Chemo 10 of 12: Uneventful

Yesterday was chemotherapy session 10 of 12.   I officially have 1 cycle left, or 2 doses of chemo, as well as the fun of riding out this week.


All this comes after a great weekend.  I felt good, and we did a lot.  I got in several bike rides, including a road ride with Sarah and her (our) new club.  We had dinner at "The Pub" at Boulder Beer, which is one of our favorites.    We also had a terrific time at a BBQ with some of our friends.  


Chemotherapy yesterday was completely uneventful for a change.  We got there plenty early just in case we had port problems.  Luckily, we did not.  So, I had my blood drawn and then had an hour to go to Starbucks for my new favorite:  An Iced, skinny, decaf latte.   Why is this my favorite now?  Iced because of the weather, skinny because I drink skim milk anyway, and decaf because it actually then counts as a positive instead of a negative on my fluid goals for the day.  I've been drinking this more and more lately.    Back to the infusion center....


Chemo went pretty fast.  My nurse even increased the rate on the dacarbazine in a trial to see if I'd notice anything since we hadn't ever changed that since getting the port.  (So far, so good!).  We were done before 3pm, and that left us time to head over to Coors Field since Sarah wanted to look for some Rockies tickets.   We picked up Lucy from doggie day care and went home.


Last night was pretty uneventful too.  I didn't take my usual nap, but the chemo fog started earlier than normal.  I basically just watched some TV and Sarah brought me a salad from Chili's To-Go.  After that I went to bed.


Although chemo fog was worse last night, it was less today.  I didn't sleep well, but I'm not so tired.  I definitely had the fog when I woke up, but I'm a little more clear as I type this.   I'm even debating whether or not I can/should ride with my bicycle club this evening.  We'll see as the day goes on.


I haven't had any pics in a long time, so, I figured I'd share how much Lucy has grown.

We are also getting in many more walks lately due to my feeling better, and due to how great the weather has been lately.  Hopefully this continues and soon I can progress into running with her!

A borrowed post: What you can do for me

Today's post is a little different because I'm not going to write it, I'm going to plagiarize it.  (I did get permission, though).


George is a kindred spirit fighting Hodgkin's Lymphoma as well.  Like myself, he lives on the front range in Colorado and loves cycling, and he has a blog, which I follow very closely.   He recently had a post which I thought was absolutely terrific and I asked if could share it and post portions from it on my own blog here to which he graciously said yes.   The link to the full blog is here called "What does it feel like to have cancer? and the call that saved my life."  


This is a great post in two parts.  I really enjoyed reading "What does it feel like to have cancer?"  My experience was a little different, which is what makes these stories interesting to me.   However, what I really want to focus on is the second part, which I'll quote, since he wrote it far more eloquently than I could have.  Truthfully, this train of thought never even occurred to me.

Many people have asked me over the last 2 1/2 months what they can do to help me. It's taken me a while to figure out a good answer but it occurred to me this week. So here it is:

The best thing you can do to help me is to promise me that you'll be diligent about getting regular diagnostic exams. Some of these exams are a bit uncomfortable and invasive (for both men and women!) so I know that there's a tendency to skip getting your check-up when you're feeling great. But feeling great isn't a guarantee that everything is all good inside you.  And you're making me a promise to do this - right? Talk to your care giver and figure out what the current best practice is because guidelines on diagnostics do change over time based on research and of course your personal history - family history, age, etc. It would really make me feel good to know that one of the benefits of this journey I'm on is that a bunch of people I care about are taking care of themselves and  if there is something wrong, they're getting the bad news early, when the cure rates are higher and the treatment course less obnoxious. My journey through cancer so far has been much easier than many other people, but I can tell you this - I would not wish this experience on anyone. Forget the wisdom, forget the renewed joy in living each day to its fullest. I'd much rather have had no illness, be healthy every day until I was 85 or 90 and then die quietly in my sleep.

So that's my request for your help. It takes some discipline because I'm expecting you to do this year in and year out. Getting one exam and then being a slacker doesn't cut it! You'll know if you're holding true to this promise and I expect you will do this - for me, for you and for your family.

Like I said, this was expressed better than I ever could have, and when I asked if I could share it, his response was as follows:

On the “what does it feel like to have cancer” front – yeah, feel free to make references, steal text verbatim, whatever. I would LOVE to think that somewhere down the road we helped someone get diagnosed early rather than later with some problem. Anything I can do to contribute to that – sign me up. 

I couldn't agree more with all of this.  I've learned an awful lot going through cancer, mostly about myself, but like George, no one wants these lessons and I'd give them all up in a second.   I truly hope that in some small way posting this request prevents someone else from having to deal with this, or at least lessens the seriousness of any potential issues.

