Wednedsay, March 26 marked two years from the end of treatment. According to Phenon’s doctors that’s a really big deal. Apparently, if there have been no signs of recurrence by two years out, they feel comfortable saying that the chances are, while not exactly zero, so low that they don’t need to keep as close an eye on her as they have been.
As such, last week was the last checkup we’ll go to in the CHNMC Hemotology/Oncology Outpatient Clinic. Phenon and I got to see both Shawna and Payal, a few nurses we’ve gotten to know over the past few years, and that’s that.
Our next appointment, in about six months, will be at a different clinic (still at Children’s) more set up for long-term and infrequent checkups. There will probably be checkups every six months until this time next year, then just yearly visits from there on out. And by “there on out” they really mean Phenon’s entire life. You see, though their worry about recurrence of Lymphoma is low, the treatment itself has increased her risk of any number of things that we’ll need to keep an eye on.
There have been a lot of chapters in this book. This one feels particularly significant to me.
After talking to Em for a while about all of the things Phenon’s docs have been telling us to be on the alert for, she said this image came to mind. It seems a perfect encapsulation of where we’re at!
Phenon is now totally done with her treatments. The last CT scan is finished, and they like the looks of it. It is unchanged from the end of chemo, but that’s what they expected. Radiation often doesn’t shrink the remaining mass, just kills it. So, she has a remaining mass that is between 3 and 4 inches in diameter in her lung. It will likely shrink as the dead cells are sloughed away and the supporting structure of blood vessels, etc. figures out it’s not needed. She has also gotten 90% of the way through her follow-up scans and measures. The only two things left are happening soon – pulmonary function test to check on what damage, if any, has been done to her lungs by the chemo and radiation, and surgery to remove her port. Surgery is scheduled for this Monday, May 14th, so she’s almost done! Remember when Nurse Chris said that getting his port out was the day he knew the ordeal was all over? Well, she’s almost there. Hooray!
At the same time, every doctor we go to is giving us a list of things to check for every single day, since she won’t be going to the hospital or being seen by the specialists for 3 months. It’s very reassuring. We only need to rush her to the hospital if she seems irritable, tired, or resistant to exercise. WTF?!? So, if she acts like a teenager, we have to rush her to the hospital? Gulp. Thank goodness for Shana, who started laughing hysterically as Tim read her the list the other doctors had given us to be vigilant for (they actually used the word vigilance!!). She said we can relax a little, and just make note of any changes. That we don’t have to follow her around evaluating her every step (which would make her irritable for sure!). We do, however, have to regularly look for more unusual things on the vigilance list, like swelling of her ankles, a blue tinge in her fingernails or toenails, swelling in her neck, any cough at all, etc. All of those could indicate the return of the tumor or impending heart failure. So, you know, relax!
To be sane in this transition to what is the new normal, I’ve decided to run a half marathon. (I know that may not sound sane. But it’s better than me following the kid all over the house checking the responsiveness of her toenails!) I’ve got to transfer this vigilance to something that won’t make my kid irritable (which would then, obviously, make me rush her to the hospital!). I decided I needed a new way to kick cancer in the teeth and to try to kick its butt permanently. So, I’m doing this combination fundraising/training thing through the Leukemia & Lymphoma Society’s Team in Training. If you are able to donate even $5 ($10 this morning would round me up to a nice even number, and I’d love that!!), it would be awesome. Must fund those fighting against the rise of evil! Click here to get to my half marathon page! I need to raise $1800 to be able to compete in the race on October 13 (almost the one-year anniversary of Phenon’s diagnosis).
In the meantime, much else has happened. My parents took us to Disney World and we got to go to Harry Potter world at Universal Studios. (Thank you, again, SO much, Mom and Dad!)
Thanks (so, so much thanks!!) to Tim’s friend Kathleen, we were able to get a behind the scenes meet-and-greet with some of the animal actors at Universal. Here’s a clip from that experience, where Ruby and Phenon got to do a little cuddling. Priceless!!!
