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The Need To Know - A Husband's Perspective
By Gregory D. Pawelski, husband
Gregory D. Pawelski e-mail:
This is an account of my wife’s treatment for recurring ovarian cancer. Her cancer treatment varied tremendously depending on which hospital she attended and the type of treatments given at our local hospital were responsible for her final tumor recurrences and her depressed quality of life in her last years.
When she first got ovarian cancer in 1972, it was treated in San Diego, post-operatively with Chlorambucil. This is one of the slowest acting and least toxic of the oral drugs, which allows the immune system to regenerate during the process. The cancer recurred in 1996 on her diaphragm and was removed at the Fox Chase Cancer Center.
It is commonplace to give the same treatment to a recurrence as was given for the original tumor(s). However, our hometown hospital in Pennsylvania gave her a ‘hard and fast’ drug combination of Taxol and Carboplatin. This suppresses the immune system, which can allow tumors to grow and can weaken the blood-brain barrier, potentially inviting cancer cells into the central nervous system.
Sure enough, the cancer turned up in her cerebellum in 1998, and was removed at the Hershey Medical Center. Our local home town hospital then treated her with Whole Brain Radiation. Literature suggests that this can result in permanent side effects such as dementia and memory loss in 90% of patients over 60. My wife was 66. Hershey suggested treatment with focal radiation to the local tumor bed. Scans to check for a possible spinal tumor were also suggested but never fully carried out.
In 1999, three tumors were found on her spine and were eradicated. In the end, my wife died of the effects of Taxol and Carboplatin, which may have caused the cerebellum tumors, and the terrible effects of Whole Brain Radiation, which further scans revealed had caused extensive damage to her brain.
Ann’s Medical History:
In 1972, my wife had been diagnosed with ovarian cancer, when she presented with a left DVT (deep vein thrombosis) and pulmonary embolism at a hospital in San Diego, CA. DVT is not uncommon in patients with ovarian cancer (it may be a presenting sign). Workup which was triggered by this presentation revealed that she did have an ovarian carcinoma for which she was cured with total abdominal hysterectomy and Chlorambucil (Leukeren) treatment. This postoperative chemotherapy drug was among the slowest acting and least toxic of the alkylating agents (well tolerated oral-dose drugs). By giving chemotherapy more often, at lower doses, it can prevent the regrowth of blood vessels that feed tumors. Depression of the immune system is slow and reversible, allowing it to regenerate and contribute to healing. A malfunctioning immune system can fail to stop the growth of cancer cells. When caught at this earliest stage, ovarian cancer has a good prognosis. At Stage I, ovarian cancer has! a five-year survival rate of around 93%. She went twenty-four years before experiencing any recurrent ovarian cancer.
During the early 90’s in Reading, Pa., she underwent a laparotomy (a surgical procedure which involves opening the abdominal cavity for examination) as a followup and this did not reveal any evidence of recurrent carcinoma. This is supposed to be the most certain way of diagnosing ovarian cancer and assessing the extent of cancer spread (metastasis). However, negative second-look patients have a 50% chance of disease recurrence anyway. For the most part, her group of oncologists relied almost entirely on the CA 125 tumor marker (a blood test done to assess the amount of an antibody that recognizes an antigen in ovarian tumor cells). The rate of “false positives” makes it inadequate for use “by itself” for screening of high-risk patients. It should be supplemented with transvaginal ultrasonography and a rectovaginal pelvic exam all done at the same time.
Metastatic Recurrence and Treatment:
It was our family doctor that found her first metastatic recurrence to her diaphragm in 1996 (not the medical oncologists at our local home town hospital). She was having dry coughing spells at first but then she began having a mucus discharge, which eventually was bloody. A chest xray and Cat Scan had shown a lesion inside her diaphragm. That recurrent ovarian cancer was surgically excised at Fox Chase Cancer Center. It was a metastatic transdiaphragmatic tumor from the original ovarian cancer (1972), with attachment to the lung and other midline structures of the chest. Parts of those structures were surgically resected (the diaphragm is a common site for ovarian metastatic recurrence).