Drugs 5: Drug Interactions

Drug Interactions is one of the first things I look at when I look at a patient's profile in the Infectious Diseases clinic.   While I have looked at my own before, it was well after I started on all these medications.  However, this is because my regimen is very standard and no serious interactions were expected.  Additionally, it is because there are other pharmacists who are looking into it for me, both in the cancer center, and also I figured Sarah would be on top of it as well.    

Prior to cancer, I only used two medications:  Zyrtec and Flonase for allergies.  Once in a while I'll use atrovent nasal for a runny nose while working out.   As you can see, my list has grown quite a bit.   No real secret about what I take, so, here they are.

Josh Medications:
Adriamycin, Bleomycin, Vinblastine, Dacarbazine - these are the actual chemotherapy agents
Aprepitant (Emend), Ondansetron (Zofran), Dexamethasone - these are the anti-nausea medications
Lorazepam (Ativan) - this is an anti-anxiety / anti-nausea medication for anticipatory nausea.  I take it before chemo.
Zolpidem (Ambien) - this is a hypnotic for sleep I was given.  I do not use it often.
Omeprazole (Prilosec) - Suddenly, with cancer, I now have occasionally very bad GERD.  (?)
Cetirizine (Zyrtec) - This is an antihistamine for allergies
Fluticasone (Flonase) - This is a nasal steroid for allergies
Acetaminophen & Ibuprofen - Occasionally for aches and pains

So, what does my interaction profile look like?   Courtesy of being able to dial in to several databases remotely, here it is in raw format from Lexi-Comp:

You can click on this to enlarge it, but don't bother.  As you can see, tons of things "flag."   So much so that I didn't even grab the entire screen.   As you can see, drug-drug interactions are "graded" as A, B, C, D, or X.  In clinical practice, A, B, and C can be fairly unimportant.  This can be for a variety of different reasons.  It may be that the documentation around the interaction isn't all that good.  Likewise, it may be that the interaction itself is theoretical and hasn't been proven clinically, or, hasn't been proven to be important clinically.   As such, I usually screen out interactions that are not at least a D or an X rating.   D interactions are potentially serious, and X interactions are usually contraindications.

Why do you get all this info if you just bypass it?  It is nice to have if you are wondering about a theoretical interaction, or hear of one, or have concerns with certain medications to know what might happen.  So, the A's, B's, and C's are good to have, but not always clinically relevant.

So, here is that same profile with the A's, B's, and C's screened out:

As you can see, there is only one drug-drug interaction that screens as a "D" and no "X's."  What is it? 

Aprepitant may increase the serum concentration of Corticosteroids (Systemic).

So, the Emend I take on "Chemo Mondays" as well as the two days after chemo doses can boost the concentrations of the dexamethasone I also take on Chemo Mondays, which is given IV.  This seems to be due to a cytochrome P450 3A4 inhibition by the aprepitant.  This may well have been a grade "C" interaction, but the manufacturer does recommend a dose change for the dexamethasone, from what may have been recommended for dexamethasone doses in regimens before aprepitant was widely used.  No big deal.   In fact, many drug-drug interactions are like this:  You must evaluate what could happen, how likely it is to happen, and how wide the therapeutic window of the agents involved actually is.  What would be the result of extra dexamethasone once every other week?  Possibly more hunger on those days.  Slightly more immune-system suppression?  Well, I already have that.  Maybe more "jittery-ness." 

So, that's what Lexi-Comp thinks of my regimen.  What about Micromedex?  

They seem to think even less.  This is why I like to use both programs:  they don't always agree completely.  Micromedex has completely screened out most of the unimportant interactions Lexi gave us.   Micromedex notes that aprepitant can boost vinblastine.   They call the interaction "major" with "fair" documentation.   This is why Lexi's screen is nice.  I can go back and see that, yes, Lexi did note this, and they called it a "C" interaction.    So, Micromedex gave this interaction more importance than Lexi did.  I'm unsure if ABVD regimens were changed after aprepitant became mainstream a few years ago or not.  I suspect not, however, because I do not see it in the medication's literature, and more so because I see no actual recommendations for dosing changes.   Which brings us to an important question:  What would you do even if you wanted to?   There isn't enough literature to suggest an empiric dose change.   P450 interactions are highly individualized, and therefore, what may be the perfect adjustment for patient "X" may not work for patient "Y."  So, we manage this interaction rather than avoid it.

Curiously, as you can see, Micromedex placed the previously noted aprepitant / dexamethasone interaction as less important than Lexi did.  They just don't agree and it is worthwhile to look at both.

The last interaction Micromedex noted was lorazepam and zolpidem.  As noted, zolpidem is a hypnotic for sleep, and lorazepam is a benzodiazepine.  Put them together and it is no surprise that you will be more sedated than with either one alone.  So, be careful if you intend to operate heavy machinery and all that.  (Lexi also called this interaction a "C.")