Back home, Phenon’s musical (the Musical Adventures of Oliver Twist) opened on Thursday night. Tonight is her last performance, and she’s amazing, if we do say so ourselves. And, her Musical Theater Conservatory ended for the season. This was Phenon and Zach’s duet on the last night of class.
And that, I believe, is all of the most important stuff. Summer, it seems, is about to begin.
P.S. I got over the $1500 mark before I left the kick-off event for the LLS training season! Thank you, thank you, thank you! But, while I was there, I heard memorials for several amazing people who died over the past year from a blood cancer. If you haven’t already contributed, if you could donate anything at all to keep these hideous diseases from agonzing other families, I would be so incredibly grateful. Thanks! Click here.
Monday was Phenon’s last day of treatment at the fabulous University of Maryland Medical Center. Rowan and I joined Julie for the special event and loved meeting all the amazing people who have been taking care of our girl for the past three weeks.
On the last day of treatment they call a “Pediatric Code Sunshine” over the PA system and doctors, nurses, and techs who are available come out to the radiation waiting area where the newly former patient rings a bell signifying the end of treatment. I wish my phone could manage to get the sound and video a bit more in sync, but fortunately I’m swinging the damn thing around so much that mostly you can’t tell who’s saying what, when, anyhow:
Then there were hugs all around and that was that: Treatment is done.
Phenon’s last radiation treatment is Monday, March 26th. Only one to go! When she is done, she will ring this bell. We have seen several others get to ring this bell. It’s a happy thing! All of the radiation technologists gather round, and cheer wildly as the (now-former) patient rings the bell. Then they hug and congratulate and send the patient on his or her way. They do helpful rituals very well in Baltimore. For kids, there’s one more step. After ringing the bell, “Princess Jill” will meet Phenon at the “Magic Castle” to grant one of her wishes. We had a little trouble finding the Magic Castle at first, but we found it under the glass stairway into the atrium that is the waiting room for Radiation Oncology.
I wanted to invite a bunch of people to come and cheer as Phenon walks out of cancer treatment and officially pronounces cancer defeated, but she was adamantly disinterested in such an embarrassing opportunity to be the center of attention. She very much wants to have a big party to celebrate the end, but she absolutely does not want it to happen in the lobby of the radiation oncology department at University of Maryland. And much as I’d like to make it into a big-ol’ hulabaloo, the kid has earned the right to celebrate in her own way and on her terms!
Phenon will still have some medical stuff to take care of in the next few months: another CT scan to see whether radiation has shrunk the remaining mass (it may have been killed but not shrunk, which is okay), an ultrasound of her heart to be sure that chemo hasn’t caused too much damage, surgery to remove her port-a-cath, and check-ups every six months (for the rest of her life) after all is said and done to monitor for recurrence. Even though that list seems kind of long when I type it all out like that, it seems like small potatoes compared to chemo and radiation.
In other news, I have amazing parents. (Wait, everyone already knows that! I guess this doesn’t count as news, in that case?) Tim’s car has long had a DNR (Do Not Resuscitate) order, but we’ve been fixing it anyway, so it would continue to hobble along. The engine light has been on almost as long as we can remember, but this week it started making an ominous rattling sound. Not good. But my parents have come to rescue! To keep us from having the stress of figuring out how to manage with one car, they have stepped in and financed a new car for us. They have been helping us all along, but this big burst of help and generosity at the end of this terrible journey is above and beyond, and we are so, so grateful.
It is beginning to look like there could be a restful night in our near future.
Finally, I’m going to leave you with a playlist. Radiation can take a while, and they don’t want you to be bored and uncomfortable as you are strapped (and head-locked) to the table. So, you’re allowed to bring in your own music. This is Phenon’s playlist that she listens to as she’s going through radiation.
- Marry the Night (Lady Gaga)
- Rumour Has It (Adele)
- Distance (Christina Perri)
- Alice (Avril Lavigne) This one sounds like an anthem for getting through radiation to me!
