July 30, 2010

Kvetching

The thrush and painfully tingly hands were so much worse today that I called both the oncologist and the naturopath to see what they could recommend.

Dr G said that the fluconazine should have worked immediately to relieve the thrush and sore throat, so he wonders if this is indeed a fungal infection. He recommends stopping the fluconazine and trying the Mycelex lozenges again. He also says the literature recommends DMSO 99% solution, applied topically to the hands. BUT it is absorbed into the body and gives one a fishy breath odor, so I think I will wait and see how I fare on Dr. B's recommendations.

Dr B the naturopath recommended increasing the L-glutamine powder to two teaspoons, taken three times a day, dissolved in water to treat the hand-foot syndrome. He also wants me to dissolve Pau d'Arco drops in a half-glass of water and rinse, also three times a day for the thrush. Dr G says the Pau d'Arco can't hurt.

I'd never heard about Pau d'Arco, but this is what Memorial Sloan Kettering Cancer Center says about it. I hope it does the trick!


Scientific Name
Tabebuia impetiginosa, Tabebuia avellanedae, Tabebuia heptaphylla

Common Name
Ipe-Roxo, lapacho, purple lapacho, trumpet bush and taheebo

Clinical Summary

Pau D'arco is a tree native to South America. Preparations derived from the bark have been traditionally used to treat bacterial, fungal, viral infections, and cancer. In vitro studies of compounds isolated from Pau D'arco demonstrated antibacterial (3) (4) (5) (6), antifungal (7), antipsoriatic (8), immunomodulatory (9) (10), anticancer (11) (12) (13) (14), and antimetastatic (14) activities. Quinones, the main constituents, have been shown to be the active principle (11) (12) (13) (14). In a small single-arm study, Lapachol, a naphthoquinone isolated from the tree bark, did not show any effects on patients with non-leukemic tumors or CML (chronic myelocytic leukemia) (15). Reported adverse events from use of Pau D'arco include nausea, vomiting, dizziness and anemia (16). This herb may also enhance the activity of anticoagulants (17).

Purported uses

Cancer treatment
Antibacterial
Antifungal

Constituents

Quinone compounds: Lapachol, beta-lapachone, xyloidone (naphthoquinones) and tabebuin (anthroquinone)
Flavonoids: Quercetin
Glycosides: Iridoid, lignan, isocoumarin, phenylthanoid, phenolic
Cyclopentene dialdehydes
(1) (2) (3)

Mechanism of Action

The anticancer activity of beta-lapachone, a quinone compound isolated from Pau D'arco, may be due to down regulation of COX-2 (cyclooxygenase) and telomerase activities (11). Beta-lapachone also induces apoptosis in cancer cells via mitochondrial-signaling (12) or by activation of caspase (3) and (9) enzymes (18). The anti-metastatic activity of beta-lapachone was shown to be due to decreasing the invasive ability of cancer cells by inducing Egr-1 that is known to suppress metatstasis (14).

Warnings

Some constituents may have toxic effects. The effectiveness of Pau d'arco for the treatment of cancer in humans remains unproven.

Adverse Reactions

Reported: Nausea, vomiting, dizziness, anemia, bleeding, and discoloration of urine (16).

Herb-Drug Interactions

Anticoagulants: Pau d'arco may potentiate effects (17).

Literature Summary and Critique

Block JB, et al. Early clinical studies with lapachol. Cancer Chemother Rep 1974;4:27-8.
Twenty-one patients with non-leukemic tumors or chronic myelocytic leukemia were given Lapachol at a dose range of 250-3750 mg daily for 5 days and up to 3000 mg daily for 21 days. Researchers reported that Lapachol did not have any effect on the clinical status of the patients.