So, drug-drug interactions, in my opinion, are extremely interesting but very often misinterpreted.  My personal experience is that some patients tend to worry far too much about them and others tend to not worry enough.  Drug-drug interactions can be chemical interactions, but rarely result in the colorful explosions you may see in a chemistry experiment gone bad.   However, this is not to say that they cannot be deadly, given the right combination and timing.  Of course, as you can see from above the vast majority are not concerning enough to make changes.   Hopefully this was moderately interesting to you, the reader.

Chemo 9 of 12: Three quarters done!

Yesterday was chemo 9 of 12.  I woke up pretty early because I wanted to get to the infusion center pretty early.  I had a 10am appointment with the oncologist, but since I needed a blood draw, and my last two times the Port was clotted, I figured I'd give them extra time.   I was a little upset while doing the morning routine, just anticipating the port clot and the long day, especially with the doctor appointment mixed in.


To my luck (and the nurse's!) it was not clotted for a change!  The day was looking up already.  So, I had an hour to kill before my appointment which I spent at Starbucks getting a caffeine free iced latte, which counts as a "positive" drink in my quest for eight 8oz drinks per day.


My visit with the oncologist was unremarkable.  She did hear breath sounds in all 5 lobes (unlike the NP last time), and my exam was fine.  We talked about radiation a little, and she again stressed its importance and basically told me I was getting it.  (Which is good).   One question I had for her was why my heart was racing so high on my bike rides, when I could never get it that high previously.  Her answer surprised me as it was something I'd never considered, as you can see below.  She believes that it is as a result of my declining hemoglobin and hematocrit.   As you can see, it doesn't appear to have changed much at all, but she said what I'm doing now is basically exercising down approximately two units of blood, and it was a bigger drop than I'd considered.

Additionally, this didn't worry her and she said I could continue to bike as I please.  Additionally, no signs of bleomycin toxicity, as my cough was dry, my relative shortness of breath was only a few hours after exercise, and she said if I'm still doing the rides I described to her, she wasn't worried.

After that, I went to chemo.  Since everything was working well, we had a relatively short day and were out of their by 2pm!  This was great.  Sarah, my nurse, and I had been discussing food and after discussing chinese, I decided that's what I wanted post-chemo, and I ate my whole order, which was generous.   Then I took a two hour nap.   After that was when the chemo hit, and it hit pretty hard.  I was dizzy most of the night and into today despite plenty of hydration.   I had some nausea last night and this morning, but not too bad.   Much of today was spent sitting in the "chemo fog" but I feel relatively OK now.   I probably will skip dinner, (we had Boston Market for lunch), but I may have some ice cream.

So, all in all, even though it was a tough session, at least it was as short session, and I've only got three more to go!  Pretty excited about that.    Also, my ANC has rebounded from 100 to 500, so, I feel downright normal in terms of my immune system, even though 500 is still far from normal.   Good news anyway, I say.

In other news...

My sunglasses fight cancer Part II:

Last Saturday was Livestrong day at one of the local bicycle shops.  They had several silent auctions, but the one I was most interested in was a pair of sunglasses.   I do not use my prescription sunglasses for riding, since my prescription isn't actually that strong.  The sunglasses up for bid were the Oakley Livestrong Jawbones.  I had been planning on some new cycling glasses this year since mine are getting pitted, and I may not have chosen these, but all the circumstances were right.  First a buddy said they were great for riding, but more importantly, since the store donated them, the entire bid went to the charity.  I was very surprised that I had won them, and was excited to get them for just a bit under retail.  So far I like the fit, I'll DEFINITELY have to get used to the look, but they seem like they would be great riding glasses.  

A beautiful beatdown

Some people and activities may have to take a back burner for now.  When confronted with a social engagement or obligation, ask yourself:  Does it tire me or does it inspire me?

-Kris Carr, Tip 13, "Crazy Sexy Cancer Tips"

Maybe both.  Why not?  That's what I decided tonight.


I haven't read "Crazy Sexy Cancer."  I haven't seen the documentary either, although it is on my Netflix queue.  I haven't even spent much time on her website.  Something that's title begins with "Crazy Sexy" usually doesn't grab my interest or attention, but a magazine article about Kris Carr did and this was the tip I took away months ago already.   I'm not sure if I've lived by it, but I've certainly spent time thinking about it.


Tonight was one of those nights.  It was the bicycle club's first weeknight hill climb, something I've enjoyed for several seasons already.  However, I knew it would be ugly.  In truth, it wasn't much of a group ride for me either.  I basically filled out the sign in sheet, said hello, and when we got to the bottom of the climb, said "See ya later!" to everyone there.


