’t ask. Frankly, I didn’t think to ask and I don’t think it matters at this point.

His recommended course of action has to be presented to a panel of other doctors, which he expects to occur on Tuesday. The recommendation is six weeks of radiation and chemotherapy. Most folks can tolerate the type of chemo used in this situation and I should be able to work while undergoing it. Then there would be a break of up to six weeks with no treatments. During the break, the radiation and chemo I previously received will continue to work. After that, surgery will be performed to remove the two growths and the necessary portions of adjacent colon. The hospital stay is usually four to six days followed by three weeks of recuperation at home. It will be necessary to have a temporary ileostomy while the colon heals. That will be reversed.

The visit with Dr. Geiger didn’t provide any great surprises. I’ve already thought the worst regarding chemo and surgery, so some of his comments were a relief. More than anything, it is good to have a map that shows the road ahead and someone I trust in the driver’s seat.

Shocked

It has been two weeks and a few days since I had my upper GI endoscopy and colonoscopy that revealed the presence of colorectal cancer. Even though follow-up tests were required the following day to provide confirmation, my gastroenterologist seemed confident. I had chosen him based on Mom’s past experience with him and her trust in his work. I didn’t have any reason to doubt his diagnosis other than the idea that I shouldn’t have cancer. The follow-up tests – CT scan and blood tests – confirmed the original diagnosis.

Even with the passage of two weeks, I still don’t know how I feel or what I should feel. This is a shock. There is very little incidence of cancer of any type in my family. Heart disease is the common problem on both sides. I am relatively young; just a few months shy of 50. I have never smoked and have drunk very little alcohol in my entire life. I’m not overweight. I eat a sensible diet, not perfectly healthy, but low in fat and the other bad stuff. I don’t exercise as much as I should, but I in recent years I have been walking fairly regularly. After giving me the confirmed diagnosis, my gastroenterologist said that sometimes a person can do all the right things and still get cancer.

This Thursday I will see an oncologist and hopefully will be told a recommended course of treatment. I haven’t done much research, but enough to know that surgery, chemotherapy, and radiation are often used depending on the type and severity of the cancer. The likelihood of having all three at some point in the next few months seems strong. I just want to know what is ahead and when it is going to happen.