Persephone: Being part of a clinical trial

 

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Greek goddess of Spring and Queen of the Underworld.      Persephone: Winter comes when she is in the underworld, Spring arrives when she returns to earth. 

 

The Persephone clinical trial set out to establish whether 6 months treatment with Herceptin is as effective as 12 months for women with early HER2+ breast cancer.

I was diagnosed HER2+ in 2012 and should point out I quickly established Googling HER2+ can scare you senseless. Almost everything I read suggested my situation was bleak. Looking back, I wish I hadn’t found those articles before talking to my consultant. They created unnecessary stress at a time that was already stressful enough.

My consultant didn’t deny the challenges of HER2+ breast cancer but she strongly emphasised a new monoclonal antibody treatment called Herceptin. In her view it improved the outlook for HER2+ patients considerably, but Google articles had yet to catch up with those developments.

If surgery was followed with chemotherapy and Herceptin, early HER2+ breast cancer was probably as treatable as hormone positive breast cancer. I was lucky – in 2012 Herceptin had only just been approved for people like me and without it I might not have been here to write this post!

I cannot deny chemotherapy was something I hoped to avoid. My aunt and mother went through it but neither survived cancer. Once again my consultant offered helpful advice: chemotherapy and Herceptin could help prevent metastases. No one dies of early breast cancer and for early breast cancer patients, the key to survival is preventing metastases. My loved ones didn’t get that chance, they both had metastases and these treatments weren’t available in the 1980’s and 90’s.

I was prescribed FEC-TH, the namesake of this blog and one of the most effective chemotherapy regimes for my particularly aggressive form of cancer. It was an adjuvant (post-surgery) therapy involving several rounds of intravenous anthracyclines followed by a concurrent taxane plus Herceptin protocol, then Herceptin on its own. At the point of consent, my oncologist asked if I’d participate in clinical trials. Breast cancer wiped out at least five generations of women in my family, all below the age of 50. It really is our family curse. Volunteering for trials was therefore quite easy and even if trials couldn’t help me, the prospect of results that might benefit future generations provided something positive to hold on to during a very turbulent period. Without hesitation, my participation in the Persephone Trial began.

Information about trials

Doctors are obliged to provide lots of information because taking part in a trial means trying something new and unproven. The first thing I had to do was read and digest the information about Persephone and there was quite a lot of it. It told me there could be risks, for example if I was randomised into the 6 month treatment group and this proved inferior to 12 months treatment, the likelihood of cancer returning might be increased.  It explained possible benefits too, for example if 6 months treatment was as effective as 12 months in dealing with cancer, it could reduce the risk that I’d suffer heart damage or a serious cardiac event. (Herceptin and anthracyclines can damage the heart, sometimes irreparably). The information also made it clear that if I was randomised into the 6 month group and decided to change my mind, I could withdraw and receive the full 12 months of Herceptin treatment.  Throughout the trial I’d be closely monitored and if I had any problems at all, I could contact people who’d be able to help.

There was a lot of detail and a lot to weigh up, so if you’re considering taking part in a clinical trial, I recommend reading the information all the way through. Then read it again, making notes on anything you’d like your doctor or trial coordinator to explain.  There are no silly questions so ask whatever you need to know or are concerned about. None of us is forced to participate in trials, but for some of us personal history or exhausting the existing range of treatments makes trials the obvious or only option. In a best case scenario, we benefit as trial participants and the research we contribute to also goes on to benefit future generations.

Follow-up during treatment

I was carefully monitored throughout the trial as well as receiving the same excellent standard of care as non-trials patients. In addition, every three weeks I completed a questionnaire summarising my experiences, sense of well-being, impact of treatment on my general health, any side-effects I’d had, and the financial impact of my treatment. Financial impacts for patients are all too often overlooked – I was glad Persephone included this alongside the clinical factors.  Herceptin caused some problems for me and at one point my treatment was delayed. Fortunately this didn’t prevent me continuing in the trial. Your medical team will be able to tell you what the follow-up involves and how the information is used if you consider taking part in a clinical trial.