The thoracic surgical oncologist left us with the knowledge that a second place an ovarian metastasis possibly could occur maybe the Central Nervous System (CNS) like the brain and/or the spine. It is very rare for ovarian cancer cells to metastisize to the CNS. In fact, up until 1994 there have been only 67 well documented cases in medical literature. A multi-institutional study of 4027 ovarian cancer patients over 30 years identified only 32 cases while an autopsy study of ovarian cancer reported an incidence of 0.9%. The surgeon at Fox Chase did not feel that further treatment with chemotherapy was indicated.
However, the ideas of our local home town Medical Oncologists were different from the Thoracic Surgical Oncologist who excised the tumor from her diaphragm. My wife received postoperative chemotherapy by these medical oncologists, seven months after having that metastatic tumor surgically excised. She did not have any cancer tumor markers indicate any cancer within her system. Some tumors send out microscopic outposts while most do not. However, medical oncologists cannot tell which ones do, so they want to give chemotherapy in nearly every case. The type of chemotherapy she received was the hit fast, hit hard type combination chemotherapy of Taxol with Carboplatin (second-line chemotherapy). It is usually given in big doses, with breaks of several weeks between doses to let the body try to recover (or else it can kill a patient).
Patients who develop recurrent ovarian cancer more than 6 months after first-line chemotherapy (in my wife’s case, 24 years), can experience another remission following treatment with the identical first-line chemotherapy that was previously used (in her case, Chlorambucil). It has not been shown that platinum-based combination therapy is superior to single agent alkylator therapy. No substantial benefit has been found in giving ovarian cancer patients second-line chemotherapy. Clinicians have found that the toxic effects of this treatment can cause a lower quality of life for these patients. Plus, the late stage of “recurrent ovarian cancer” makes the combination chemotherapy of Taxol & Carboplatin drug resistent to cancer cells and suppresses the immune system, making it possible new tumors to grow because the patient has been rendered unable to resist them.
In recent years the incidence of central nervous system (CNS) metastasis has increased. Unfortunately, some chemotherapeutic agents can weaken the blood-brain barrier (BBB) transiently and allow CNS seeding. Taxol & Carboplatin are two of the drugs that violate the blood-brain barrier (dose dependent). In essence, it breaks down, damages the blood-brain barrier (BBB) to invite microscopic cancer cells into the CNS. A NCI observational study in 1995 reported experience in their clinic where recurrent systemic disease occurred in all patients for which they received dose intense paclitaxel (Taxol) therapy. Brain metastasis was the only site of disease recurrence, presenting with headache, dizziness, unsteady gait, nausea and vomiting.
It was our family doctor that found her second metastatic recurrence to her cerebellum in 1998 (not the medical oncologists at our local home town hospital). She was presenting with headache, dizziness, unsteady gait, nausea and vomiting. A large (3.5cm) solitary cerebellar brain tumor was found via enchanced Cat Scan (later confirmed by an enhanced MRI). The tumor was excised from her brain by a Neurosurgeon at Hershey Medical Center. Histologic features were consistent with metastatic papillary adenocarcinoma with extensive necrosis from the ovary.
The Neurosurgeon stated that he was 99% successful and felt that she should go back to our local home town hospital and receive focal radiation to the local tumor bed (which is 2cm beyond the periphery of the excised tumor site). The treatment protocol recommended for brain metastases of large solitary tumors exceeding 2cm in diameter is surgical resection followed by 5 fractions of local radiation to the tumor bed. At the same time, she should receive an MRI of the spine because of suspicions of either another tumor, on her spine or a herniated disc, causing her leg problems.
However, the ideas of our local home town Radiation Oncologist were different from the Neurosurgeon who excised the tumor from her brain. The Radiation Oncologist took it upon himself to give my wife 5 fractions of focal radiation to the local tumor bed, plus 20 fractions of Whole Brain Radiation over a 35 day period. The risk of neurotoxicity from Whole Brain Radiation is not insignificant and this approach is not indicated in all patients with a solitary brain metastases, particularly when platinum drugs lower the tolerance of the CNS to radiation.