- Arms (Christina Perri)
- Blackbird (The Beatles)
- Someone Like You (Adele)
- Penguin (Christina Perri)
- Uptown Girl (Glee Cast Version)
- Set Fire to the Rain (Adele)
- The Edge of Glory (Lady Gaga)
- Sad Song (Christina Perri)
- Rolling in the Deep (Adele)
The staff play this music loud for Phenon. Even with the thick, radiation repelling door closed, you can hear her music blasting down the hall. It’s almost like it’s all been a f**k cancer party, all along!
Radiation began Monday, and we think it’s going to be fine. The staff are amazingly solicitous and lovely, and they provide lots of candy for each accomplished event. Seriously. Last night, three different staff members ran to Phenon with tootsie pops after radiation was finished. Then a fourth asked her about her favorite kind of candy. Phenon had a very difficult time thinking of a favorite, but was pushed and pushed, so finally she said, “Reese’s peanut butter cups.” The technician exclaimed, “Yay!” and ran away, only to return moments later with the very same. My goodness. There will be no problem with weight loss during radiation!
The first night of radiation was an ordeal. They were having problems with their computer, and the lining up of Phenon with the xray on which they made the radiation plan. See the laser levelers like you use to hang a picture in your house? That’s what all the flourescent pink lights in this picture are:
They kept having to tilt the table, or the cushion she was on, by one millimeter at a time, and then the stupid computer would re-set the original settings and they would have to start over. So her half-hour appointment turned into three full hours. This would not have been a big deal, because the staff are fun (and, don’t forget, they bring candy to EVERYTHING), and they play music throughout, and generally try to make radiation as much of a party as they can. However, to get Phenon’s head positioned properly, she has to wear a mask. And that mask was jamming the head “cushion” into the back of her head for more than an hour. And it gave her a horrible, terrible, no-good, rotten headache.
To me, this mask looks horribly clausterphobic, but Phenon said it doesn’t bother her and it’s generally comfortable. For a few minutes. But the mask does leave funny marks on your face and head, just so you know.
They also have to draw lines on you in sharpie to make sure they are sending radiation to the EXACT right spot. Good thing it was wacky day at school on Tuesday – that’s how she explained the sharpie lines she couldn’t get off with alcohol.
The lines on her throat are special. They are to line up the block over her vocal cords. Originally, Dr. Talk told us it wasn’t an option to cover Phenon’s vocal cords for the radiation because you have lymph nodes right behind your vocal cords that you want to hit with the radiation. If you cover the vocal cords, you increase the chances that the cancer comes back there in a more aggressive, bad-ass fashion. But we pushed and pushed on that, because he also indicated that radiation can cause permanent damage to your voice. We were agonizing over the thought of damaging her voice forever (some reports I read on the, ahem, internet, indicated discomfort in speaking voice that happened after talking for just a few minutes) only to learn in 10 years that radiation was unnecessary for people in Phenon’s position. That was intolerable. So, we kept pushing. Finally, Dr. Talk came to a compromise. They do radiation from the front and the back of her body, so they decided to shield her vocal cords from the front, but still do radiation from the back – that way they can hit the lymph nodes that are behind the vocal cords, and thus NOT increase her risk of the worse cancer coming back there. Her vocal cords will still get radiation, but only very small amounts, which should end up making no detectable difference in her voice.
In the end, Phenon got through the first night of radiation, but it was worse than she had hoped for. But the actual treatment was not painful, and we were able to get home by 8:30pm. At which point I promptly passed out on the sofa.
The second night, WE were the problem. We had a series of minor delays that added up to a major delay getting to the hospital (for example, Phenon spilled apple juice all over her clothes so badly that we had to stop and get her new clothes!). But the staff were accommodating and kind (didn’t seem to reduce the candy offerings at all!), and the treatment took only about 30 minutes this time. They said it should genuinely be 15 minutes by the time they get the routine down, hopefully by the end of the week.
Phenon has radiation every weekday until March 26, which is the last day of treatment. Really, really, really looking forward to that.