Follow-up after treatment

In May this year, Persephone reported on its initial findings after four years follow-up with the original trial patients. I was sent information about the results over the summer. My oncologist will follow-up with me for 10 years because I’ve been a trials patient and further reports from the Persephone study might be published along the way or shortly after the 10 year point. Although I’m past the five year ‘no evidence of disease’ milestone which can be significant in early HER2+ breast cancer, returning to the chemotherapy centre still makes me apprehensive. To avoid becoming a jibbering wreck immediately prior to each visit, I’ve convinced myself the extended follow-up period is a good thing. Having someone who really understands cancer keeping an eye on me and knowing they’ll take action if anything remotely suspicious shows up provides a degree of comfort.

This extended period of follow-up also lends itself to some of the commentary about the Persephone trial. One of the areas of uncertainty is the current four-year follow-up. Four years may not be long enough to fully understand the benefits of a six month treatment regime in preventing reoccurrence or distant metastases because cancer can reoccur many years later. (Most but not all HER2+ reoccurrences happen within 5 years).

Outcome of the trial

I’m encouraged and enthusiastic about this, and although my oncologist is deeply scientific (=immune to any high jinks), initial results for some groups of patients made him enthusiastic too.

Over 4000 women with early stage HER2+ breast cancer took part in the Persephone trial and a full article on the research and its outcomes is available here. The National Institute for Health Research (NIHR) reported “89.4% of patients taking six months treatment were free of disease after four years compared with 89.8% of patients taking twelve months of treatment. This shows six months of treatment is as effective as twelve for many women. In addition, only 4% of women in the six month arm stopped taking the drug early because of heart problems compared with 8% in the twelve month arm.”

The NIHR report goes on to say further analysis of tumour and blood samples from trial participants will help researchers understand which women can stop Herceptin at six months, and which women need extended treatment.

Herceptin has already improved the outlook for people with early-stage HER2+ breast cancer. Further information about its impact is available here if you want to see some statistics, but please bear in mind cancer is unpredictable and none of us is purely a statistic.

If the Persephone trial concludes some people can safely receive a shorter treatment regime offering the same cancer survival benefits and a significantly reduced risk of heart damage or serious cardiac events then I’m really glad I took part. Doctors sometimes struggle to find enough patients who are willing to participate in clinical trials. As a patient it can be a daunting prospect. For me, family history and taking part in something with the potential to improve treatment for countless other people as well as myself was the most significant and influential factor.

 

 

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Five things about Autoimmune conditions and me

I’m not an expert in this field but I’m trying to understand it as best I can. In much the same way that I set about researching information on my particular form of cancer, I’m now researching and learning about autoimmune conditions. I have them and they run in multiple generations of my family. Since none of my affected relatives are here to tell me about their experiences, I’m trying to piece it together myself. It’s a bit like looking for a needle in a haystack but so far I’ve discovered five things:

1. How many people are affected?

It’s difficult to find accurate figures on the number of people with autoimmune conditions. Estimates vary considerably. The American Autoimmune Related Diseases Association suggests 50 million Americans – more than twice as many as the National Institutes of Health suggest. That’s a significant difference. Most sources seem to agree women are more likely to be affected than men – that holds true within my own family. Overall, the prevalence of autoimmune conditions seems to be rising. As yet no-one really knows why.

2. How many autoimmune conditions are there and how are they diagnosed?

There are many autoimmune conditions – at least 80 to 100 and despite research, they can be difficult to diagnose. For some people diagnosis is made by accident when assessing a seemingly more obvious illness. That happened to me. For others, diagnosis becomes a process of elimination – which means undergoing many different tests to rule out common or more obvious causes until such time as a less likely cause is deemed the culprit. As a patient, this can feel frustrating and traumatic in equal measure, especially when the outcome always seems to involve more tests. This happened to me too. Fortunately my GP is not in the habit of passing things off as a virus or post-viral fatigue.