Literature of the early and mid-80’s on morbidity of Whole Brain Radiation, is flooded with papers reporting long-term side effects, such as dementia, memory loss, radiation induced necrosis, leukoencephalopathy, in up to 50% of two year survivors. Whole Brain Radiation Therapy has been recognized to cause considerable permanent side effects in patients over 60 years of age. The side effects from WBR Therapy affect up to 90% of patients in this age group. My wife was 66 years of age while receiving Whole Brain Radiation Therapy.
During radiation treatment, my wife received an Unenhanced MRI to the spine that showed a 1cm lesion. Instead of performing an Enhanced MRI to the spine or a Triple Phase Bone Scan to further evaluate, our local home town hospital performed a Regular Bone Scan that showed normal bone imaging. However, a Regular Bone Scan cannot distinguish what a lesion represents and cannot differentiate between a tumor, an infection or a fracture (a Triple Phase Bone Scan may occasionally be helpful in determining benign from malignant lesions). Enhanced (contrast) agents increase the sensitivity, conspicuity and accuracy of an exam. The agent most commonly used is Gadolinium. The proper medical protocol for all Brain and Spinal MRI’s for metastatic diseases is Enhanced with contrast (today, it is the Pet Scan). An Enhanced MRI was not performed and the Radiation Oncologist told us the lesion was nothing and not to worry about it. He also ignored my complaints about her having seizures dur! ing radiation therapy.
Nine months later, my wife was admitted to our local home town hospital during the Memorial Day Weekend of 1999, for a week of testing and evaluation for unexplained falls and light-headiness. After two weeks of failing to find out what was wrong with her, I took her by ambulance to Hershey Medical Center for proper medical treatment. At Hershey Medical Center, we found out by a medical onocologist and a neurologist that she had Leptomeningeal Carcinomatous (remember the undiagnose tumor of nine months prior, not further evaluated?). An Enhanced MRI showed now three (3) metastatic tumors on her spine. Spinal metastases can grow into adjacent structures, such as into the meninges from the spine. The largest of these tumors grew into the meninges on the spine into the spinal fluid, hence Leptomeningeal Carcinomatous. This was confirmed by a spinal tap.
With the damage already done to her by our local home town hospital, the doctors at Hershey Medical (in order to save her life or at least give her some time) had to administer Intrathecal Methotrexate along with systemic radiation to the spine (Admitted June 19,1999). When both therapies are performed at the same time it doubles the theraputic dosages of each therapy (increasing the neuro-toxic effects on the brain). However, the cancer cells were eradicated completely from her central nervous system by this protocol. Ever since the second spinal tap at Hershey (when methotrexate was already being administered), all of her spinal taps were negative for 10 consecutive times up until January 14, 2000. A Whole Body Bone Scan (November 3, 1999) indicated that the skeletal system demonstrated normal uptake and an Enhanced Brain MRI (November 3, 1999) showed no new areas of abnormal enhancement.
Adverse Side Effects of Treatments:
My first experience with the side effects of combination chemotherapy and whole brain radiation was when she was at Hershey Medical Center in 1999. The doctors showed me the Enhanced Brain MRI from her previous year’s cerebellum excision and the one done in 1999. The scans showed the progressive deteriation of her white matter (white matter disease). Late delayed effects, occuring several months to many years later, are classified into diffuse white-matter injury, radiation-induced arteriopathy & stroke, and late delayed Radiation Necrosis. These reactions are due to changes in the white matter and death of brain tissue caused by radiation-damaged blood vessels. This clinical syndrome generally occurs 6 months to 2 years after radiation therapy. Symptoms include decreased intellect, memory impairment, confusion, personality changes and alteration of the normal function of the area irradiated (all symptoms my wife had over the past year).
Radiation Necrosis can be fatal! It causes pathological changes that impair vascular integrity. Delayed radiation injuries result in increased tissue pressure from edema, vascular injury leading to infarction (stroke), damage to endothelial cells and fibrinoid necrosis of small arteries and arterioles. My wife suffered a stroke to the left basal ganlia area of the brain in January 2000, confirmed by an enhanced MRI.