References

1. Warashina T, Nagatani Y, Noro T. Further constituents from the bark of Tabebuia impetiginosa. Phytochemistry. 2005;66(5):589-597.
2. Koyama J, Morita I, Tagahara K, Hirai K. Cyclopentene dialdehydes from Tabebuia impetiginosa. Phytochemistry. 2000;53(8):869-872.
3. Park BS, Lee HK, Lee SE, et al. Antibacterial activity of Tabebuia impetiginosa Martius ex DC (Taheebo) against Helicobacter pylori. J Ethnopharmacol. 2006;105(1-2):255-262.
4. Anesini C, Perez C. Screening of plants used in Argentine folk medicine for antimicrobial activity. J Ethnopharmacol. 1993;39(2):119-128.
5. Park BS, Kim JR, Lee SE, et al. Selective growth-inhibiting effects of compounds identified in Tabebuia impetiginosa inner bark on human intestinal bacteria.J Agric Food Chem. 2005;53(4):1152-1157.
6. Pereira EM, Machado Tde B, Leal IC, et al. Tabebuia avellanedae naphthoquinones: activity against methicillin-resistant staphylococcal strains, cytotoxic activity and in vivo dermal irritability analysis. Ann Clin Microbiol Antimicrob. 2006;5:5.
7. Portillo A, Vila R, Freixa B, et al. Antifungal activity of Paraguayan plants used in traditional medicine. J Ethnopharmacol. 2001;76(1):93-98.
8. Muller K, Sellmer A, Wiegrebe W. Potential antipsoriatic agents: lapacho compounds as potent inhibitors of HaCaT cell growth. J Nat Prod. 1999;62(8):1134-1136.
9. Bohler T, Nolting J, Gurragchaa P, et al. Tabebuia avellanedae extracts inhibit IL-2-independent T-lymphocyte activation and proliferation.Transpl Immunol. 2008;18(4):319-323.
10. Son DJ, Lim Y, Park YH, et al. Inhibitory effects of Tabebuia impetiginosa inner bark extract on platelet aggregation and vascular smooth muscle cell proliferation through suppressions of arachidonic acid liberation and ERK1/2 MAPK activation. J Ethnopharmacol. 2006;108(1):148-151.
11. Lee JH, Cheong J, Park YM, Choi YH. Down-regulation of cyclooxygenase-2 and telomerase activity by beta-lapachone in human prostate carcinoma cells. Pharmacol Res. 2005;51(6):553-560.
12. Lee JI, Choi DY, Chung HS, et al. beta-lapachone induces growth inhibition and apoptosis in bladder cancer cells by modulation of Bcl-2 family and activation of caspases. Exp Oncol. 2006;28(1):30-35.
13. Kung HN, Chien CL, Chau GY, et al. Involvement of NO/cGMP signaling in the apoptotic and anti-angiogenic effects of beta-lapachone on endothelial cells in vitro. J Cell Physiol. 2007;211(2):522-532.
14. Kim SO, Kwon JI, Jeong YK, et al. Induction of Egr-1 is associated with anti-metastatic and anti-invasive ability of beta-lapachone in human hepatocarcinoma cells. Biosci Biotechnol Biochem. 2007;71(9):2169-2176.
15. Block JB, Serpick AA, Miller W, Wiernik PH. Early clinical studies with lapachol (NSC-11905). Cancer Chemother Rep 2. 1974;4(4):27-28.
16. Foster S. Tyler's Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies. New York: Haworth Herbal Press; 1999.
17. Brinker F. Herb Contraindications and Drug Interactions. 2nd ed. Sandy (OR): Eclectic Med Publications; 1998.
18. Woo HJ, Park KY, Rhu CH, et al. Beta-lapachone, a quinone isolated from Tabebuia avellanedae, induces apoptosis in HepG2 hepatoma cell line through induction of Bax and activation of caspase. J Med Food. 2006;9(2):161-168.

July 28, 2010

And the doc says....

I saw Dr G today and he was extremely pleased with the way the Doxil appears to be working. First he said I "looked good," then he reviewed last week's labs and had more blood drawn from my port. I didn't stay long enough to get those results but they will be mailed to me.

