Chemotherapy

      “You need to come in so we can redo your mammogram.”  Words a woman never wants to hear.

      There is no need to panic yet.  The voice on the cell phone explains that the radiologist saw a spot and wants to investigate further.  It may be nothing, but he wants to err on the side of caution.

      In July, the Goodwife showed up for her second mammogram.  A few days later, the voice on the cell phone informed her she needed to schedule a biopsy.  The biopsy was painful.

     The physician probed the breast using the X-ray image to locate the small growth.  After taking a tissue sample, she implants a small chip next to the tumor so it can be found easily next time, if there is a next time.

      Wait and hope until the pathology report arrives.  The news is bad, but not the worst.  The tissue tests positive for cancer, but not an aggressive cancer, a “garden variety” of cancer, as the radiologist put it.  He could have stopped there, but he didn’t.  “The kind you get as you get older.”  Double whammy, but still not as bad as it could be.  It’s not an aggressive cancer.

      Wherever our life was headed, it now turned a new direction with a new driver in control of the wheel.  Would she be able to do the shave-ice business in August?  Yes, since the cancer was not aggressive, there was time to think and plan.  The lump must be removed. 

     Consultation with the oncologist (she spoke Japanese, so she and the Goodwife had a great time chatting) who recommended a surgeon, followed by a visit with a navigator who was to coordinate the patient’s visits with all the different doctors, nurses, technicians, etc.  Surgery was scheduled for late August.

     The surgeon and oncologist recommended a partial mastectomy, or lumpectomy in layman terms, rather than a full mastectomy, complete removal of the breast.  The surgery itself was fairly simple, open the flesh enough to cut out the growth, knife and scissors, the surgeon said.

     There were things that had to be done prior to and following that operation.  A technician inserted a wire through the side of the breast to the telltale chip left there during the biopsy.  That was done pre-surgery with a local anesthetic.

      When the surgeon came to visit with the patient just before the surgery, he was studying an image of the breast where the wire running through her breast and the chip were clearly visible.  He also had her mark her breast with a magic marker—no cutting into the wrong breast. (Why have her do it? It might upset some guys to have a strange man writing on his wife’s left breast with a magic marker.  It took me awhile to figure that out.  Maybe I haven’t figured it out yet.)

     Then the anesthesiologist took over.   By that time, we had been there over two hours.

     The Goodwife was wheeled off again, and we wouldn’t see her for another two or three hours.  During that time, the lump was removed, she was taken to X-ray to see if the lump was all gone, and two of her three “sentinel lymph nodes” were removed.

      A couple of hours in the recovery room, and the day was about done.  The surgeon’s post-op report had good and bad news—the lump was small, less than a half inch, and was completely removed with healthy flesh all around it.  But, the first sentinel lymph node tested positive for cancer. 

      The lymph system is the body’s garbage collector.  The nodes collect the waste and send it off to either the kidneys or the bowel for disposal.  That the lymph node was infected indicated that the cancer had moved and was not completely localized.  We were in for some more testing.

      Somewhere along the line, a study group recruited the Goodwife.  That made the decision of what regimen to follow a little more difficult.  The study wanted ladies with early stage breast cancer.  The ladies in the experimental group would skip the chemotherapy and undergo radiation and endocrine therapy.  The ladies in the control group would follow the normal regimen, chemotherapy followed by radiation and endocrine therapy.

      The study group recruiters were especially interested in enlisting the Goodwife because of her Asian background.  They needed the diversity, but apparently, breast cancer in Japanese women in Japan is rare.  Breast cancer in Japanese women transplanted to the United States is much less rare.

      Initially, the lure of participating in the study was the possibility of forgoing chemotherapy.  Participants will be closely monitored for fifteen years, another good reason to participate.  In order to participate, the Goodwife had to undergo some additional testing.  The panel had a method of scoring her tumor and her overall fitness for becoming a participant.    

     The small size of the tumor was acceptable.  Her oncologist ordered a PET scan to be sure there were no other tumors or signs that the cancer had spread.  She passed that test.  She was in the study.  Now, would she be part of the experimental group and skip chemotherapy?  Supposedly, it was a random draw, half the women in the control group, half in the experimental group.  In reality, the final decision was up to her.

      In order to make that decision, it was necessary to know what her standard procedure would be.  A jury of her superiors, the oncologist, the surgeon, radiologist, perhaps some others we did not know, came up with a recommendation:  twelve weeks of chemotherapy consisting of six treatments every two weeks.  Later, they revised that to twelve weeks with four treatments every three weeks.

     The decision was made over a period of two or three weeks while she recovered from the surgery.  Ultimately, she decided to go with the chemotherapy because if there were cancer cells floating around in her body, the chemotherapy should eliminate them.  It seemed the safer bet. 

