Following Up On Issues Raised in Second Opinions

We began our consultation with Dr. Merkel on May 6 by reviewing the issues brought up in our consultations the previous day with Drs. Cobleigh and Kaklamani:

• Re-Test Tumor for HER2 Status

  Referring to Ann’s 2003 cancer treatment, Dr. Merkel agreed that micro metastasis in two lymph nodes was unusual for such a small primary breast tumor. However, he disputed that this quick spreading was due to this tumor being Human Epidermal growth factor Receptor 2 positive (HER2+), which would indicate an aggressive type of breast cancer. He reminded us that Ann did not receive HER2+-targeted treatment and indicated that without such treatment a HER2+ tumor probably would have recurred in just 2-3 years. The fact that Ann remained cancer-free for seven years corroborates that the pathologist’s determination that Ann’s first cancer was not HER2+.

  Moreover, with respect to re-testing her 2010 tumor’s HER2 status, he was not willing to order a re-test at a research laboratory. He challenged the value of any diagnostic test not validated by clinical trials because he would not base Ann’s treatment plan on an unproven test.

  Nevertheless, the HER2 status for the 2010 tumor was equivocal and he was willing to order a second HER2 test for it using techniques established for clinical use. He will arrange to have Mayo Clinic’s regular pathologists re-test her 2010 tumor for HER2 status.

• Oophorectomy to Prevent a Future Recurrence

  We reminded Dr. Merkel that we’d asked his opinion about removing Ann’s ovaries during her first cancer treatment and that he’d advised against it then because it would cause an accelerated shift into menopause and the usual side-effects, e.g., hot flashes, would be accentuated.

  He responded by referring to Ann’s clinical record and noted that hormone tests, e.g., Follicle-stimulating hormone (FSH) and estradiol, on three occasions indicated that her ovaries were no longer producing estrogen. Consequently, an oophorectomy would no longer result in menopausal side-effects.

  He agreed that the idea of Femara effectively reviving her ovaries into producing estrogen, which in turn stimulated a remissive or new tumor, was a good story. However, since there was no clinical evidence that her ovaries were indeed re-awakened, he saw no basis in this mechanism for her recurrence.

  Nevertheless, removing her ovaries would have the benefit of eliminating the possibility of ovarian cancer. He recommended that she consider doing this after recovering from chemotherapy.

• Number of Chemotherapy Rounds (4 vs. 6)

  Dr. Merkel indicated that there is no proof that more than four rounds of Cytoxan (generic: cyclophosphamide) and Taxotere (generic: docetaxel) would be either safe or effective. Nevertheless, he has enrolled other women in a clinical trial to determine the benefits and risk of additional rounds. Therefore, if Ann tolerated four rounds well, he would be willing to add another two rounds provided she acknowledged in writing that the efficacy and safety of the additional rounds is unknown.

  He took issue with Dr. Kaklamani‘s concern that two additional rounds of Cytoxan carried a risk of leukemia. He pointed out that an outdated chemotherapy regime—cyclophosphamide, methotrexate, and fluorouracil (CMF)—had much more Cytoxan than Ann would receive and didn’t show an elevated risk of leukemia.

• Zometa to Prevent Metastases to Bones

  Dr. Merkel has been prescribing Zometa (generic: zoledronic acid) to patients for over a year and would recommend it for Ann too. He recommended administering it—twice a year for three years—concurrently with hormone therapy, after recovering from chemotherapy.

• Genetic Testing

  Dr. Merkel would provide a referral to Dr. Wendy Rubinstein, Ann’s geneticist of choice.

Chemotherapy Scheduled with Dr. Merkel

Having answered all Ann’s issues, our discussion turned to preparation and scheduling for her chemotherapy.

We wanted to schedule Ann’s chemotherapy so that her worst times would be toward the beginning of a week, when Alison would have other activities scheduled outside the house. This would give Ann the best rest and quiet when she needed it most. We reviewed Ann’s experience in 2003 and found that chemotherapy’s nadir was usually a few days after it was administered. Thus, we wanted to schedule Ann’s chemotherapy on Fridays so that she’d be hitting bottom the following Monday when Alison would be gone. However, Ann needs an injection of Neulasta (generic: pegfilgrastim) to boost her white cell count and this is administered the day after chemotherapy. Therefore, the last day of the week for chemotherapy is Thursday because Friday is the last day she can get her Neulasta.

Installation of Ann’s portacath, an ambulatory surgical procedure, is scheduled for Tuesday, May 11. Chemotherapy can’t be administered until at least a week after the port is installed.

Thus, Ann scheduled her four chemotherapy treatments at the Kellogg Cancer Center in Evanston, once every three weeks on a Thursday:

• May 20
• June 10
• July 1
• July 22

Posted by Nello at May 6, 2010 11:40 AM

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