The plan is to have an ultrasound of my abdomen next week to check on the liver mets. If they don't appear on the ultrasound, which Dr G says is possible even after only two treatments of Doxil, he will order another CT scan after my fourth treatment. (Ultrasounds and CTs give different information. He doesn't want me to have too much radioactive contrast, which is given with CTs and not ultrasounds.) If that future CT looks clear, then I will have two more rounds of Doxil for a total of six altogether.

This assumes that I continue to tolerate the Doxil well, with manageable side effects, and that it is indeed very effective.

I am also going to have a bone scan some time in August, date tbd. I haven't had a bone scan in more than a year and of course bone mets wouldn't show up on a CT, which looks at soft tissues.

Dr G also gave me a tip on managing hand-foot syndrome. He told me that the Doxil won't enter a chilled area as easily, so I should rest my hands and feet on ice packs while getting the chemo. Ice packs are now on my bring-to-chemo list.

In the meantime I have some mouth sores, a sore throat and pain swallowing (more drugs for that), and stinging hands (Vicodin helps, as does the glutamine and B6). All of these side effects are manageable at this level, if annoying. Even more annoying is that I have lost almost all my eyelashes. All the lower ones are gone, and the upper lashes I can count on the fingers of one hand each. So a lot of dirt is getting into my eyes, which eyelashes would normally filter out. Wearing my glasses only keeps some of the stuff out. And of course I am trying not to rub my eyes so I can keep the remaining lashes.

Still: Doxil is turning out to be manageable, well-tolerated and apparently very effective.

July 26, 2010

Hand-foot syndrome

The hand-foot syndrome seems to have stopped with stingy pain on the tips of the thumb and first two fingers of my left (dominant) hand, which is also the lymphedema hand. Vicodin is taking care of the pain and reducing it to manageable levels, but it still feels weird and tingly. I notice it when trying to open a jar, tear a piece of masking tape, or use other small motor skills.

The soles of my feet feel less red and painful. I actually walked the dog and stood for an hour yesterday at the Gilda's Club Dog Walk in Magnuson Park. There were many booths from vets, groomers, and other dog-oriented businesses, as well as an agility demonstration area and 1K and 3K walks. (We just wandered around the tent area.) N came with their dog and the five of us had a jolly time meeting other dogs and their people. Bobber was not particularly enthusiastic about other dogs but extremely well behaved at the $5 dog nail trim tent. He jumped straight into the arms of the groomer and made friends.

I am hoping that the B6 complex and glutamine powder are working to reduce or at least halt the hand-foot side effects. Last night I bandaged my hand for the first time in a week and it was not especially red in the morning despite the tight wrappings. I will go for more tonight and hope in this way to manage my lymphedema despite the hand-foot syndrome.

July 24, 2010

Much better

After a night and a day, the nausea has calmed down quite a bit. Although I spent most of Friday lying on the couch, I feel much better today. The anti-nausea meds made me very sleepy, so one three hour nap turned into a second one after I took a break to eat lunch.

We had been invited to have Shabbat dinner with friends and I felt well enough to go. It was a large crowd of about 12 people, with much laughter and telling of jokes and stories. Not to mention plenty of delicious food, including home-made vanilla ice cream. It was good for my soul to be with people only a few days after chemo.

The hand/foot syndrome is bugging me now. The sole of my right foot and the thumb of my left hand are tingly and just at the edge of painful. At the naturopath's and oncologist's suggestion, I started taking vitamin B6 supplements and have increased the amount of glutamine powder. (I was measuring inaccurately. One of my teaspoons holds two actual teaspoons.) I hope this is as bad as it gets, because I really need to address the lymphedema issue again. After almost a week of doing nothing, my left hand and arm are okay but would benefit from bandaging at night.

Today is supposed to be warm and sunny and I look forward to catching up on a good book and taking it easy!

July 23, 2010

Day 5 post-treatment

On Tuesday I had the Neulasta shot to boost my white blood cell count. On Wednesday evening I developed some back pain that may or may not be related to the joint pain side effect I was told I might experience. So I called the onc, and took Vicodin, and took Vicodin, and took Vicodin. Even on Thursday evening my neck was stiff and uncomfortable. Today it seems better.