My wife had developed necrotizing leukoencephalopathy (a form of diffuse white matter injury that can follow combination chemotherapy), confirmed by an enhanced MRI in July of 1998 at Hershey. The white matter is the covering of the nerves within the brain. Its function is to speed up the passage of impulses along the nerves. Necrosis is simply a cell dying, all of its coordinated activities going wrong and things shut down. If a cell gets too much heat or is poisoned by a toxic substance or exposed to chemicals that damage its proteins and membraines or radiation that breaks its DNA molecules, that cell can just stop functioning.
An EEG showed generalized diffuse slowing that was significant with global encephalopathy. It is most commonly seen in toxic metabolic and degenerative conditions. There appeared to be a real amount of focal right sided slowing which would indicate cortical dysfunction on that side. Her MRI’s showed the ventricles overall were prominent and there was widening of the sulci consistent with cerebral atrophy (wasting away of brain cells and tissues). There was diffuse, abnormal signal intensity within the periventricular white matter, consistent with post radiation changes. The signal abnormality within the white matter appeared slightly increased compared to her prior studies. A Pet Scan showed globally decreased radiotracer uptake within the brain, bilaterally, consistent with involutional change and prior radiation therapy.
Because of the previous chemo-radiation treatments, a recurrence of the cerebral metastasis was very likely to happen in the future. Some long-term effects can include development of secondary maligancies (the risk is 16 times greater). Resistance to standard chemotherapy regimens of Carboplatin with Taxol ultimately develops in nearly all adenocarcinoma cancer patients (mainly because of the late stages of the cancer). Recurrent ovarian cancer being such a late stage cancer, can be resistant to the combination chemotherapy of Taxol/Carboplatin. It can actually spread the cancerous cells rather than the cancer itself spreading. Since both radiation and chemotherapy suppress the immune system, it is possible that new tumors are allowed to grow because the patient has been rendered unable to resist them. A person who is cured of cancer by these drastic means may find himself struggling with a new, drug-induced tumor a few years later. A malfunctioning immune system can fail to! stop the growth of cancer cells.
Recurrence of the cerebral metastasis was observed via an Enhanced MRI of May 2000 at Hershey Medical Center and a Pet Scan of August 2000 at the University of Pennsylvania. Four, mm-sized metastatic tumors were found in and around the previously resected cerebeller tumor and because of my wife’s weakened condition, Gamma-Knife would be the only best medical protocol. She received Gamma-Knife treatment at University of Maryland Medical Center on September 12, 2000. During the whole time of her admission at the hospital, the doctors kept referring to her continued diffuse white-matter injury (brain necrosis), as if she may be too far advanced in that injury to survive much longer. She died at home on Thursday, September 21, 2000 at the age of 68 from Cardio-Pulmonary Failure. Minutes before she expired, her temperature was normal, her blood pressure was normal but her pulse was 150 (tachycardia). Her heart was racing to keep up with the lack of brain function and finally quit!
The white matter disease that my wife experienced and caused her death was primarily a result of Whole Brain Radiation and secondary a result of Combination Chemotherapy of Taxol & Carboplatin (Methotrexate was icing on the cake). The Combination Chemotherapy of Taxol & Carboplatin caused microscopic ovarian cancer cells to seed inside the CNS to form a tumor on the cerebellum and tumors on the spinal cord, with concomitant necrotizing leukoencephalopathy. Carboplatin lowered the tolerance of her Central Nervous System to any radiation treatment.The Whole Brain Radiation resulted in the death of tumor cells and associated reaction in surrounding normal brain. Such reactions tend to occur more frequently in larger metastatic lesions. Late delayed Radiation Necrosis (also known as Radiation Encephalopathy) is often irreversible and progressive, leading to severe disability or death (all symptoms my wife experienced).
Cancer Treatments as Killers:
Ann’s life was greatly shortened and neurologically deteriorated by the chemo and radiation treatment received at our local home town hospital. Patients who develop recurrent ovarian cancer more than 6 months after first-line chemotherapy can experience another remission following treatment with the identical first-line chemotherapy that was previously used. Aggressive treatment, like surgical excision of tumor and focal radiation to the local tumor bed, in patients with limited or no systemic disease can yield long-term survival. In such patients, delayed deleterious side effects of whole brain radiation therapy are particularly tragic and there is no survival benefit or prolonged independence. The patient cannot experience the benefical improvement in quality of life.