3. Does it run in the family or are the conditions linked?

With my scientific hat on, it looks likely certain autoimmune conditions are linked. Having one in the family might mean other members of the family can have the same or similar conditions. Having one condition myself might generate a greater likelihood of having another… Or not… because autoimmunity seems to be another a very complex area of medicine and quite poorly understood unless you specialise in this field. My level of science doesn’t extend to anywhere near the expertise required to get to grips with all of this. Even if it did, our propensity for focusing on specific diseases or groups of symptoms makes it possible to miss subtle links – hence the turbulent experience of diagnosis via a process of elimination.

4. Is it worrying?

None of us wants to be or feel unwell. Having unexplained and debilitating symptoms is worrying. Having test after test without any clear answers becomes far more worrying, even for those of us who’ve been through countless tests, treatments and operations before. Without solid answers, the hamster wheel of tests can eventually lead to self-doubt, questioning your sanity or convincing yourself you’re imagining it all. I only escaped this downward spiral because a very dear friend with CFS had similar experiences. She isn’t insane and hadn’t imagined her chronic and very debilitating illness, but for years an array of professionals told her there was nothing wrong, even when she could barely stand or stay awake.

5. Has it changed things?

It’s said with age comes wisdom and I’d like to live long enough to be wise. Surviving a very aggressive cancer didn’t grant me wisdom but I do think quite differently about life. My health dipped suddenly a few weeks ago and a plethora of tests ensued. It’s autoimmune, not more cancer. In my world almost anything is better than more cancer, even if it isn’t great. Pre-cancer I’d have ignored this latest health thing in favour of work. Now I have a more considered approach. Of all the rogue genes in my gene pool, ‘nine-lives-of-a-cat gene’ isn’t going to be one of them. I’ve spent enough time in hospitals to absorb the fact life is fragile. So I’m giving up the career I’ve worked my socks off for over the last 20 years because simply being here for my loved ones for as long as possible is more important to me than anything else. My work has been a buzz and somewhat addictive; stretching, fun, full-on and frustrating, usually in that order. I’ll miss that I’m sure. But in 2019 and for the first time ever I get to take a proper break, take proper care of myself, and get on with the business of living instead of simply existing.

If life zooms by like a bullet train, people along the route become a faceless blur. Why have a family album full of blurs when pausing for a while is all it takes to stay in focus, and experience the detail in full HD…?

Reflections: seven years on

This time seven years ago I was readying myself for the first of numerous major surgeries following a grade 3 HER2+++ breast cancer diagnosis. Back then I wasn’t sure if I’d still be around now. Thankfully I am.

So how are things?

I can’t lie, the journey has been tough at times. I assumed, opportunistically, that after treatment I’d bounce back and be able to do all the things I was able to do before. The oncologist hinted as much, the oncoplastic consultant surgeon was more realistic.

I can do many things, not all, and it isn’t a simple case of the ageing process as I gently head towards 49. There are lots of frustrations, but in spite of everything I love life more than ever and feel enormously grateful to be here. In 2012 that wasn’t a given. As I approach the last few days of my 48th year it seems appropriate to pause for a moment and take stock, now the whole situation is less raw.

Would I take the same course of action again?

This is easy to answer because there wasn’t really a choice. Grade 3 and HER2+++ don’t make for a great combination. If anything I’d have liked shorter gaps between the initial suspicious findings and formal diagnosis, diagnosis and surgery, and surgery and adjuvant therapy. It was almost 7 months until adjuvant therapy commenced, outside the NICE guidelines. It felt like a long time, long enough for any distant cancer cells to take hold. I didn’t want that.

I wish I’d known more about the challenges of surgery and how long it would take to regain my upper body strength (I’m still not as strong as I used to be). I remain glad that I opted for the more radical surgery, because choosing a conservative option may well have seen me going through it all again about now.

What was the most worrying moment?

