Meeting with Oncologist

We met with Oncologist this morning. He had a completely different perspective, it seems, for treatment priorities and timing of treatments. We had looked him up on the internet (Dean web site) and Debi said he didn't look as scary in person.

He took a complete history (it seems like we need to do this for every doctor we see - and they're all using the same software and accessing the same databases). He wanted to know all about my family - parents, siblings and children. He was amazed that I don't take any medicine (every doctor is amazed at this - maybe my brother is right when he calls them all pill pushers). He wanted to know about any aches and pains; problems climbing stairs; whether we own a house; problems with any bodily functions. These were new questions. (I need to start a log of symptoms, treatments, visits, surgeries, etc. )

He was very much in favor of beginning chemo even before surgery. He says there is no evidence of spread (based on CT scan and observation) but it only takes one or two cells getting into the liver or bones to cause problems in the future. He maintained"you can live without a bladder but not bone, liver, or kidney.

He is strongly recommending a course of neo-adjuvant chemotherapy. Start right now and attack any cancer that may be floating around - both in the bladder and anywhere else it may be - and then have the surgery to remove the bladder. The alternative is to wait till after I recover from surgery and then begin chemo. This will delay beginning this attack for months while I recover from surgery which would give any cells that may be outside the bladder time to take better hold in these other places and even spread more.

He says what we're going for is disease free in 10 years not only survability. There's a big difference.

At least a two month course of 3 per month with one week off between. If I tolerate the therapy we might do more. The total he recommends is 6 cycles. This can be split before surgery and after. Or all at once.

He really shocked us by asking if I wanted to start today!! I recoiled at first but after a while I reconsiderred. He said it probably was best to wait till next week to give me a chance to consider. His arguement was that there are risks and if we jump into this without due consideration, I may feel like I was forced and regret it later.

The treatement he recommends is based on Cispatin with
gemcitabine/cisplatin (jem-SITE-ah-been-sis-PLA-tin)

From Cancer Society Web Site; "A chemotherapy combination used to treat malignant mesothelioma, advanced non-small cell lung cancer, advanced bladder cancer, advanced cervical cancer, pancreatic cancer, and epithelial ovarian cancer. It is also being studied in the treatment of other types of cancer. It includes the drugs gemcitabine hydrochloride and cisplatin. Also called gemcitabine/cisplatin regimen."

He has scheduled me for the following (unless I change my mind):

• Tmt one - Aug 10 with gemcitabine/cisplatin combination for 5 hours. The length of time for this first treatment is because cisplatin can be very hard on the kidneys and must be administered very slowly and with lots of fluids. Otherwise it can build up in the kidneys and cause damage.
• Tmt two - Aug 17 with gemcitabine alone for 45 min.
• tmt three - Aug 24 with gemcitabine alone for 45 minutes.
• one week break and the repeat this cycle for at least one more before surgery.
  

There are two studies listed Cancer.gov web site relating to neo-adjuvant chemotherapy (pre surgical):
First from 2000 where they spacifically studied bladder cancer. The results were clear but the study was relatively small and that 7 previous studies had failed to detect any benifit to this approach. This study used three rounds of chemo prior to surgury with another Cisplatin based regime (MVAC - methotrexate, vinblastine, doxorubicin, and cisplatin).

The second study sited was published in 2010 and was on biliary tract cancer (liver associated) in locally advanced stages or metastatic (spred into system). They compared cisplatin alone and cisplatin with gemcitabline regimes. This study was aimed at a condition is relatively rare and nearly always fatal (5 year survival is 15 percent). This treatment was very successful at increasing the number who had progression-free survival. The disturbing result was the side effects of the therapy. Althought noone died due to the treatment there were hematologic toxic effects in 32 percent of the patients who were given the gemcitabin/cisplatin regime.

Or oncologist says they have learned how to mitigate these effects and he assures us that the risk is extreemly minimal, especially compared to the potential benifit of increasing the odds of being CANCER FREE after 10 years.

This is all very compelling.