Chemo 1A in Review

It has been two weeks since I completed my first chemo treatment and tomorrow is treatment 1B.  At this point I feel mostly normal with the exception of some slight neuropathy (numbness) in my fingers and a really annoying mouth sore.  Both are fairly common adverse effects of ABVD/SGN-35.  The lymphadenopathy in my neck has reduced greatly and I have not experienced any B symptoms since treatment day.

Here is a daily breakdown of my experience starting with the day after 1A infusion:

Wednesday: I was moderately nauseous and fatigued but never felt like I was going to vomit.  Appetite was normal but food, especially water, tasted strange. 

Thursday: Nausea was about the same as Wednesday but I had no interest in food at all for most of the day; all I could stomach was ice cream and a small amount Gatorade.  I was very fatigued and spent most of the day in bed.

Friday: Morning and afternoon were similar to Thursday.  I spent most of the day in bed and didn’t eat until 3PM, but I did go out in the evening and did not feel terrible most of the time I was out of the house.

Saturday: Nausea had mostly subsided by Saturday morning, but I was still very fatigued and my back and legs were very sore (probably due to spending a lot of time standing the night before).  I did not eat much during the day and spent the day in bed but the guys came over for poker in the evening and Timbe brought me turkey dinner leftovers (thanks again dude), which probably meant I ate a sufficient number of calories for the day.  Dinner Saturday seemed to stimulate my appetite; I was hungry again not long after and have not had any issues eating since.

Sunday: Still very fatigued and sore.  Spent most of the day in bed.

Monday-Wednesday: Fatigue had passed and I was feeling pretty normal in the morning but in the afternoon of each day I started feeling nauseous again (WTF; I thought I passed that part already).

Thursday: Nausea passed and my energy levels were pretty good. Numbness in my fingertips started. 

Friday: Developed a mouth sore.  It is not in an area I chew with so it does not interfere with eating too much, but it is painful and annoying.

Saturday-Current: No change. 

I spoke with my Onc yesterday about the nausea and loss of appetite and we decided to adjust my antiemetics for the next treatment.   In addition to the previous protocol I will take Aprepitent (Emend) the day of chemo and for two days following and will take Ondansetron (Zofran) the day after chemo (as opposed to only on the day of).  Hopefully this will do the trick.  In the 10 days following chemo I lost 6.1lbs; we do not want that happening again.

The Last Supper and Chemo 1A

Since I’m not supposed to eat raw meat during chemo (due to risk of infection) the guys and I went to Sushi California in Coquitlam for my final sushi meal.  Sushi Cal has the best spicy tuna sashimi I have ever eaten (and I have tried it at over 40 sushi restaurants in the GVRD).  Julio the Judas did not show up so he will have his legs beaten next week.

Spicy Tuna Sashimi :)

My first chemo treatment was yesterday and went smoothly.  The chemo ward is on the top (6^th) floor of the BCCA; the south side view of Vancouver is excellent.

Infusion started at about 9:15AM after I took my oral antiemetics (12mg Dexamethasone and 8mg Ondansetron).  Accessing my portacath was slightly more uncomfortable than a normal needle poke but was much more comfortable than a peripheral IV once the needle was in.  

The IV drugs started with the ‘Red Devil’ Adriamycin.  Some people can taste this drug (apparently it tastes metallic) and it often causes them to hate drinking red drinks.  I felt a bit of warmth in the back of my throat with a hint of taste but nothing significant; I sucked on a lifesaver, which easily overwhelmed this taste.  Adriamycin also turned my urine red; this could have been disconcerting but I expected it.  Next up were Vinblastine, Hydrocortisone (a steroid to help with nausea and appetite), and Bleomycin (the bastard that can cause lung damage).  Finally we finished with Dacarbzine, and while it is a clear liquid, it comes out in a dark brownish green bag to protect it from light.  We finished with the trial drug SGN-35 (Brentuximab Vedotin).  Infusion finished at 12:35PM but I was not yet free to go.  They needed to keep me for an hour to ensure I did not explode from the SGN-35.  Once freed from the chemo ward I had to hang around the BCCA for 3 more hours to give blood at 2:35PM and 4:35PM.  Luckily I PVR’d the Canucks game so I didn’t miss any of the game.  For more details on the drugs see my Previous Post on the subject.