In other news, the Make-A-Wish team came to our house on Sunday afternoon. This was very exciting. We got the sofas cleaned so our little dog’s bladder issues wouldn’t be so obvious and the MAW team would have someplace pee-free to sit! The team (Linda and Tina) were lovely, and came bearing presents for both Phenon and Rowan. They had a nice long chat with the us, and Phenon settled on a request for a Royal Caribbean cruise on the Oasis of the Seas boat (zipline on board! Teen “neighborhood”!) to the Western Caribbean (Mexico, Jamaica, Haiti). Day trips to Mayan ruins, swimming with dolphins/sea lions/turtles/horses, snorkeling, glass-bottomed boats, and a helicopter ride for an aerial photography session. Plus, Phenon added on a request for an extra day in Florida at the beginning or end to see our friend Janet’s art studio and to visit with Don and Janet. Hooray! They also asked her to make a back-up wish, so she pushed for a week at the beach with her 9 closest friends (plus one for Rowan), even though bringing friends along is against the rules. We pushed for additional adult chaperones if that’s the wish they make an exception for and grant it. It is NOT my wish to be alone at the beach with 10 teenage girls and 2 pre-teen boys. Seriously.
Finally, the chamber choir website has some audio of the Dallas performance accompanied by a slide show of the trip. Phenon had a great time!
What a difference a second opinion makes! It took a little while, because we were trying to arrange for a consultation with Children’s Hospital of Philadelphia from a distance. Since a physical exam with Phenon yields exactly NO information, we didn’t want to take any more leave time and make the day-trip if we didn’t have to. I was hoping to arrange for them to just look at her PET/CT scans and tell us what treatment plan they would recommend. Turns out the health care system is profoundly inflexible (gasp from shock!). I knew insurance wouldn’t cover the visit if the doctor didn’t physically meet Phenon, so we were hoping to just pay out of pocket for a consultation. But there isn’t even an internal hospital billing mechanism for a doctor to do a consultation without actually meeting with the patient. This was frustrating, time-consuming to discover, and annoying. Shana urged us to let this go, and do our second opinion with Dr. Young Kwok at University of Maryland Medical Center in Baltimore. She told us that he has lots of pediatric experience, and is talented and trustworthy and has come from a different training philosophy than Dr. Dritschilo, so it would be worth getting his perspective.
First a slight aside – our friend Chandra dubbed Dr. Dritschilo “Dr. Mustache.” Our friend Lisa dubbed him “Supermario.” When Dr. Kwok’s resident asked the name of the first opinion doctor, those were the only two names I could remember! I had to text Tim and ask him to text me Dr. Mustache’s real name! So embarrassing!
Anyway, go visit Dr. Kwok we did. This is him (current picture, as far as I can tell). Whereas Supermario was fairly close-lipped and “not the world’s greatest communicator,” Dr. Kwok talked and talked and talked and talked. He talked about the unlikely success of a career in music and lectured Phenon for a LONG time about alternate career options. He also discussed the importance of the specifics in taking care of her health and breasts in her 20’s, then how it would be different in her 30’s, and then how it would be different in her 40’s, and then how it would be different in her 50’s. Our 1 hour appointment took 2-1/2 hours – and not because of hospital math or a long time in the waiting room. Nonetheless, he answered all of our questions, and was very familiar with the research. And his treatment plan recommendation was EXACTLY THE SAME as the one proposed by Dr. Mustache. Shana strongly concurred with both recommendations, and feels that the plan is sound. The plan is to do low-dose radiation (21 Gray or 21Gy) to the full original affected area (neck, clavicle, right lung), and slightly higher dose (24Gy) to the remaining mass. Dr. Mustache was very squirrely about specifics with us, but got very specific on the phone with Shana – thus, while he said to us that he could go as high as 36Gy, he told Shana that he would not go higher than 24Gy. This is really important, since 30Gy causes spine damage and would likely cause her spine to stop growing. Since Phenon is, ahem, somewhat smaller than her friends:
Growth, therefore, is actually really important. In the end, everyone agrees, and that makes me feel better. But the Baltimore doctor did earn the nickname “Dr. Talk” from us.
