Wednesday, October 22, 2008

October 20th, 2008: Back to the UCSF cancer clinic this morning, and into my first meeting with Dr. Daud who specializes in melanoma treatment. For the first time, I was on my own this morning. After many visits, I think it’s best to have an extra set of eyes and ears, but I also have a good history of staying in my body while taking notes and talking with the doctors. Dr. Daud started by asking about my previous melanoma excisions done by dermatologists on an out-patient basis, first in 1997 and again in 2004. Since my margins were clean after the melanomas were removed, there was no follow-up radiation or chemo at either time. Then, Dr. Daud called Dr. Christman who had performed the 2004 melanoma removal. He found that she had sent the tissue samples to the UCSF pathology lab for healthy verification. It’s likely that the samples as well as the history of the removal—depth of tumor, etc.—were still on record at UCSF. Then, Dr. Daud promised to present my case to the melanoma tumor board that meets this very day. I’m also going to be presented at the sarcoma tumor board this Friday, Oct. 24th. All this attention is good.

Bottom line: it is still not certain what type of tumor I have. After Dr. O’Donnell’s open biopsy, the estimates lean toward melanoma. However, the biopsy results are still not back from the pathology lab. Given these unknowns, Dr. Daud moved forward and said, “Let’s suppose that what you have is a melanoma. We can talk about types of treatment.” So that’s what we did. He started by talking about the Immunological drugs, such as Interluekon 2 which is quite toxic and requires a stay in the Intensive Care Unit (ICU) during administration. Then, there are the chemotherapy drugs, some of which have been used for up to 30 years. Newer chemo drugs are also available, and they may be used in combination to maximize effectiveness. The caution is that two chemo drugs used together also multiplies the side-affects. Additionally, there are clinical trials that Dr. Daud participates in and I may qualify of one of those. These are experimental protocols testing new drugs or new combinations of known drugs. Point being, there are several treatment options.

It seems that there are genetic variants between melanomas that occur on the head and neck and melanomas that grow on the back (and possibly others as well that didn’t apply to our discussion). My melanomas were both on the upper back and these tumors are characterized by the presence of BRAF inhibitors. Check this out for yourself on Google.

So, what’s the plan? Dr. Daud’s strategy is to first verify that this is a melanoma. If yes, then we can start me, say, early next week on a chemo combination that has a good probability of being effective. Baring a violent allergic reaction (something that isn’t a part of my medical history) I would complete the six to eight week course of treatment. Scans would monitor whether the tumors are responding or not. If the tumors don’t substantially decrease in size, then we proceed to the next drug regimen. All of these courses of treatment have their own pitfalls with fatigue, nausea, and the lurid list of chemo side effects. If this is not a melanoma, then I move back to the sarcoma side of the house and consult with Dr. Jahan who was initially recommended ages ago (four weeks, actually).

The effectiveness of these programs is surprisingly low. Some drugs have 15 to 20% effectiveness. Others are as high as 20 to 30%. That was hard to hear since those seem like very low odds. However, Dr. Daud reminded me, each time you enter a new program, you increment your chances of effective treatment. So, two treatments, one 15% and one 25% equals a 40% chance of finding something that works. Of course this is not exact math, but you get the idea.

At the end of the interview we discussed time. “You don’t have a lot of time,” Dr. Daud cautioned. It has already been eight weeks since the tumor was discovered and the cancer has grown at several sites during that time. Eight weeks is approximately one treatment cycle. I can’t recover that time. So the urgency is to identify what I have and get me started on a drug treatment most likely to be effective.

Two things I liked about this guy. First, he has deep experience with melanoma clinical trials so he’s a cutting edge guy. Second, he had broken his leg while roller blading, so he likes to be out there sailing through the air.

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