I've already pointed out my climbing time on the bike is basically double what it was a year ago.  I am half as fast as I used to be.  Curiously, in less than a mile from leaving the parking lot, I can get my heart rate up 15 beats higher than my previous maximum effort (a year ago), no matter how intense the interval.   Fighting allergies, I expected my nose to run like a faucet causing further problems.


Despite all this, it was a great night.  Yeah, I rode alone.  I do a lot anyway.  It was very windy, but warm enough and the skies were clear.  The views were spectacular, and I fixed my nose problem by taking a 4x overdose on my atrovent nasal inhaler.   (For the record, as a pharmacist, I do not condone nor recommend this behavior.  But it worked.)  It is still a little bit of a downer to be passed by absolutely everything on the road:  Cars, cyclists, mtn bikers, senior citizens with walkers, etc.   At one point, in the wind, I looked down and I was doing a whopping 3.7 mph.   Actually, no, that's a lie.  That happened at several points.  Wow.   I can walk faster than this.  It took me longer than I'd hoped, but when I got to the top, I had enough left to do an optional loop, which is a first for the year.


I expect I'll make zero progress pretty much for most of summer.  While riding, I got to thinking about that huge lymph node comfortably wedged between the top of my heart and one of my lungs.  It may be big enough that it won't shrink all the way, even with chemo and radiation, that's what I was told.  So I don't know if I'll ever get completely back to where I was.  No sense worrying about it, though.  May as well have as much fun as I can in the meantime.

Drugs 4: Dacarbazine

Out of all the chemotherapy drugs I am getting, dacarbazine is the one I really loathe.  The reason for this is because of the pain that it causes.   At my first chemotherapy session, I already had a bizarre arm pain from this drug.  They put hot compresses on my arm, but that only helped minimally.  It is because of dacarbazine that I eventually had to get the line and then the port.  Dacarbazine is also known as DTIC.


Truthfully, I couldn't find many interesting tidbits or factoids about dacarbazine while surfing the web.  I'm sure some are out there, but they were not obvious to me.  


Doing a quick google image search, I found the structure of dacarbazine.  It appears to be a (relatively) simple molecule.

So, how does it work?

Per Lexi-Comp:

Alkylating agent which appears to form methylcarbonium ions that attack nucleophilic groups in DNA; cross-links strands of DNA resulting in the inhibition of DNA, RNA, and protein synthesis, the exact mechanism of action is still unclear.

In other words, much like some of the others, it inserts itself into the cancer cells' DNA, and prevents "normal" replication.  I put normal in quotation marks, since cancer cells obviously do not have a normal replication process.  

What side effects does it cause?
Well, as noted above, the side effects for this drug starts and ends with arm pain, in my case that left arm.  It would seem that the package insert does not agree with me.  Astonishingly, it does not even mention infusion pain, although it does discuss extravasation.  Lexi, however, does note that > 10% of patients will have pain on infusion, and suggests the drug be given over 30-60 minutes as rapid infusion can cause severe venous irritation.


The other side effects noted include GI side effects, which mostly include nausea and vomiting.  Curiously, the package insert suggests a strategy of having patients not eat for 4-6 hours prior to infusion to combat diarrhea.  Since so many other parts of my treatment are constipating, I guess this tends to even those out since (thankfully), I haven't had too much burden with either problem.  I can say from my own experience that the only thing worse than being really full during chemotherapy session is being very hungry.  Dacarbazine obviously also causes leukopenia, thrombocytopenia, and myelosuppression. I have not noticed thrombocytopenia.


Also, like others in this regimen, dacarbazine displays biphasic elimination, with an initial half-life of 20 minutes and a terminal half-life of 5 hours.  In other words, this is mostly gone after about a day.  It is eliminated 30-50% unchanged in the urine, and the other half or two-thirds is extensively metabolized by  1A2 and 2E1, which are less common P450 isozymes.  It is minimally protein bound, and has a volume of distribution not much more than the total body water, in other words, fairly small.


As a result of being a 1A2 and 2E1 substrate, there are some potential drug interactions, but none that affect me, or (I'd venture) most people on the ABVD regimen.


The typical dacarbazine dose is 375 mg/m2.  So, given my own math of a BSA of ~ 2.26m2, that would be about 847mg, and my dose is 840mg.   As a result of all the pain I had, I now get this in a bag that is approximately somewhere between 500mL and 1 liter, and so even with the port, this drug feels like it takes forever to infuse.  Dacarbazine is colorless.


What other cancers is dacarbazine used in?
It is used in malignant melanoma and Hodgkin's, obviously, it is also being studied in treatment of soft-tissue sarcomas, islet cell tumors, pheochromocytoma, and medullary carcinoma of the thyroid, per Lexi.


What else can I say about dacarbazine?
Not much.  Just a boring, painful drug. Doing this post doesn't make me like it any more, that's for sure. Package insert is here.  Chemocare's website is here.