Given that both radiation oncologists left a little bit to be desired in the bedside manner department, how did we then pick which place to go? It was EASY, actually. Although it is only 11 miles from our house to Dr. Mustache’s office, it took a full 50 minutes in what I would consider “moderate” city traffic. It is 39 miles from our house to Dr. Talk’s office, but it only took us 42 minutes in “typical” traffic on that route.
Also, Georgetown’s radiation department is in a dank, depressing basement area that is clearly designed for adults. They treated Phenon like an overly needy adult. They were shocked by her resistance to the painful tattoos. Since our last post and during follow-up questions, they told us that they see approximately 8 pediatric oncology patients per year. They were friendly, but clearly not so awesome with kids.
At Baltimore, the radiation department waiting room is in an atrium with palm trees and lots of natural light. See? They haven’t done tattoos in 15 years – they just use permanent
marker, which they refresh as needed. Why? Because they don’t see any need to cause a kid pain unnecessarily. They see 3-4 pediatric patients per month. When it was time for her CT/simulation of radiation, they walked me right into the room with Phenon and pointed me to the parent chair. (This is a major contrast with our experience at Georgetown.) They also have a program called “Magic Castle” in which they give each pediatric patient a big present when they finish radiation, so they have something to look forward to as things get tough. They rejected Phenon’s list – the stuff on it wasn’t expensive enough. I know all this stuff is trivial compared to the competence of the doctors and the reputation of the facility, but given the equality of those two things, this place was far better with kids, was more physically pleasant, and Phenon was delighted with them. She said she was looking forward to going there for several weeks. So, like I said, it was an easy decision.
Phenon begins radiation this coming Monday, March 5th. The long-term side effects are bad, but they will be the same no matter where we go. In the meantime, Phenon enjoyed her trip to Dallas with Chamber Choir. Much to my tremendous relief, she had no incidents going through security from the D.C. end. In Texas, they apparently gave her a bit of a hard time, patting down her hat pretty extensively, and painting her hands with explosive detector chemicals. But, the most important thing was that they did not force her to take her hat/wig off in front of the security line, and no private hairless security scan was deemed necessary. Phew! And now we are very happy to have her back home with us!
Since her return, Phenon has been very focused on finalizing her wish trip fantasy for Make-a-Wish. They come to interview us tomorrow (Sunday), and Phenon could not be more excited. Since finding out that she cannot bring friends along for her wish (her longest-standing wish was to bring her 10 closest friends to the beach with us for a week for the fun and as a thank you for the unbelievable level of support they have provided), she has struggled to come up with a vacation magical enough to keep a hold on her. She has narrowed it down to someplace warm and tropical (sorry London and Ireland, which were high on MY list), and possibly a cruise. Last night she found a cruise that has lots of musical theater on board, and makes day trips to various islands in the Bahamas. She has also considered a cruise from Canada to Hawaii with day trips there. We’ll keep you posted, and keep those wonderful vacation ideas coming! (Though you should be aware that anything that has a flavor of being immersed in a culture that does not speak English and having “adventures” seems to sound like too much work for her right now…)
In other news, our friend Beth posted an article that I found really compelling. The author talks about being a cancer “veteran,” and the emotional complications that come with ending treatment. I thought it was interesting that Phenon expressed some of these thoughts almost immediately upon finishing chemo – particularly the ones about missing the nurses and doctors at Children’s Hospital, since she saw them more days than not for three months. How will we find out how nurse Stephanie’s wedding went? Is nurse Jen (from Canada) terribly disappointed in our American winter this year? When will we get to see Shana and Payal and nurse Molly again? Some of the other concerns described in the article seem more adult and long-term focused and I don’t think they apply to Phenon. But I think they do apply to, for example, the parents of a child ending cancer treatment. I just thought it was interesting food for thought, and I’m grateful Beth posted it.
