Life After Chemotherapy


Now that we are past Ann's last chemotherapy we are starting to plan for the next phase of her therapy, namely, radiation therapy (also known as radiotherapy). This email outlines Ann's current condition, follow up exams and consultations related to Ann's lumpectomy and arm condition, and the steps that we are taking to select a radiation oncologist.


CHEMOTHERAPY SYMPTOMS

As expected, the latter chemotherapies were more difficult than the early ones and new symptoms are surfacing including: hot flashes and chills; cracking finger and toe nails; and numbness, tingling, and pain in fingers and toes. All of these are known side effects of Ann's chemotherapy regime. The temperature swings result from menopause which may be permanent. The problems with nails and sensations in fingers and toes are from the Taxotere; the nerve damage it is doing is expected to reverse in the coming months. 

On occasion, Ann experiences problems with short-term memory, a condition popularly known as "chemo brain." The medical profession doesn't talk much about chemo brain but there is a limited amount of information about it online:

http://www.uicc.org/publ/pr/home/00071401.shtml#fs
http://www.susanlovemd.com/community/flashes/hotflash000330.htm
http://pubmed.com/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12533268&dopt=Abstract
http://pubmed.com/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11786578&dopt=Abstract
http://pubmed.com/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11768035&dopt=Abstract
http://asco.org/ac/1,1003,_12-002489-00_18-002003-00_19-00102416-00_29-00A,00.asp?AbstractID=102416

You'll hear about chemo brain any time you get together with a group of cancer survivors (who had chemotherapy). Coincidentally, Nello also seems a bit less sharp than he was before chemotherapy started so maybe this mental fog is nothing more than a sign of the emotional stress of cancer treatment. We hope so. Whatever its cause, we expect both fogs to lift after Ann completes her treatments.

Fatigue (or "drug drag" as Ann likes to call it) continues to be a problem. Aranesp, the drug to stimulate red cell production, it doing a fine job and Ann's anemia is almost gone; her hemoglobin on 5/30/03 was 11.8, just a smidgen below the normal range of 12 to 14. Unfortunately, chemotherapy-induced fatigue remains substantial even as anemia fades. As in the past, Ann is using aerobic exercise to fight her drug drag.

With the 5th cycle, Ann started additional therapies to address fatigue, namely guided imagery meditation audio tapes and Healing Touch. Both seem to help. Ann often listens to her tapes before naps or at bedtime. They seem to relax both her and our hyperactive cat, Limpopo. Healing Touch (surprisingly) involves little touching. The therapist passes her hands over the patient to sense energy fields and redirects them to promote natural healing. Nello calls this talk about energy fields voodoo but acknowledges that Ann's recovery from her 5th chemotherapy was at least 3 days faster. More information about Healing Touch is available online:

http://www.healingtouch.net/
http://www.phact.org/e/tt/
http://pubmed.com/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9533499
http://www.ncbi.nlm.nih.gov:80/books/bv.fcgi?tool=bookshelf&call=bv.View..ShowSection&searchterm=healing&rid=cmed.section.17928




POST-SURGICAL EXAM/CONSULTATION WITH DR. WINCHESTER

As you may recall, there was one loose end that required followup regarding Ann's lumpectomy on January 17, 2003. When she had her stereotactic core needle biopsies in December, 2002, a small metal clip was left in each cavity from where the tissue was taken. Both clips showed up in mammograms the day before her lumpectomy. However, the clip from her first biopsy--the one associated with the malignant tumor--was not apparent in the tissue removed from her breast, i.e., the surgical specimen. At the time, Ann's surgeon, Dr. David P. Winchester, said that we would have to look for the clip after Ann had recovered from her surgical wound in about six months. He mentioned that additional surgery to remove the clip might be needed if the clip were still present in the breast. With chemotherapy coming to a close we scheduled an appointment with Dr. Winchester to followup on the missing clip; we wanted to find it prior to beginning radiation therapy. 

In preparation for this exam she had the following imaging studies: mammogram, ultrasound, and Magnetic Resonance Imaging (MRI). These images were ordered to help Dr. Winchester assess her healing and perhaps find that missing clip. Ultrasound and mammography are standard breast imaging techniques for detecting cancer and Ann had these procedures before. Information about breast cancer screening techniques is available online:

http://www.imaginis.com/breasthealth/mammography.asp
http://www.imaginis.com/breasthealth/ultrasound.asp
http://www.cancer.org/docroot/PED/content/PED_2_3X_Mammography_and_Other_Breast_Imaging_Procedures.asp
http://www.ncbi.nlm.nih.gov:80/books/bv.fcgi?call=bv.View..ShowSection&rid=cmed.chapter.7002

The use of MRI breast imaging for cancer detection is relatively new. Apparently MRI is much more sensitive than mammography and ultrasound especially in younger women (under 50) with dense breast tissue. Unfortunately, MRI is much more expensive and also results in more false positives, i.e., MRI images sometimes indicate the presence of cancer when it isn't there. Consequently, MRI breast imaging is not used for routine breast cancer screening. More information about MRI breast imaging is available online:

http://www.imaginis.com/breasthealth/mri.asp
http://www.advanceforioa.com/common/editorialsearch/viewer.aspx?FN=02jul1_arp28.html&AD=7/1/2002&reload=true&FP=ar
http://www.plwc.org/plwc/MainConstructor/1,1744,_12-001148-00_17-001029-00_18-0028026-00_19-0028033-00_20-001-00_21-008,00.html

As you may recall, Dr. Winchester was very surprised to find cancer in any of Ann's lymph nodes because her tumor was very small (<1 mm). In fact, immediately following her surgery he expressed the possibility of occult cancer, i.e., another tumor which was not visible in her mammograms. We assume that he ordered the MRI test because its increased sensitivity would either find or rule out any additional tumor(s).