Post chemo I felt mostly normal; I was tired and wanted to go home but other than that I was fine.  I even went to the gym and managed to get about 30 minutes of cardio in.  In the evening I ate normally without issue.  I did have a lot of trouble sleeping.  Despite being very tired I didn’t not get to sleep until about 4:00AM and was awake by 8:00AM; this is a common issue with large doses of corticosteroids.

The day after chemo (today) I have felt pretty good although I have been fairly tired.  This is probably due to the lack of sleep.  My taste is also off: water tastes terrible which is annoying since I am  used to drinking about 8L (2 gallons) per day.  I have been drinking Gatorade 20 (basically diet Gatorade). Fruit does not taste as sweet as normal and ginger ale tastes ‘off’.  The lymphadenopathy (inflammation of the lymph nodes) in my neck and left armpit is greatly reduced especially on the right side of my neck where the tumor was getting very large (about 8cm x 5cm and very thick).   Hopefully I’ll actually be able to button up a shirt now. ;)

The Decision

Yesterday I went to see Doc Restrepo to discuss the SGN-35 and give him my decision.  Before arriving at his office I was pretty sure I was going to join but I wanted to hear what he had to say first.  Doc and I both believe joining the trial is a good decision for me.  The drug’s success rate with relapsed and refractory patients has been excellent and other monoclonal antibodies have been very effective when combined with chemotherapy for frontline Lymphoma treatment.

During the physical Doc noticed minor lymphadenopathy in my left armpit.  This was not present during the last physical.  The enlarged node is approximately 7.5mm (my estimate).   

I have a PET scan scheduled for April 8^th.  Normally in BC PET scans are not done before frontline treatment but it is a requirement for the clinical trial so I will be getting one.  In the US and UK PET pre-treatment PET scans are the standard for staging, but in BC normally just a CT scan is done. PET scans differ from CT’s in that they show molecular activity instead of structure.  This is achieved by injecting the subject with a radioactive glucose analog then monitoring its uptake into cells with a gamma camera.

Chemo will begin on April 19^th 2011.  In case it wasn’t clear in my previous post I will be getting SGN+35 in addition to the original treatment plan of six cycles of ABVD, rather than instead of.

Decision Time

Doc Restrepo called me yesterday to let me know Seattle Genetics has opened a clinical trial for their new drug SGN-35 (Brentuximab Vedotin) that I qualify for. This is a phase I trail for evaluating the safety of SGN-35 combined with ABVD for HL treatment.  SGN-35 will be administered at 0.6-1.2 mg/kg with each ABVD treatment.

SGN-35 is an antibody-drug conjugate targeted to CD30 (that’s the bad guy we want to whack).  Results have been published from two SGN-35 trails: one for relapsed and refractory (disease that resists treatment) HL patients, and the other for Anaplastic Large-cell Lymphoma (ALCL, a type of non-Hodgkin’s Lymphoma).  In both trials SGN-35 was used alone not in conjunction with chemotherapy.  

In the HL trial 75% of 102 patients achieved an objective response (complete or partial remission), as assessed by an independent review.  34% of patients achieved full remission.  Tumor reductions were achieved in 94% of patients.  18 patients discontinued this trial due to adverse events. To qualify for this trail patients must have previously received an autologous stem cell transplant (ASCT, that means they collect your own stem cells before a chemotherapy regimen kills your immune system then transplant the collected stem cells to re-grow the bone marrow).  The median number of previous chemotherapy regimens for patients in this trail was 4 (range 1-13).

The ALCL trial included 58 patients.  All patients had previously received front line treatments.  SGN-35 was administered alone once every 21 days by IV (1.8mg/kg).  86% of patients achieved an objective response to the drug.  53% achieved complete remission. The most common adverse events were nausea (38%), peripheral neuropathy (38% - numbing of the fingers and the toes), fatigue (34%), fever (33%) and diarrhea (29%).

If I decide to join the trail I will have to get several blood test and scans (CT and PET).  This will delay the start of treatment by about two weeks.  Doc Restrepo feels that given the positive response to the Prednisone and Cyclophosphamide I was on delaying treatment will not adversely affect prognosis. While taking the drugs all of my b-symptoms were relieved but since completing the cycle I have experienced some fatigue and discomfort in my neck.  Both are very minor compared to before the drugs but I am concerned that will change inside of three weeks.  I cannot take the Prednisone or Cyclophosphamide in the interim due to the side effects, and as a result I risk the disease progressing in the interim.