Chemotherapy/Immunotherapy

My oncology team recommended, in addition to thirty-five radiation treatments, eight infusions of Cetuximab.

Cetuximab is not the only medical (pharmaceutical) option for treatment of head and neck cancers. Other agents, such as Cisplatin, fluorouracil, Paclitaxel, and more, are used depending on each specific patient and recommendation of the oncology team. In my case, Cetuximab is considered to be effective for advanced stages of squamous cell head and neck cancer. The benefit for me is that it has fewer side effects than Cisplatin, which would be the next choice.

Surgery, radiation and chemotherapy were all considerations for my disease. I wanted to know why I needed chemotherapy in addition to radiation therapy.

Although surgical advancements are being made at a rapid rate and my surgeon has my full trust, surgical treatment can carry a risk for significant function and cosmetic disability, such as loss of the larynx (voice box), and/or mandible. My surgeon never suggested I begin with a surgical option, as he felt there were successful ways to treat me that would avoid such risks. If any cancer remains after my courses of radiation and chemotherapy, I was told surgery could be an option, but would be limited to specific areas of known disease and less extensive. We hoped no surgery would be required, and this was a better option in my mind.

Radiation is directed to areas where I have known disease and areas where the disease is most likely to spread. Fortunately, doctors today know a lot about how squamous cell tumors at the base of the tongue spread to defined areas, and those are the areas that receive attention.

My PET scan showed that my cancer has not spread past my neck. It has looked at other areas where this cancer spreads, such as the lungs. I don’t show cancer in these areas, or anywhere else that was not already known. So far, so good.

But might there be areas of microscopic spread that do not show? Not likely, but not impossible. This is where Cetuximab comes into play. Cetuximab will improve the effectiveness of radiation therapy, and thus the success of my cure. Cetuximab (Erbitux) is a chemotherapy agent called a monoclonal antibody that kills cancer cells in a different way.

How does it do this? This question is best answered by oncologists, but a brief explanation would be that what a monoclonal antibody does is work with the body’s own immune system to attack cancer cells. It does this by blocking the function of a protein carried in cells that causes the cells to grow and divide (EGFR, or epidermal growth factor receptor.) When introduced into the body, Cetuximab will bind with and “tag” the cancer cells so that the body’s immune system seeks out and kills the cancer cells.

One can see that man is working hand in hand with God here. The medical scientist finds a way to prompt God’s handiwork to do the job, and we marvel at the result.

I have already described my first infusion, but now will provide more detail.

My infusions will take place once a week but I have radiation treatments daily Monday through Friday. Since “chemo day” happens on the same day I have a radiation treatment, it’s always a long day. I prepare for that by packing a little insulated bag with what I need for the day, and assemble comfort items for waiting periods. The bag was a gift from a friend received from an organization called #BetterEveryDay that supports people receiving cancer treatment. You can locate them on Facebook.

I bring a snack, lunch, a spoon, some containers with mouth rinses, skin lotion, hand sanitizer, and any medications I will need throughout the day. The infusion nurses will provide me with water and tissues, and will give me a warm blanket, but I find it helpful to also bring a throw or sweater. I dress in comfortable clothes.

Although I’ve not had a problem, some of the medications I am given may cause drowsiness or make me ill, so Chris does the driving. This allows me to get some things done while he drives, like using a mouth rinse or doing speech therapy exercises. Only one guest is allowed in the infusion room.

I bring something to entertain myself during the wait, usually my Kindle and my iPhone. There will be time between appointments and the infusion will take up to two hours.

When I enter the large waiting area, I sign in at a kiosk and receive a registration number. When my number is called, usually only a few minutes, I proceed to one of ten registration stations. An attendant looks me up on a computer, finds my registration, and confirms my name and birthdate. An appointment packet is printed and handed to me, I am signed in, and I return to my seat, waiting to be called for lab tests.

Soon a medical assistant calls my number and I follow the assistant to a room where my blood is drawn. Two tubes are taken. The lab will do a blood count, blood chemistries, and a magnesium level, since Cetuximab depletes magnesium. After my blood is drawn, I return to the waiting room again.

Before long I am called to an exam room by another assistant who takes my temperature, oxygen, weight, and blood pressure. A nurse practitioner then enters the room and goes over my condition, complaints, and answers questions, entering all the information into a computer. She then listens to my heart and lungs, examines my mouth and any areas of concern I may have, and checks my back and abdomen for tenderness. She spends as much time with me as I need until all questions are answered.