Although cancer runs in the maternal side of my family – it wiped out the vast majority of my female relatives – I quickly realised just how little I knew about it and how complex it is. As soon as I was diagnosed I wanted it out of my body. I didn’t realise how much biopsy-ing, testing, imaging and investigation takes place before decisions about appropriate surgery, neoadjuvant or adjuvant treatments can be made.

The results of the MRI scan were by far the most worrying event for me because it “lit up like a Christmas tree.” I thought it might be too late even though I’d seen the Dr straight away. I had countless sleepless nights worrying that I’d die at a crucial stage in my son’s life leaving him motherless, homeless and unsupported. I love my family, I really didn’t want to leave them alone and destitute.

Was treatment hard?

On reflection, I think it was. It took 18 months+ and knocked the stuffing out of me. At the time I didn’t realise quite how big a toll it took. I kept pushing myself forward, trying to be “normal,” getting on with life as best I could. But life was far from normal, and normal didn’t include me.

I didn’t feel seriously ill pre-diagnosis even though I was seriously ill. At some points during treatment I wondered what else or how much more I might need to endure. At times I felt extremely ill. The lowest point came when I had to inject myself with granulocyte colony stimulating factor, to combat low white blood cell levels which increase the risk of serious or life-threatening infections. At night the pain in my bones was unimaginable yet still I carried on. That pain is still unlike anything I’d experienced before or since. So yes, treatment was hard but the alternative doesn’t bear thinking about. I’m still here and as far as we know, cancer-free. It was hard but it was worth it.

What else happened?

Having cancer taught me a lot. Psychological lessons included learning my body was no longer my own. I couldn’t trust it and felt trapped in a shell that might break into a thousand hopeless pieces at any moment. Coming to terms with my own fragility and unpredictability took time. Physical lessons involved treatments designed to obliterate the disease that also obliterated my joints, my thought processes and my hearing. Although cognition has improved a little, my joints and hearing are permanently damaged. C’est la vie. Emotional lessons centred on relationships. People who promised to stand with me simply vanished into thin air and that was very hard. Thankfully strangers and acquaintances came closer, they became friends and remain loyal friends today.

More difficult and painful than any other part of this journey was the continuing loss of friends who were also fellow cancer patients. Some older, many younger, these were people for whom surgeries and therapies did not prove successful. There are so very many of them, not ones or twos but tens and tens. My heart gets a little more broken every time I remember friends and loved ones who have died of this spiteful disease, and think of those who are dying now as I write this post. Cancer still kills.

What next?

I don’t plan or daydream. Life is too uncertain and time is too precious for maybes, tomorrow perhaps or one day. I love my family more than ever and make the most of every moment with them. When they’re happy, I’m happy and nothing else matters. I enjoy my work, still thrive on pushing boundaries and encourage my colleagues to do likewise – why spend time in a job that feels like drudgery? I’ve taken control of things I can control (diet, exercise, rest) but I’m relaxed about it, not a zealot. Spending an extra hour in bed when I’m aching or tired isn’t going to kill me, and cancer won’t return just because I drink a glass of wine or eat a decent steak every now and then. I find beauty all around me and spend as much time as possible creating environments where nature can do its thing. In nature I find solace.

I’d like to stay cancer-free and live for a few more decades because life is good this way. But I never take anything for granted.

Close the door, keep walking

Close the door, keep walking

Wherever you are, whatever your situation, I wish all readers much happiness, love and wellness for everyday of 2018, these are life’s greatest riches and I hope you find them in abundance.

2017 was a difficult year for us. Although there were some high points, there were also terrors. The kind that bring sleepless nights and frantic days. We learn from all experiences, the good and the bad, but last night we pushed the door firmly closed on 2017.