I felt the beginnings of nausea last night and this morning as well. They tell you to take the anti-nausea meds at the first sign of an upset tummy so that it can act before you feel really ill, which I did promptly as soon as I realized that what I was experiencing was nausea.

Yesterday I met with a new shrink at the Cancer Institute (my former psychiatrist is no longer in practice). Thankfully Pacificare Behavioral Health allowed an exception for me to see Dr. Dobie, and now I believe she is on their list of preferred providers. She asked me five pages of questions from her "get to know you" assessment. We agreed that she would be a good fit for me, and that I need one more tool in my cancer toolbox.

I wanted to see a shrink because no matter how wonderful a support group can be, you still have to share the focus with the other people in the group. In our 45 minute sessions, Dr. Dobie is there only for me. I don't have to worry about hogging the limelight or talking too much.

She recommended increasing the Zoloft by another 25 mg in order to improve my sleep (insomnia is a problem with depression) and told me that I could take Ativan to get better sleep any time.

Last night, between the Vicodin, the anti-nausea drug and the Ativan, I got the best night's sleep I've had in days. That's certainly a step in the right direction.

July 20, 2010

Visiting a friend

This morning I was fortunate to spent some time visiting with my friend Josh who recently entered hospice care for his advanced epitheliod sarcoma. You may remember his film, My Left Hand, and of course his blog.

A week ago everyone was sure he was dying, and soon. When I arrived today he was sitting in a chair eating breakfast. He was able to take a cell phone call. The human body's ability to hang onto quality of life and the human spirit's need to connect with loved ones never cease to amaze me.

Josh was surrounded by family and beloved friends last week. That's a good way for all of us to live, basking in the care of those we love and who love us.

Doxil round #2

Yesterday I had the second treatment of Doxil. I was much less stressed than the first one, and my blood pressure was suitably lower. I received 8 mg oral Decadron (steroid) and 1 mg oral Ativan (anti-anxiety), plus IV Emend (anti-nausea) as pre-meds, all exactly the same as last time. I was relatively relaxed and the Ativan actually made me doze a bit.

The Doxil went smoothly. I also received my monthly treatment of Zometa, the bone building wonder drug that also has cancer fighting properties. L the charge nurse was so on top of things! Last Friday she was looking ahead and saw that I was due for Zometa this week, called Dr. G and got him to order it. Everything was ready when I arrived, although it did take a while to get all the drugs.

I asked Rik to take me to Molly Moon's for ice cream afterwards. (I needed the sugar hit to counter the Ativan drowsiness.) With a half scoop each of salted caramel and ginger covered with hot fudge sauce in me, I felt so terrific that I didn't need a nap and was able to bake a pizza for dinner. And I slept well at night without any sleep aids.

This morning I took the second of three doses of Emend. I also went back to the Cancer Institute for a shot of Neulasta, a drug which builds white blood cells. Because my white count was down a bit (but not too much to cancel treatment), and because the Doxil will continue to lower my white count, Dr. G prescribed Neulasta to help my body build neutrophils (immature white blood cells). Increased white counts should keep me from getting an infection. The shot hardly stung when administered in the fatty part of my upper arm. I may have bone pain in 12-18 hours that might last for one day, but this is hardly new to a woman who has had bone mets in more than 20 sites for the past almost eight years.

July 18, 2010

What's new

I thought we were having a mostly quiet weekend but things ended up busier than I expected. It's wonderful to be able to enjoy life again.

Shabbat dinner on Friday night ended up being quite lively, with two dogs and multiple, energetic conversations in the living room and at the table. The mocha affogato (chocolate-coffee sauce) over ice cream was a particular hit.

The prescription lozenges for the thrush infection appear to be helping. My throat and tongue feel less sore. I will keep sucking on these puppies five times a day until they're gone!

I went to synagogue on Saturday morning and enjoyed seeing and hearing our former rabbi speak. Not to mention how gracious our current rabbi is in sharing her pulpit!

