Treatment – a reluctant trailblazer

“A trailblazer on a path you don’t want to be on.”

I paraphrase slightly, but that’s what the specialist breast cancer nurse at the hospital where I’m being treated said I was.

I have to say I was touched by the huge degree of empathy with which the nurse said it. This was just after the consultant told me that the treatment she was proposing for my secondary breast cancer was a combination of drugs that has just been made available under the NHS in England for women in my specific situation.

Given together, the drugs have been shown to improve what’s called “progression free survival”, ie the length of time patients live without their disease getting worse, and so delay the need for chemotherapy.

This latest development has been described as “fantastic news” for women such as me. The nurse was spot on with her description. I’m the first person at my stage of the disease and at my stage of treatment to have this therapy at the hospital trust where I’m being treated. I’m definitely grateful, but it’s a funny kind of gratefulness.

I started treatment on 22 May and I’m trying to focus more on the fact that the consultant is hoping for a “durable clinical response” than on the “significant, unavoidable or frequently occurring” risks of the treatment that are ticked on the consent form (see image).

The drugs are abemaciclib and fulvestrant – the brand names are Verzenios and Faslodex respectively for anyone who’s interested.

Abemaciclib is taken continuously in 28-day cycles as tablets – one tablet, twice a day, 12 hours apart. Fulvestrant is given as two injections – one in each buttock, not pleasant – each of which takes a couple of minutes to administer. You’re given it on Day 1 and Day 15 of Cycle 1, then on Day 1 of Cycle 2 and all future cycles – so that’s every two weeks for the first three doses, then once every four weeks.

You stay on these drugs for as long as they’re keeping the cancer in check and you can manage the side effects. Or, officially, for “as long as the patient is deriving clinical benefit from therapy or until unacceptable toxicity occurs”.

It could be a few months before we find out whether the drugs are working or not. If they’re not, you move straight away on to the next line of treatment. As for toxicity, the big worry with abemaciclib is diarrhoea. It’s a very common side effect and it can be so severe that the dose has to be reduced or a break in treatment is required. Three weeks in and I’m extremely relieved to report that I have got off very lightly indeed on this front. That may be partly explained by the fact that one of the side effects of the painkiller I’m on for the pain from the “bone mets” I have is constipation. I like to imagine the two drugs battling it out together inside me for supremacy.

You’re under close medical supervision, especially in the initial phase of treatment. You have blood tests every two weeks for the first two months, monthly for the following two months, and then as needed. You have scans every few months to check whether the drugs are working.

The cancer is in my bone marrow and bones, most significantly in my spine. Bone mets weakens your bones and puts you at risk of fracture, so I’m also back on the bone-strengthening drug, zoledronic acid or Zometa. I have that monthly too – via infusion, like chemo, on the same day I have the fulvestrant injections. The infusion itself takes 15 – 20 minutes. Zometa can also ease the pain that comes with bone mets. On the downside, as I mentioned when I started taking it before, it can also occasionally cause a very nasty condition called osteonecrosis of the jaw.

Fulvestrant is a hormonal therapy that aims to help shrink or slow the growth of metastatic breast cancer such as mine that feeds on oestrogen. Abemaciclib is what’s called “targeted therapy”, ie it’s a type of drug that targets specific characteristics of cancer cells, such as a protein that allows the cancer cells to grow in a rapid or abnormal way. Abemaciclib is one of a class of drugs called CDK4/6 inhibitors, which work by targeting two crucial cell division proteins, CDK4 and CDK6.

There’s a bit of a debate over whether CDK4/6 inhibitors are chemo or not. In the end, it seems it comes down to definitions.

This new combination treatment that I’m on hasn’t been in use long enough for it to be clear whether it also improves long-term survival, ie whether you live longer overall. In terms of quality of life, though, improvement in progression free survival is hugely important. The treatments don’t get any easier as your cancer gets worse. Not do the effects of the cancer itself, of course, so the longer it can be held in check, the better.

It’s very early days. Let’s hope I fare well on that trail I’m reluctantly blazing.

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