If more people researched how and why their loved-one died after being treated by orthodox cancer therapies then I believe there would be a movement to have more effective and less toxic treatments available. Ideally, we would conduct such research before the treatments were administered but we usually don’t have the luxury of time to learn what the oncologists are not telling us when it matters most. It is scary when we try to give oncologists the benefits of doing what needs to be done but we have to learn to ask more questions and seek more answers.
It seems the medical profession doesn’t want to hear about the side effects of treatment for gynological cancer and keeps referring to the lives of women loss this way as “rare”. If it was their lives, they might not call it “rare”. Some people would have you believe that because “their” bodies didn’t give out after receiving chemotherapy or radiation that these treatments are “o.k.”. Cancer patients who die, having undergone toxic treatments which sap their energy and harm their immune systems are heralded as brave souls. Sometimes it is good for the soul to hear what others in similar circumstances have to say.
The quality of life must be considered as a major decision point in cancer care. That element, so long missing in most clinics, hopefully will be brought to the fore expecially in the many cancer clinical trials. I hope that quality of life soon becomes a major outcome issue for all involved in the treatment of patients with cancer. I will continue to be an advocate for my loved ones and help others in their own journeys with cancer.
Because of the experience with my wife, I spent three years on cancer research. I’ve written to over 3,000 medical professionals and institutions all over the United States and across the globe. I have studied over 500 medical web sites (like MedLine, Pub Med, Oncololink, Johns-Hopkins, NCI, NIH, etc.). I have all of my wife’s medical records to relay first hand experience. I even retained a medical expert (a retired surgeon of 25 years at our local home town hospital) to concur my findings. I had to learn the how and why, what happened to my wife.
There are three main points that I’ve found out in my three years of cancer research.
* An understanding of the doctors involved with my wife’s medical care at our local home town hospital.
* An understanding of the lack of uniformed cancer care being practiced here in the United States.
* Cancer patients frequently die from their cancer treatments and not from the cancer itself.
Cancer chemotherapy and radiation therapy almost without exception, will damage some normal tissue and diminish the immune system. Radiation has been known for a long time to both enhance cancer growth and to halt cancer growth. Damaging the immune system in turn is known to foster the growth of some kinds of other cancer. We do not yet have really outstanding treatments for most cancers. Modern medicine in general and cancer treatment in particular, is very imperfect. In the hopes of curing disease or helping patients, the medical profession uses rather drastic treatments for devastating diseases they know will kill someone in a short time. Many oncologists don’t make the families aware enough that these treatments are drastic and can have serious side effects.
It takes time for doctors to sit down with patients and truly explain the benefits and the risks of treatment. In an ideal world, patients would consider the benefits and the risks of each treatment and make an informed decision with the guidance of a wise doctor. But, hurried doctors seldom spend much time discussing the benefits and the risks and few patients ever question whether treatment may do more harm than good.
comments = Why, after 24 years, had ovarian cancer cells proliferated inside my wife’s diaphragm? Her presentation of a left deep vein thrombosis and pulmonary embolism in 1972 enabled her doctors to find her ovarian cancer at its earliest stage, where surgical oncology alone is over 93% curative. Her postoperative chemotherapy drug was among the slowest acting and least toxic of the alkylating agents whereas the depression of the immune system was slow and reversible, allowing it to regenerate and contribute to healing her disease. Plus, she was only 40 years of age.
My wife had been taking Premarin for over twenty years. The National Institutes of Health had published articles about two large studies indicating the increased risk of ovarian cancer linked to Estrogen Replacement Therapy. For women who used estrogen for 20 years or more, it was increased by more than 300% (3-fold), compared to women who had never taken it. And from the North American Menopause Society, “it has been known for many years that estrogen therapy is also associated with an increase in DVT’s and pulmonary embolism”. As one email respondent to me noted, “well that’s interesting, I wonder why they didn’t choose to let us in on it!”
Gregory D. Pawelski
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