Ann already had several mammograms and an ultrasound but the MRI was a new experience for her. Just days before her MRI appointment, Garrison Keillor mused about what it is like to have an MRI during his weekly radio show, "A Prairie Home Companion." The skit is available online both as a script and as an audio clip. (You must have RealPlayer installed on your computer to listen to the audio clip; RealPlayer can be downloaded free from www.real.com). As Garrison says in the skit, "If you ever have the chance to get an M.R.I., take it, you'll learn a lot about yourself and about claustrophobia." In any case, we enjoyed the skit and maybe you will too.

http://phc.mpr.org/performances/20030517/mri.shtml
http://phc.mpr.org/performances/20030517/ram_files/02_mri.ram


Ann had her post-operative examination and consultation with Dr. Winchester at his Evanston office on Thursday, 5/22/03. Dr. Winchester indicated that the surgical wounds had healed well. Moreover, there is no need for additional surgery because the clip is no longer missing! The case of the missing clip was solved by a colleague who pointed it out during Dr. Winchester's presentation of Ann's case at Breast Conference on the Monday before her appointment, 5/19/03. Apparently the clip showed in the x-ray of the surgical specimen but was hidden by one of the guide wires making it hard to see until the image was magnified. Next, Dr. Winchester turned to the new breast imaging studies. The radiologist said that the MRI that Ann had on Monday, 5/19/03, was "unreadable" and a second MRI was scheduled for Tuesday, 5/26/03. The ultrasound indicated no problems. But, as Dr. Winchester was reading the mammogram report he started shaking his head: the report was inconsistent. The report described benign conditions but it concluded that there was a malignancy which required followup. Dr. Winchester dismissed the conclusion as a typographical error because he had seen the mammogram and talked to the radiologist about Ann's case at the Breast Conference. Later followup confirmed Dr. Winchester's suspicion; neither Ann's second MRI nor her re-interpreted mammogram showed any cancer. Ann's surgery was a success and it is officially behind her. Nevertheless, Ann complained of continued tightness and pain ("cording") in her arm. Dr. Winchester referred her to Dr. Joseph Larry Feldman, a physical and rehabilitation medicine specialist.




ARM EXAM WITH DR. FELDMAN

On Thursday, 5/29/03, we met with Dr. Feldman at Highland Park Hospital for a consultation and examination of Ann's arm. Dr. Feldman specializes in lymphedema treatment and serves on the National Lymphedema Network Medical Advisory Committee (www.lymphnet.org). Limited background information about Dr. Feldman is available online at the Evanston Northwestern Healthcare (ENH) website:

http://www.enh.org/findadoctor/ENHDoctorData.asp?id=710

Dr. Feldman diagnosed Ann with an early form of lymphedema. This diagnosis is not based on arm volume measurements. Instead, it was based on the feeling of the bottom of Ann's upper arm. In comparison to her right arm, the skin under her left upper arm--the side of her lumpectomy--had a slight separation from the underlying muscle. Nello thought that it felt slightly like the loose shoulder skin of a well-hydrated cat; the skin sits on a slight cushion of fluid. Dr. Feldman suggested that Ann's cording as well as this early and mild form of lymphedema would benefit from her wearing her compression sleeve for at least six hours a day for at least a week. He also prescribed physical therapy for her twice a week for the next three weeks. Dr. Feldman will examine Ann again after she completes radiation therapy.




CONSULTATIONS SCHEDULED WITH RADIATION ONCOLOGISTS

We scheduled consultations with two radiation oncologists, namely Dr. Vathsala T. Raghavan at Glenbrook Hospital on Friday, 6/6/03 and Dr. William David Bloomer at Evanston Hospital on Wednesday, 6/11/03. The ENH website lists some information about these doctors.

http://www.enh.org/findadoctor/ENHDoctorData.asp?id=248
http://www.enh.org/findadoctor/ENHDoctorData.asp?id=64

Having radiation therapy with Dr. Raghavan would be more convenient since she practices at Glenbrook Hospital which is near to Ann's office. Throughout Ann's treatment we've sought second opinions at every major decision point; Dr. Bloomer will supply the second opinion regarding radiation therapy options and recommendations.




ADMINISTRIVIA

Soon after we started writing these email updates a few people mentioned that the information might be helpful for others working though their own breast cancer options. As a result, several months ago the notes were published on a (now out-of-date) website:

http://lucchesi.org/ann

Any suggestions that you have for improving the website would be appreciated.




Finally spring has arrived in the Chicago area and we are taking time to smell the flowers. The irises are in spectacular bloom with oriental poppies to follow soon. 

Thank you for your help and support. We hope that you are well.

Love,

Ann and Nello

Posted: Thu - June 5, 2003 at 04:50 PM        

©