The wonders and possibilities of 2018 are most welcome because the last 365 days have been a long, hard slog. Though the desire to wipe away the past is strong there are tributes to pay and deep gratitude to note before moving on:

  • For the medics who helped J survive meningitis and J’s will to recover from a very traumatic experience
  • For my father who continues to help others and spares little thought for himself
  • For our journey to the furthest reaches of Norway and our once in a lifetime experience of the Mirrie Dancers
  • For friends and family across the globe, and loved ones lost but never forgotten
  • For food, clean water, warmth and shelter – all so easily taken for granted yet still beyond reach for far too many
  • For life, however long it lasts, because every day is a day further from cancer. This year will be my sixth post-diagnosis.

This new year has barely started but it comes complete with some significant milestones for us, big events that will shape the future in ways we can’t fully imagine as yet. It also comes with lots of blank canvas, new days ready to receive whatever memories we chose to paint there. We are a family of three, and all three of us have brushed with death at an age that is far from being “old.” So as we continue this journey we remain optimistic about the possibilities that lie ahead. There is much to explore and too little time to grumble along the way. We know now that wherever the path takes us, we’ll make the most of it and keep walking on. It is, in every sense, a happy new year.

Such a long time

It’s been such a long time since I’ve written. Not just here at FEC-THis but anywhere really (except reports for work).

Maybe its because life has been busy and recovering after cancer takes a lot of energy. Maybe it because between living and working there isn’t much energy left for anything else. Or maybe it’s just that dwelling on what’s gone before and fretting over what might lay ahead just isn’t my thing (it really isn’t). I don’t want to remember much about what having cancer did to me though it’s all still too vivid to blank out completely. I guess it takes time.

So here I am almost 5 years on. Still alive, still well – with a few non life-threatening health issues to live with – still working, still being a wife, Mom and daughter and still grateful for all the extra days I’ve had even if the cancer treatment itself was far from idyllic.

Aside from ongoing check-ups I thought I’d put long hospital visits well behind me. But life has a funny way of throwing up issues just when you think it’s approaching what might be called normal. Our latest exploits include spending most the last fortnight in an isolation ward, including a 36 hour stint with no sleep, because my son J contracted meningitis.

Cancer is a really crappy disease and now I know meningitis is really crappy too. Within a few hours J went from being a healthy, active, fit young man to completely bed-ridden, very unwell and mainly unconscious. He didn’t move for almost 48 hours. Fortunately the out of hours GP we saw decided J needed to be admitted to hospital and once admitted, they started IV antibiotics, antivirals and fluids almost immediately. Within about 7 days there was a marked improvement and after about 12 days J was almost his usual self.

Once again we’ve been lucky. Lucky we didn’t ignore the symptoms (earlier the same day we’d been told it might be migraine or sinusitis – he’s never suffered with either), lucky we went to a very seasoned out of hours doctor, lucky we got the treatment needed before any long term damage was caused.

Like cancer, this isn’t an experience I’d want to go through again. Diseases that strike kids and young people seem particularly cruel. As a parent you want to keep your children safe but there are some things you just can’t protect them from. For me, this was one of them and it’s worth knowing that meningitis symptoms don’t always involve a rash.

Lots has happened since the last time I wrote here and most of it has been good / normal / uneventful. But life is unpredictable and I guess there’ll always be a few hiccups along the way. It’s a miracle any of us stay sane!

 

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Leaving hospital… and looking a trillion times better than when we went in 🙂

 

Research and rationing


Our ability to research pathogens and continually develop drugs or treatments that thwart them is likely to have changed the course of human life on Earth. Without medicines it’s probable our numbers would be severely curtailed through regular outbreaks of communicable diseases. Many of us may never have survived beyond childhood. In the mid 1800’s around 15% of infants died in their first year and many more before the age of five*. Our quest to cure illness and preserve life has, for many years, been founded on our ability to design and conduct well formulated scientific research. 

Roll forward about 180 years and we’re still conducting valuable research, advancing the discovery of new treatments or more effective drugs for the control of human illnesses, even if we remain unable to cure many of the ailments that afflict us. We appeal regularly and insistently to the public at large to help fund gargantuan efforts of scientific and humanitarian endeavour because resources are scarce and without them we might never find a cure.