Beth has also contributed to our cancer experience by her celebration of the cancer presents she received during her own treatment for (non-Hodgkins) lymphoma over the past (too many) months. And we wanted to brag for a minute, because we just received one of the best cancer presents EVER – Alison, Gillian, and their girl scout daughters went together and brought us a box containing littler boxes inside. They gave us one box each of every kind of girl scout cookie that exists. Now, how thoughtful is that?!? A short-lived present, but a truly grand gesture for which we are incredibly grateful! Oh, how we love Girl Scouts!
Finally, we had interesting medical news from Tim last night – he has mono! He denies kissing anyone outside this family, at least in recent months. But, if anyone has any information about the exciting activities he’s been engaging in on his nights out with David, feel free to let us know. In all seriousness, though, we are looking forward to getting input from Phenon’s docs on Monday about whether we need to do anything special to protect her as radiation begins. Always a surprising adventure! Have a nice weekend, everyone!
…and a dude who is a comedian who went through chemo…well then this would totally be her!
Shit Cancer Patients Say
I couldn’t think of a clever title for this post – I think my brain may be a bit over-cooked. But I can feel the blog post timer counting down, and thought I’d better post an update tonight, inarticulate or not!
I’m going to start with the lovely things. Rowan won the lottery! A school lottery, but hey – I’m not going to downplay good luck! He will be going to a public magnet school for aerospace engineering. In practice, this means they focus on math and science and they have electives in robotics, astronomy, and computers, and then the usual stuff you can have for electives (he is very excited about art). Rowan is really excited, and so are we. There are very competitive math and science magnets here that you get into through testing, but they all involve doing a huge amount of extra work and much more pressure. We are thrilled Rowan will get to focus on the things that interest him the most without the additional pressure. (To say nothing of the fact that he did not actually test into those other programs. Ahem.)
In other good news, Phenon got the part that she wanted in the school musical. She will be the Artful Dodger in the Musical Adventures of Oliver Twist. This is apparently quite a different show than Oliver, just so you know. (If you want more information about that, you’ll have to talk to Phenon, specifically, because I clearly don’t understand musicals enough.) The other good news is that her part was double-cast, which means she will do some of the shows and her good friend Victoria will do others. Therefore, when Phenon has to miss some rehearsals to do radiation, it will not negatively impact the rest of the cast. It seems a nice, low pressure solution. (Are you catching the theme of my thrill with the low pressure situations right now?)
Also, the radiation oncologist (I think the technically correct term is radiotherapist) said it is safe to postpone radiation until Phenon gets back from her big Chamber Choir trip. Thus, radiation will not begin until March 5th. This is especially nice because a side effect of radiation that we didn’t know about yet is that radiation will cause Phenon to get hoarse and be unable to sing for 4-6 weeks. The timing means she should be able to do her trip, come back and do radiation, and then be fully recovered before Oliver performances begin.
And in even MORE good news, our friend Dan, the Hodgkin’s oncologist, talked to Shana. I’ve known Dan for about 30 years, and even worked for him at the National Institutes of Health for a while. Therefore, I know that he has very high standards for intelligence and competence. He has been extraordinarily helpful in this decision-making process about radiation. Dan’s assessment of Shana was that she is awesome. I already knew this, but for some reason I found it phenomenally reassuring to get affirmation of that from an expert. I believe his exact words were “extraordinarily accomplished and intelligent” and “has an impressive knowledge of the research.” He also said that she was able to have an “incredibly high-octane discussion of Phenon’s case.” My doctor-crush on Shana has now moved into the permanent realm. This is Shana. She is not 10, and this is not an old picture – she really looks like this. I think she is close to my age (maybe as many as 5 years younger?). Remember, you don’t have to be scared about how young she looks, because Dan says she rocks. (Okay, not his words, but wouldn’t you say that’s an accurate summary of what he said?)
