Health Update #22: Brainiac

MRI: Not quite sure what I'm looking at here,
but I thought the eyeballs looked cool. 

Teaching 

There are only a few active weeks left in the semester, and my students in creative nonfiction have been incredible. They're a small group of very talented and self-motivated writers and have been gracious about my lapses. I've nearly caught up on scoring and commenting on their work, but there's also a lot of peer feedback and they are all quite skilled at that. Nearly all of the students are writing consultants in either the writing center or the embedded writing specialist program. We had a fantastic face-to-face session this last week with Curtis Chin, author of the new memoir Everything I Learned, I Learned in a Chinese Restaurant. 

Curtis Chin. That's me in the (back left) corner.

I'm thinking that this might be my last semester of teaching, and what a good class to go out on. I'm looking into extending my paid medical leave through May, taking summer off, and considering retiring at the end of the academic year (mid-August), depending on how I feel and what my prognosis is at that point.

New Tests: MRI and Brain Metastasis

There have been a lot of test results and more tests and procedures over the last two weeks. It’s not as scary as it sounds, but the most recent MRI picked up on a small, isolated lesion in the brain: "A new 3 mm focus of enhancement is noted along the left cerebral convexity/left high parietal region. This is compatible with an isolated focus of intracerebral metastatic tumor." That’s the part of the brain that integrates sensory information and controls proprioception, or awareness of the body in space. It doesn’t necessarily affect cognitive ability or language function, though it can cause excruciating headaches and nausea; luckily, I'm experiencing neither at the moment. A little fatigue and shortness of breath, but otherwise asymptomatic. 

The new finding doesn’t change my prognosis; just confirms that this is the path I’m on. Brain metastasis, as we’ve known from the beginning, is a natural progression of lung cancer and a sign of late stage metastasis. It might accelerate the timeline a bit, but my current understanding of the timeline is a pretty wide range anyway: at least months, maybe years. A few (2-3%) have lived for 10 years after brain metastasis. My last reflection on prognosis and longevity included the possibility of brain mets, so there's no real change. That the current metastasis is small, isolated, and asymptomatic is a best case scenario if there is going to be brain metastasis.

Treatment for metastatic brain cancer from the Journal of Clinical Oncology

Now that there’s one spot of metastasis in the brain, we can expect more metastases in the coming months. We’ll monitor it regularly for new occurrences and treat each occurrence as is practical. Right now, that means a single, focal, high-dose radiation treatment in Grand Rapids to cauterize that 3 mm lesion in my parietal lobe. I went in for a radiation simulation this past Monday where they created the frame that goes around my head during the actual procedure. I'll go back to Grand Rapids on Tuesday, November 14th, for actual radiation. The Butterworth Cancer Pavilion in Grand Rapids is very pleasant and professional and only about 3 hours from Chicago.

As I 've mentioned, the MRI results don't really change my prognosis -- just something they were expecting and already factored in. But, you know, it's certainly not a good thing. I have a focal stereotactic radiosurgery (SRS) as opposed to Whole Brain Radiation Therapy (WBRT) scheduled for Tuesday (11/14/23) on the isolated 3 mm lesion in my parietal lobe -- the part of the brain that controls spatial awareness. It’s a perfectly safe procedure with minimal side effects (at most, headache and nausea). They’ll continue to monitor my brain for future metastatic lesions, which they expect to see sooner or later, and will plan radiation as appropriate when they find it. If they come back in multiple spots, they might switch to Whole Brain Radiation (WBRT), depending on multiple factors at the time.  

I also have a procedure to cement the fracture in my sacrum on the Monday after Thanksgiving that should help with the pain in my lower back. There's no risk and high reward to that procedure in terms of pain relief. I'm still waiting to see if the radiation to my rib (5 sessions ending last Tuesday) will relieve some of that pain. With both procedures, I should have much less pain when standing and sitting and walking.