As a scientist at heart, the importance of research isn’t lost on me. Neither is the dedication of the people who make it their life’s work to find a breakthrough that might just deliver the elusive cure. The process of research is a huge commitment; intense, time consuming and expensive. Resources involved run to millions of dollars yet recent articles suggest anywhere between 95 – 99% of Alzheimer’s and cancer research fails when tested in humans. It’s a high stakes situation for everyone, scientists, funding bodies, those newly diagnosed and those now desperate for new drugs because all else has failed them.

In the U.K. the situation becomes even more desperate when patients are prohibited from accessing new, proven drugs classified too expensive for NICE (the National Institute for Health and Care Excellence) to support. In reality this non-departmental public body ought to be called the National Institute for Health if it’s Cost Efficient because cost plays a major role when evaluating the provision of new, breakthrough drugs. The postcode lottery NICE was supposed to eradicate has been replaced by a national lottery where no-one wins when a new drug is deemed too expensive. At this juncture I’m left wondering whether any of the money I’ve donated to medical research over the last 25 years has achieved anything worthwhile. Continued rationing of life changing or prolonging drugs makes me suspect my small contribution may have been better invested in items to support those undergoing existing treatments. 

Just recently news of significant research grants includes the statement “hope this work could improve survival rates.” We all hold on to this hope but hope alone isn’t enough. Drugs evaluated as clinically effective are rejected by NICE if the price is too high.  Nivolumab is one example, there are many others. So if NICE continues preventing access to new treatments and patients can only receive older, cheaper drugs, what real term improvements can we expect to see?  Have we forgotten Articles 3 and 25 in the Universal Declaration of Human Rights and if so, should we continue donating to clinical research or would our donations be better spent providing respite or hospice care? Once upon a time I’d have argued medical research was money well spent, but as more and more of my friends get caught in the fight between NICE and the Pharmaceuticals my thoughts become increasingly conflicted.  When life is slipping away, it seems better care for the dying is more important.

*In Western societies 

Hopes for the New Year

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2016 has come and gone. There were a few health hiccups for me along the way but nothing compared to the amount of grief and suffering in the world at large.  Now 2017 is here and already people are committing atrocities, inhumane and yet so tragically human. My hopes for a peaceful new year will just have to lie dormant for another 364 days and see what 2018 brings. Something tells me it’ll be much longer before we all wake up to find our planet free from strife with every vestige of humanity behaving as truly civilised. I live in hope though, as I’m sure many others do.

Since world peace is well beyond my capabilities, my hopes for 2017 are considerably smaller and more intimate.  While many people have been enjoying the Christmas break, work, study and revision (a lot of revision) have been the order of the day for our family. So my first hope is that those of us who’ve been working get a break and those of us who’ve been revising pass our upcoming exams and settle in to our placements for the year ahead.

My next hope is that my friends and family stay happy and healthy in 2017.  Last year was something of a trial for most of us and in the end we weren’t unhappy to wish it goodbye.  None of us is equipped to deal with too much death, despair and difficulty in such a short period of time.  I know I’m still a bit worn down by it all so a less eventful year on the bad news front together with positive physical and mental wellbeing for all of you is my wish this year.

The last of my hopes for 2017 is a personal one because this year marks the 5 year anniversary of my cancer diagnosis.  If I sat down to write all the things that have happened since June 2012, the challenges, the bête noir, the unending uncertainty and the sheer weight of it all I fear I might lose touch with my sanity.  So instead it shall stay in the past where it rightly belongs and I shall hold hope that health-wise, 2017 is incredibly, remarkably and boringly uneventful for me.  Because uneventful means the likelihood of a reoccurrence, whilst never fully extinguished, is considerably diminished from June onwards.

Whatever you leave behind from 2016 and whatever you hope for from this new year, may health and happiness be your faithful companions in 2017 too.