So that’s all the awesome that’s been happening. Phenon had her first appointment with the radiation oncologist on Tuesday, and had the radiation simulation this afternoon. It is quite apparent that Georgetown University Hospital is not a Children’s Hospital. They don’t seem quite prepared to talk to parents, and were fairly shocked that I wanted to be in the room to hold Phenon’s hand (at her request) as she got her first two tattoos ever. (The amount of pain she experienced suggests that these may be her only tattoos ever, so I feel honored to have been able to be there for them.) I was not allowed in the room for the CT scan. Phenon was okay with that, but it was strange that it was not an option. At Children’s, the parent is in the room for CT’s and all other procedures unless the teen specifically requests that you NOT be there. They also don’t seem to have much practice talking to teens. They do have a nice cartoon book for little kids to explain radiation, though.
The radiation oncologist’s name is Dr. Anatoly Dritschilo. This is him. I think this picture is not entirely recent. Today he said that they had previously been unable to open Phenon’s original PET scan, and they were just able to open it before we arrived to the simulation appointment. Dr. Dritschilo said that the PET scan suggests they need to revise their treatment plan entirely. He wants to widen the radiation field beyond what we had previously discussed. (So, instead of neck, clavicle, and the center of her chest, he wants to add her entire right lung.) He also believes that the lower dose radiation will be insufficient. When asked about long-term side effects, he listed all of the things we already knew about. But he added that Phenon will require twice yearly check-ups to screen for spine cancer in addition to all of the other problems we wrote about here. That knocked the wind out of me a little bit. I’ve requested a copy of the treatment plan.
It turns out that Dan has known Dr. Dritschilo since the early 1970’s. He went to Harvard and has been the head of the radiation department at Georgetown for most of his career. This is impressive. And I know from the psychology literature I had to learn from all of my years of learnin’ that doctors with many years of experience more accurately and efficiently can identify what to do than anyone else, but also may have more difficulty explaining how they know what they see and what to do. This is also reassuring. Nonetheless, I think we are going to get a second opinion. Apparently there is a much broader range of decision points in radiation than there is in chemotherapy, and that means that clinical opinions and experience can result in dramatically varying opinions about treatment plans. If we are going to do a higher dose of radiation, and a broader radiation field, and her spine is in the mix along with all of the other important parts, I think I’d really, really like to know that it’s because we’ve got to. Before knowing who the doctor was, Dan suggested that we might get a second opinion at Children’s Hospital in Philadelphia. Apparently their radiation team is pretty awesome. It seems the next few weeks may not include enjoying time away from hospitals.
I feel like I’m behind the ball in learning the radiation terminology, and want to get fluent faster, if I can. It seems important that I understand this shit better to be able to focus on asking really good questions. If anyone reading this has the ability to give me a primer on the terminology, I’d really appreciate it.
I really, really, really hate cancer. And that is all.
Thanks so much to everyone who sent us questions. It was very helpful. On Friday night, Shana (the attending doc) spent about 30 minutes on the phone with me talking through questions, research studies, hunches, and moral implications. As a side note, I’m extraordinarily impressed by Shana’s ability to make me think she has all the time in the world to answer my every question. I’m sure she doesn’t, and I’m sure she had a time limit, but she gave me not a hint of limitation. She offered to talk to me for as long and as many times as it took to make a decision. That seems very impressive to me.
The bottom line is that we have decided Phenon will do the radiation therapy. By we, I mean all of us, including Phenon. She wanted to be involved in this decision, including wanting to know about all of the long-term side effects. For some things, she has not wanted to be involved in the decision. I’ve been impressed by her ability to determine which details she is willing/able to handle.
So, that was the bottom line. Now for the detail.
As I previously mentioned, our biggest concern was the long-term side effects of the radiation. They include breast cancer (15 times the risk of the general population, which is a lot), higher mortality rates from breast cancer, lung cancer, thyroid cancer, heart disease, and stroke. Shana agreed that these are risks, but also pointed out some details of these studies that I had not attended to. To determine the long-term side effects you have to treat someone, and then follow them for 20 to 30 years. That means that the current data is about people who received the doses and frequencies of radiation that they gave to kids 20 to 30 years ago. The treatment back then involved much higher doses of radiation than they give now. Shana said that there is NO data yet about the long-term side effects of the current doses of radiation. Presumably, the risk is lower than the current data suggests, but we don’t know how much lower. It could reduce the risk just slightly or by a huge amount. We are entirely shooting in the dark on this one, but I do feel a little better knowing that the risk is probably at least a little bit lower.
