Chemo starts again

So we went and saw Ken Monday, Raven, Tim and myself. We took an hour and a quarter to discuss all the options and the outcomes and the implications and the permutations of various treatments. Basically the three main options were – step down from the first treatment plan and administer doxyrubicin (strongest chemo drug) every 3 weeks for 6 treatments. This was never considered as for me it had certain drawbacks that I didn’t want to contemplate. A it is a heart muscle damaging drug and really they need to have a very good reason for giving it more than 8 times (Raven has already had it 4 times with the last cycle of chemo) and B It would never give her a chance of a cure only remission and statistically speaking the remission would be less time the second time around. So less than 10 months basically before the cancer would be back. We pretty much ruled that treatment option out immediately. Second option choice was the exactly the same as last time. And again whilst it would put her in remission there is no chance of cure now (as opposed to 15% with the first round) and of course her remission would be less. 10 months is not very long so an even shorter period than that is just not an option for me. She has just turned 8, whilst not young for a Border Collie I wouldn’t describe it as old either, more late middle age. Contemplating this healthy looking and to all intensive purposes, perfectly well and happy 8 year old Border Collie being dead in months is just inconceivable to me. So we looked at the final option and the ‘top of the range’ treatment I guess you’d call it. The Autologous Bone Marrow Transplant. Sounds impressive doesn’t it? Well when you consider what they do then I guess it is.

This treatment involves the following. Exactly the same as her first round of chemo the first 8 treatments go the same way. She goes in once a week and is given her usual chemo cycle, Vincristine, Cyclophosphamide, Vincristine and then Doxyrubicin. A four week cycle. She goes in for two of those 4 week cycles having a week off after the Doxy. All things being well she should be in full clinical remission by then, nodes all normal and no signs of abnormal cancer cells in her blood work. One week after the doxy on the second cycle I will administer injections twice a day under her skin. This drug is extremely expensive but necessary in order to put her bone marrow production into overdrive in preparation for the marrow harvest. So then at the end of that week she goes in for her usual chemo however they put her under a full general anaesthetic and with two vets working on her over two hours they withdraw 160ml of bone marrow from her shoulder. Hopefully just the one shoulder on rare occasions they’ve had to use both. They then give her usual Vincristine that day as per the first week of her chemo cycle. One week later she comes in for the Cyclophosphamide however this time they give her double the normal dose. This dose effectively wipes out her entire bone marrow supply thus leaving her without any immunity. I still take her home that day as per normal however I am given two weeks of antibiotics to place her on to reduce any potential for infections to develop. I asked if she comes home in a bubble but apparently that’s neither necessary nor practical! Two days later, once the Cyclophosphamide has cycled through her system and is no longer present they reinfuse what is hopefully completely cancer free marrow back into her via slow intravenous infusion. After that they see her each week for a month to check her blood, then monthly for a year and then every two months for a year.

Approximately world wide 40% of dogs appear to be cured by this process. Those are odds I am willing to take. When it comes down to it though if she happens to be one of the unlucky ones who drops out of remission months after this I’ll still be glad we tried. At least then I’ll know I have absolutely done everything within my power to extend her quality of life.

Of course as Ken stressed, this procedure is no walk in the park. Along with the possibility of cure there are also risks (Immune mediated thrombocytopenia – where your immune system attacks the platelets that help clot blood, sterile cystitis, sepsis, nausea, allergic reactions during marrow transplant and others) and these were all outlined in the literature we received informing use about the procedure. Of course I asked about her already compromised immune system, given her atopy and he did say that they may impact on how quickly her immune system is back to normal after the marrow transplant. We asked all sorts of questions about what to do at home in preparation and her usual habits and Ken seemed to think that her resistance to all the usual infections out there would not be an issue. I asked about her naturally low white blood cell count (in all her treatment so far she had only ever reached 6 once all other times we were looking at 3 or below) and the impact that may have, his reply was that it is possible - if her low WBC count is due to a low number of stem cells, then that may mean they harvest less and recovery takes longer. I asked about how they check when her immune system has recovered and he stated that testing the immune system in general is very difficult in a laboratory. A low neutrophil count, which is the WBC they monitor is a good indicator of risk of bacterial infection. The other WBC including memory T cells that protect against anything that your body learns resistance to (including vaccination) is unharmed by treatment.

They have done a total of 12 BMT’s at Murdoch now. About 6 of those dogs presented like Raven with the standard form of lymphoma and still clinically well and healthy. 5 of those dogs are still in full remission doing well, for one the cancer came back after a couple of months. The other 6 all presented with aggressive and unusual forms of lymphoma and all much further along the stages, therefore most of those have dropped out of remission. You have to take into account though that not all those BMT’s were recommended by Ken, and the fact that these were last ditch attempts to buy even just a little time for the dogs and their owners. Owners who clearly had the means and didn’t have to care about the money factor.

It certainly isn’t cheap – the bone marrow harvest day alone is $2,500. All up by the time you finish paying for all the drugs, visits, procedures and treatments you are looking at around the $10,000 mark. It really doesn’t matter to me as I look at it like this, I am fortunate enough to have a stable income, I can’t take my money with me when I die, and even if I have to pay off debt for a few years at least I’ll know I did absolutely everything to extend Raven’s quality of life. That to me is the most important thing.

Raven went in Tuesday and had the Vincristine at a slightly reduced dosage due to the history of Neutropenia related to the Vinc. She had 0.6 instead of 0.7. She came home as happy as usual and was severely sulking when she realised she wasn’t coming to training that night. She had a bit of an upset tummy Wednesday night after training but that has settled down. Despite a slight weight drop (she dropped to 15.5) and a bit of a subdued attitude she has been fine. Our next hurdle is just making sure she stays on track with her scheduled chemo appointments and getting her into clinical remission as soon as possible. Short term I want to get a bit more weight on her, which is kind of hard to do when you have to avoid animal fats which feed cancer cells. But I am on the look out for raw healthy foods to feed her. She is basically on the BARF patties and veggie mash we make for her but I think I should up her raw meat intake, she hasn’t had chicken wings or carcasses for a while so I’ll start buying those again. She’s still on her fish oil caps and her Sasha’s blend, think I’ll look at adding further vitamin and mineral supplements again. So far so good, her nodes actually feel smaller than they did last week before chemo and I can’t feel the one in her left pre-scap that I felt last Monday. It’s only been one treatment so early days yet but the signs are good.

So that there is the latest lymphoma update. We ultimately hope to have another good couple of years with her but I know I have to be realistic. We may just be one of the lucky ones. And boy if I could employ the world to sift through those marrow cells harvested to get rid of every single cancer cell I would! But the machines that do that are out of reach from veterinary science so far. Give it another hundred years Ken says. Sure Ken, so could you cryogenically freeze us all in the meantime so we can come back when that’s all organised please? Thanks :-)