My oncologist then comes in, having reviewed the information, does another examination, and answers any additional questions. By that time my blood tests have been completed, and the infusion for the day is ordered, the dosage calculated and sent to the pharmacy to be prepared. I have been told that multiple checks of doses are done between the doctor and the hospital pharmacist to insure accuracy.

I then walk over to radiation therapy for the day’s treatment, and then return to medical oncology. I check into the infusion laboratory and wait to be sent back to the infusion room (pod). I make use of time between appointments to eat a snack, take medications, apply skin lotions, or complete other items on my daily care list I can fit in. My waits are relatively short, and I move quickly from one appointment to the next. Nonetheless, I am beginning to feel the effects of a long day.

I am greeted by the infusion nurses and taken to a reclining chair. There are ten “stations” in the room, some more private than others.  I place my belongings on a guest chair and make a trip to the restroom. I know that the fluids that will be “pushed” into me in the next couple of hours are going to make me uncomfortable if I don’t start with an empty bladder, and, in fact, maybe even if I do.

When I return I settle into my recliner, put my feet up, and wait for my nurse to put in an IV catheter. I watch her assemble what she needs, use sanitizer on her hands, and put on gloves. She looks at the backs of my hands and wrists to select a vein, and scrubs it with an alcohol wipe. The catheter is flexible and very thin and I only feel a momentary sharp pinch. I am fortunate that I have good veins in both hands, so this almost always goes smoothly for me, and I have little discomfort. She tests the line by flushing with a syringe of saline, and pulls back to be sure blood returns into the syringe to assure it is working properly. Sometimes this feels cool.

The nurses are friendly and we chat while this goes on, getting to know each other. One of them is someone who worked with me years ago and we catch up, sharing memories and laughs. The atmosphere is light and positive.

Once my IV line is inserted, I am given pre-infusion medications. Before this is done, I am asked to identify myself, my wrist bracelet ID and my medications are scanned into a computer on a rolling stand. It is reassuring to know that this precaution is taken and I cannot be given the wrong medication in error. I receive three pre-infusion medications through the IV: Benadryl prevents allergic reaction to Cetuximab; Decadron helps to control nausea and boosts the effect of Cetuximab; and Aloxi is given to prevent nausea.

Many patients will need only the Benadryl. Nausea is not a common side effect of Cetuximab, but I am exceptionally sensitive to nausea and vomiting. My first infusion demonstrated that. This is not just a comfort issue, as nausea will prevent me from eating, and eating is vital to the success of my therapy.

The three syringes are injected into my IV. Aloxi will burn if it is injected too quickly, I discovered, so I remind my nurse to inject slowly, and there is no sensation except sometimes of coolness. After this is done, I will need to wait up to thirty minutes for the medications to take effect.

When the time is up, two nurses arrive with a small bag of clear fluid, which is my infusion of Cetuximab. It has been prepared in the pharmacy shortly before my arrival. Again the bag and my wrist ID are scanned, and one nurse repeats my name, reads the label on the bag, and sets the program on the pump that dispenses the Cetuximab, while the other nurse confirms the information with the order in the computer, the settings on the pump, and records the details of the infusion. Check and double-check. The bag of Cetuximab is hung on an IV stand, attached to the pump and to my IV, and Cetuximab begins to drip slowly into me. I don’t feel anything unusual during the infusion, which will take an hour.

Although I’m prepared with reading material and the general atmosphere is relaxed, I find that I have little desire to read, despite the fact that I am a lifelong avid reader. I usually unpack and eat whatever I have brought for lunch, and then I generally lean back and shut my eyes. I may check or send emails or texts, and sometimes I sleep briefly. Although the hour usually goes by quickly, I may need to make a trip to the restroom. This may seem awkward, but the infusion pump runs on a battery and is easily unplugged, allowing me to roll it to a nearby restroom without assistance.

When the infusion bag is empty, the pump beeps and the nurse returns to disconnect me, remove the catheter, and send me on my way. By now it is late afternoon or even early evening, my day is done, and Chris and I head out to fight rush hour traffic. I will eat something as soon as I get home and check off everything essential on my daily medical to-do list, as I am tired now and will want to crash at the first opportunity. And I do just that.

I must stress again that every patient has a different experience. Some feel weak or ill after chemotherapy, but I found that the premedications I was given before my infusions actually gave me two days when I felt a little better, since I was free of nausea and the Decadron gave me a little energy boost, although I was also a little “fuzzy” in the head.

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