On Saturday night we went for Chinese food with friends who then came back here for chocolate cake and an attempt to find some ripe raspberries in our garden. A good time was had by all, even though the raspberries appear to be at a standstill.

I switched back to Ambien a couple of nights ago and had weird, disturbing dreams. So decided I should come off of all sleep aid meds and try to get some natural sleep, even though I am still bandaging for the lymphedema at night. The price of doing this is always a few nights of insomnia. I got about four hours' sleep Saturday night but did take a nice nap this afternoon.

Today I ran errands and Rik just hung out. We are having dinner with friends. Tomorrow I report to the cancer institute for the second round of Doxil. Assuming my blood counts are high enough...

July 16, 2010

Thrush

I seem to have developed a mild case of thrush, a fungal infection of the mouth that can be caused by a lowered immune system due to chemotherapy.

My tongue, throat and mouth felt a little sore, like when you're coming down with a cold, and my tongue got white and coated. At my new support group I asked if this might be mouth sores (also due to lowered immunity from chemo) and was told it sounded like thrush.

Thrush is common in babies and young children, as well as cancer patients on chemo. Dr. G prescribed clotrimazol (Mycelex), dissolving lozenges. You place one on your tongue and let is slowly dissolve over 15-30 minutes -- five times a day. It might take seven to ten days for this infection to clear up. Like antibiotics, the symptoms may disappear sooner but you have to finish the whole dose.

So far it's just annoying and hasn't stopped me from swallowing or eating. But it's a symbol that the chemo is doing something, and that makes me feel hopeful it will be very effective, have manageable side effects, and be very tolerable. The next dose of Doxil is scheduled for on Monday, if my counts permit.

July 13, 2010

At the beach


We spent last week in Moclips, WA, a tiny beach town on the Washington coast. There's nothing there but houses and a few motels, a general store and miles of sandy beach. We bring in everything, including food, and spend our days taking long walks, reading books, and generally relaxing. It's a very quiet vacation, just what the educator needs after a long year of teaching high school.


The Moclips beach is particularly dog friendly. We missed having Pumpkin with us. He used to love romping on the sand and getting really dirty, although he was never all that interested in going into the Pacific Ocean or the mighty Moclips River. Bobka LOVED running on the beach with Rik, chasing seagulls and greeting other dogs and their people. His first experience of an ocean wave was so unexpected, it toppled him off his feet. But his doggy swimming instinct kicked in (they don't call it the "dog paddle" for nothing).


We visited with friends, made a couple of bonfires on the beach to roast marshmallows for s'mores and sing Beatles tunes, ate well, and walked every day. The weather was sunny and fine for three days, then got misty and cool for the rest of the week. That was okay with us, since it turned out we missed a serious heat wave in Seattle, with temps in the 90s.

I felt really good the entire time. It might have been the sunshine, the salt air, or the good company, but I felt almost normal for the first time in a month.

Back to the usual

Yesterday was a return to the usual -- saw a doctor, ran errands, bought groceries, and had a two hour nap. It was very cool in Seattle again. The thermometer barely broke 60 degrees. Hard to believe this is summer.

My primary care doc asked me to take the depression assessment again and after two weeks on Zoloft I have lowered my score from 15 (moderately severe depression) to 9 (moderate depression). So evidently the 50 mg dose of Zoloft is working, although I personally believe that just getting a medical professional to listen to me and write a prescription was half the battle. I'll stay on it for a while.

After a week away we were in need of major groceries. Since we were already downtown we went to Big John's Pacific Food Importers where we bought farro (a low-carb carbohydrate that you cook like rice, very yummy) and assorted imported delights such as Bulgarian feta cheese and ajvar (roasted red pepper puree), fresh filo, sour cherry syrup to mix into seltzer, smoked gouda cheese, etc. I don't go there often but when I do I always have fun! Spanakopita for dinner tonight.

Then off to the main supermarket where kosher poultry was on sale so we stocked up on chicken and turkey thighs to put in the freezer. I am looking forward to a barbecue soon.