The research data on the usefulness of radiation studied two groups of kids: Early Responders and Late Responders. Early Responders do not need radiation. Late Responders must have radiation. Phenon isn’t either one. In fact, she’s squarely in the middle. Therefore, there is NO data that says what she should do. So, for all of you who asked what the data is for other kids in her situation, there is NONE. Everyone just has to make a guess. Even though I profoundly hate having to guess when the stakes are this high, I really did feel reassured by Shana saying that whatever decision we made would be reasonable based on the lack of real data. She made it alright to go either direction, which somehow made it a little easier to consider all options more rationally.
PET scans have only been used as a diagnostic tool in Hodgkin’s for the last 2 years or so. Therefore, there is NO data on the relative usefulness of the negative PET in determining whether or not someone needs radiation. Based on her experience, but not on hard data, Shana estimated that there is only a 5% risk that there are still any malignant cells in the mass still remaining in Phenon’s lung. Shana said she would be comfortable with a decision to not do radiation. She feels like a 95% chance of a cure is a good gamble, if we choose to take it.
However, here’s the rub. If we followed Phenon’s idea (wait 6 months, do another PET), if there was any PET activity, radiation would not be enough to kill the cancer. It would be a new, more resistant form of Hodgkins. The treatment for that is a higher dose and longer course of chemo, higher dose radiation, PLUS stem cell transplant. All of these would have significantly greater side effects than the low dose radiation she could get right now (remembering that all of the awful side effects are well-established for the high-dose radiation).
Kids who are given the FULL range of treatment indicated by their status as Early Responders or Late Responders have a 13% chance of having the lymphoma come back. If you add the 5% chance that there are still some malignant cells in Phenon’s mass, that’s about an 18% chance that she would need that longer, more intense, higher side-effect treatment. (Don’t worry, I know that math is a little bit suspect, but since it’s all based on guesses, not science, I decided to not get too hung up on the adding apples to oranges aspect of that.) Thus, giving Phenon radiation now could reduce her risk from a 1 in 5 chance of recurrence to a 1 in 7 chance.
We took the whole weekend to digest the data. I spoke with a long-time family friend, Dan, who is a Hodgkin’s oncologist for adults. His instinct was to do the radiation also. He’s also going to talk to Shana, and send out all of Phenon’s data to his network of friends and colleagues who are pediatric Hodgkin’s specialists for additional opinions, as well as to some radiological oncologists. Dan said his assumption is that all will say the same thing as him (and Shana), but he wanted to see if he could find anyone who would disagree and what argument they would offer that he might not have thought of. Tim’s cousin also sent out Phenon’s information to another family member who is a pediatric nurse at another Children’s hospital, and she argued that a short course of low-dose radiation was worth the risk to try to reduce the chances of needing to do the second occurrence treatment that comes with much worse effects.
Given all of that, we are 98% committed to doing the radiation. (We will only change our minds if we get some compelling arguments from some of the other experts this week.) The short-term side effects are not nearly as bad as chemo. She will likely be fatigued, but not dramatically so. Also, there is the possibility of burns. However, they are usually no worse than a sunburn and are generally treated adequately with salves for sunburn. Payal thinks that Georgetown can accommodate her school schedule, so she should be able to go to school full-time and just go to radiation every afternoon. It will be 14 days of treatment, weekdays only, so nearly three weeks. We think this means she will start at the end of this week and be finished before the big Chamber Choir trip to Dallas at the end of February.
One of my big goals in all of this was to be able to explain our decision very clearly to Phenon later in life. If, God forbid, one of the horrid side effects comes to pass, I want to be able to explain to her, logically and with adequate detail, why we made the decision we did based on the data we have. I feel like we’ve gotten there. All of this may be a guess, but I think it’s as well-educated a guess as we can muster. And that, as they say, is that.