      A truckload of information then fell upon us.  We went to “chemo school” where we were introduced to a bundle of drugs such as Ativan (anxiety and nausea relief), dexamethasone (steroid for nausea and other allergic reactions), Zofran and Compazine (anti-nausea), Cytoxan and docetaxel (the cancer killers, the “chemo”), Aloxi (anti-nausea), Gabapentin (foot pain), and Neulasta (given by injection on day 2 of every cycle to stimulate white blood cell production).

     The decision to go the chemo route meant another trip to the surgeon to put in the “port” through which the chemicals would be administered.  That was surgery, complete with pre-op meeting, the anesthesiologist, the recovery room and the fatigue following the surgery.  That was on Friday.  The first chemo was scheduled for the following Monday.   

     We weren’t the best of students in the chemo class.  The day before the chemo treatment, the Goodwife was supposed to take the steroid dexamethasone twice, morning and night. That would be Sunday. We went to a wedding in the Eastern part of the state that weekend.  We had neglected to pick up the prescriptions at Wal-Mart pharmacy before we left town Friday.

      When we came back Sunday afternoon, the pharmacy was closed.  It soon was obvious after visiting with the Wal-Mart manager on duty that it would be easier to open hell’s gates and let out some of the condemned than it would be to get a pharmacist to open the Wal-Mart pharmacy gates and get her pills.

      What to do?  In our schooling, the Nurse Practitioner gave us some important information to be placed on the refrigerator door.  We had done that all right.  The phone number for all inquiries was the same, the cancer center number.  Calling that number got us the answering service, the real live person kind.  She relayed our call to the doctor on call, who promptly called us.

      We explained what we had done, or neglected to do.  He said it was important to take the drug, she should take it that night even if she missed the morning dose, and did we have a 24 hour pharmacy close by?  We found a Walgreen’s with 24-hour service, where eventually we got her prescription filled and her pills taken.

    The first thing Monday morning I called the cancer center and explained the situation and asked if we should go ahead with the chemo.  Yes, we should.  Should she take a second dose of the pills she failed to take yesterday?  No, she should not.  Part of the infusion included some of the same steroid drug, so come in as scheduled, which we did.

      The most painful part of the chemo was about to occur.  Since the port had been installed only three days before, the area was still swollen and tender.  The first nurse couldn’t locate the port and tried injecting the initial saline solution into tender flesh surrounding the port.  It was terribly painful.  A more-practiced nurse succeeded in finding the port on the third try and things settled down to the humdrum boredom that would become routine.

     The routine consisted of running a needle into the port.  A nurse friend advised us to ask for a prescription for a numbing salve.  Putting the salve on about fifteen minutes before we arrived at the cancer center made accessing the port much less painful.

     The nurse drew blood and sent it off to the lab to see that things were okay before administering another dose of the chemo.  Nothing to do but wait until the lab reports came in. When they got the go-ahead, the nurse would dress herself up and hook her up to a bag of Cytoxan.  (It gives you pause to think that the stuff is so bad that the nurse wears protective clothing, and they’re dumping that into your body.  They do deal with it several times a day, the patient only once every two or three weeks.)

     When that was done, she would get a bag of docetaxel.  Each of those treatments took over an hour each.  With flushing lines and other such necessities, the procedure took four hours. The first time, there was a lot of apprehension, which kept things from getting boring.  After that, we took stuff to read or work on to pass the time.

     On day two, the patient got an injection of Neulasta to stimulate her white blood cells. One of the nurses said they had far fewer chemo patients in the hospital since they began using that drug. 

       Nausea was not one of the side effects the Goodwife experienced, something she was extremely grateful to avoid.  Fatigue was common to all four cycles.  The worst side effects seem to come from the Neulasta.  After the second day injections, the Goodwife would experience pain in her bones for two or three days.  The worst was the pain in her feet, which made walking difficult. 

      The PA sent in a prescription for Gabapentin for the foot pain, but somewhere we missed that act.  Finally, Wal-Mart called and said we had three days to pick the prescription up. I did go get it, but the Goodwife had gone to Hawaii where she worked at cleaning up her mother’s apartment.  (She got home from that on Thursday and on Friday left for McCook, Nebraska at 4:30 a.m., returning about 8 p.m. Friday.  So much for letting chemo interfere with normal activities.

       This Monday, she took her last dose of chemo.  The Neulasta injection was postponed until Wednesday due to the snowstorm that struck Monday night.  After her injection, all the nurses on duty escorted her to the lobby where there is a sign on the wall and a bell.  We all read aloud the sign and then she rang the bell.  It was a very touching moment that neither of us was prepared for.

    The sign says, "What Cancer Cannot Do.  It cannot and will not . . .destroy confidence, cripple love, shatter hope, take away peace, corrode faith, kill friendship, shut out memories, silence courage, reduce eternal life nor quench the spirit."

    She will have the Christmas season to recover.  In January she will undergo radiation, five days a week for four weeks.  She’s part of a study group, there, too, evaluating skin cream used to deal with side effects of radiation.

    Then she will begin the endocrine therapy, which may go on for years, I understand. 

    Moral:  Live clean.  Avoid cancer.                    

     Like all good advice, easier said then done.