One bit of good news is that Sky, the care rep. at Pacificare Behavioral Health who has been advocating for me, put in for an "accommodation" for me to be able to see a psychiatrist at the Swedish Cancer Institute, who was not one of their in-network providers. She is cautiously optimistic that the request will be approved and I await notification in the mail.

I promise I will post about our vacation soon, but am off to yet another doctor this morning, followed by a visit to see a dying friend and a meeting this afternoon. Perhaps I can get to the photos tonight.

July 11, 2010

Back from the beach

We are back from spending a week on the Washington coast in the small town of Moclips. We've been going there for several years (missed last summer due to the bathroom remodel). Moclips is a whopping three streets big, with houses along the oceanfront. The beach is wide and sandy, the salt air invigorating, and we both feel rested and relaxed.

More later after the unpacking!

July 05, 2010

Independence Day


I just had to share this funny memory of my dad singing his words to John Philips Sousa's "Stars and Stripes Forever" every 4th of July --

Be kind to your web-footed friends
For a duck may be somebody's mother,
They live in the field and the swamp
Where it is cold and damp.

You may think that this is the end...
Well it is!

Taking it easy

I got through the first week on Doxil pretty well. I've had more energy in the mornings, been tired in the afternoons and needed a nap, and generally been taking it easy. I believe I will continue this pattern for the next few days, so don't be surprised if I don't post -- nothing to say.

This "hunkering down" is just so I don't overwhelm myself with too much to do. Summer should be relaxed and easy going, and if I have to spend mine on chemo, I plan to try to enjoy the warm weather we're (finally!) expecting.

Rik picked another pint of strawberries today, I think the last of the season. Plus he picked about a quart of raspberries. If we continue to pick them, we may have fruit all summer long. Although this does seem early for raspberries..... The chesterberry vines are HUGE, sprawling 15 feet into the air. I can't imagine how we will reach that fruit. Maybe with a ladder, although I don't want Rik climbing ladders anymore after last summer's fall from the height of the plum tree.

Our young friend H did about ten hours of work in the garden, weeding everything in sight and mulching over where she had to remove too many weed-choked plants. So things look generally spruced up.

We're finally expecting summer in the Puget Sound this week. I can hardly wait for warm temperatures! But I promise to be careful in the sun (a Doxil issue).

July 02, 2010

Keeping up energy

I was so busy on Tuesday that I took it VERY easy on Wednesday and Thursday. The uptick in energy I got from the Decadron on Monday began to wear off by Thursday.

Wednesday began with coffee with a friend. I am so grateful to my friends who call, send email, and persist in trying to reach me. Even if I don't feel like talking, I want you to know that I love getting your messages.

In the afternoon I went to my support group of young women with metastatic breast cancer. This group meets monthly, has no facilitator, but we are in the same boat metaphorically speaking and always have a lot to say. I am the "mother" of the group, the oldest at 50, and the others are in the late 30s and early 40s, some married, some with kids, some single. We were visited by a reflexology practitioner who gave us a 30 minute overview and then did some hands-on practicum on our feet.

I'm not sure I buy in to the philosophy, and this particular reflexologist struck me as fairly dogmatic in her belief that reflexology cures all. It's certainly not a cure for cancer. But she did provide some good tips, such as how to apply pressure to the palm of the hand with the opposite elbow to address nausea. I would have appreciated more tips and less lecture.

Thursday was even quieter. We did some marketing and I had a long nap in the afternoon. I did however make dinner for the synagogue's development team. We find we are most productive over food and wine. I made oven-roasted salmon with lemon and rosemary; ramen-cabbage salad; lemonade. We had freshly baked bread with hummus or butter. For dessert (no good meal is complete without dessert!) I baked shortcakes and topped them with strawberries and raspberries from our garden and whipped cream. Indeed we accomplished a lot at this meeting!

I plan to take it easy as I adjust to this first Doxil treatment, so don't worry if I post infrequently for a while.

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I dance with cancer. Oy!