Second Opinion at Northwestern in Chicago

We met yesterday with the oncologist, Dr. G. at Northwestern in the downtown loop in Chicago. She had pretty much identical recommendations as both UM and my current oncologist, but she does recommend that whatever I do, I start immediately and not wait for the new year insurance cycle. So, it will have to be something in Michigan rather than Illinois for now since my insurance doesn’t currently transfer to Illinois. After the new year, once I’m on Corrine’s insurance, we’ll reconsider whether to transfer to Illinois. 

Treatment Recommendations

My previous tests for genetic mutations did not find anything helpful, but Dr. G. at Northwestern recommended that they perform a Guardant Reveal Blood Test for genetic markers since those markers can change over time and my previous DNA tests have all been based on the tissue sample from my original biopsy last March. 

The 2nd line standard of care treatment according to my oncologist (Dr. H), Dr. Q at UM, and Dr. G at Northwestern is an infusion of standard of care 2nd line therapy with docetaxel plus ramucirumab. This treatment is given via a 3 hour infusion at any cancer infusion center every 21 days, so if we went this route, we’d probably start at either Reed City near the lake house as we’ve been doing (but driving back and forth to Chicago) or in Benton Harbor/St. Joseph which is about 2 hours out of Chicago across the Michigan line. Later cycles might be in Illinois after the new year.

The main clinical trial right now at both UM and Northwestern (and pretty much around the country)  is a NSCLC cancer treatment trial called Pragmatica-Lung Trial, a prospective randomized study of ramucirumab plus pembrolizumab (Keytruda) in a 3 hour IV infusion at one of the clinical trial sites, either UM or Northwestern or Rush University. That could start in Michigan (Ann Arbor or Grand Rapids or St. Joseph) though it may be possible to transfer to Illinois afterward. I would have a 50% chance of being assigned to the control group, in which I’d receive the 2nd line standard of care treatment (docetaxel plus ramuciumab) as described above. The potential benefit of the clinical trial is a possible extra month or two survival rate vs. if I had standard of care. And contributing to research, of course.

Whatever we do, the oncologist at Northwestern suggests that we start it right away. The question we face is whether or not it’s worth the side effects and extra hassle of the clinical trial, or if we should go straight into second line treatment. This is the main question that we’ll take with us to our next meeting with our Dr. H. We'll probably talk to him next week. I've already sent him a message.

A secondary question if we start on second line treatment (docetaxel plus ramucirumab) is whether that would exclude us from a future trial with pembrolizumab plus ramucirumab. As a Phase 3 trial, there's an indication that if one has started second line care, they would not be eligible for this trial. We just need to clarify that.

In other words, our questions for the oncologist are:

1. Is it better to initiate Second Line Treatment (Ramucirumab plus Docetaxel) or go into the Pragmatica-Lung Trial (Ramucirumab plus Pembrolizumab)? Whichever one we choose, where should we have treatment so that we balance convenience with cost?
   
   
2. If we choose Second Line Treatment for the sake of starting something right away, does that rule us out for the clinical trial? 

We’ll talk to Dr. H this week and decide on which direction to go from here, hopefully starting treatment by the end of November or beginning of December. Whichever way we go will involve an infusion every three weeks, most likely with similar side effects as last time (hair loss, fatigue, shortness of breath) for either treatment. I plan to schedule treatment so that there’s a period in February or March where I feel well enough to fly down to Louisiana and have Corrine and Priscilla come down as well. And I should be well enough to welcome visitors either in Chicago or at the lake house throughout all of this, I expect, especially if you don't mind my being fatigued.

That's the brunt of the news. Thanks for all the love and support. We'll be in Chicago for the next week or so. We'll return to the Ludington area next week for Thanksgiving with Priscilla, Dan, Connie, Thompson, Otilia, Mikki, Julian, Charles, Corrine, and me. I think we're going traditional turkey and stuffing and sides. After that, we'll probably head back to Chicago for the duration, even if we're traveling to Michigan now and then for treatment or week long summer excursions after the long, cold winter. 

One of the best things to happen this year: Arlo
recorded a birthday greeting for Greg!