Lymphomania: Fun With Particle Accelerators
When we last left our intrepid hero, he had just finished chemotherapy! And now – the next exciting installment!
Shortly after my last chemo treatment, I was sent to a radiation oncologist, who is basically another cancer doctor that specializes in radiation treatments. My first appointment was for a consultation. They put in all my medical history (that I'd given to other doctors before... not sure why all that stuff isn't linked together...), and then I had a long talk with the doc where he explained all about the process. Now, this guy is as big of a nerd as I am, so at the end, he told me that he went into a lot more detail with me than he usually does, but he figured I'd appreciate it, which was a correct judgment. :) [an aside: Does anyone else think that “judgment” should have an “e” between the “g” and “m”? Either that, or “judge” should not have an “e” at all. In fact, it should be spelled “judj”. No need for all this “soft 'g'” business!]
So to pass along one of the more interesting pieces of information, he told me how the radiation actually kills the cancer cells. X-rays of a certain frequency are shot through your body. At lower frequencies, your body is transparent to them, but bone is not, which is why you can get x-ray images of bone and internal structure. If we increase the frequency of the x-rays (which is synonymous with increasing the energy when we talk about radiation), bone becomes transparent as well. The rays end up interacting with particles in your cells in ways that can break the cells' DNA. Now, your DNA is rather resilient, and it can normally repair itself, but if the cell is in the process of dividing, then the DNA, which is normally in the structure of a ladder, is in an “unzipped” state (picture halving a ladder by breaking all the steps on it), and breaks while it is in this state cannot be repaired. If the DNA can't be repaired, the cell dies. So basically, the radiation has a higher probability of killing cells that are dividing, and since cancer cells divide at a higher rate, they have a higher probability of being in that vulnerable state. You actually use the high rate of division against it. Neat! That of course means that the radiation can still affect healthy cells that have a high division rate, but just not to the same extent, so it's just like chemo in that way.
With regard to my specific case, he went over the pros and cons of treatment, since I could actually opt not to have it. (My thinking there is that the docs know more about it than me, so if they suggest it, I'm doing it!) The radiation is there to clean up what the chemo didn't get. This isn't always the case since sometimes it's used to shrink tumors before surgery. He said that the particular location and the bulkiness when it was found both increase the risk of recurrence, so he was in favor of the treatment. I'll admit, it felt weird going over that stuff again, even though it wasn't anything that I hadn't heard before. I just had to keep telling myself that that increased risk he talked about was already taken into account when I got my original prognosis. Otherwise, you can start feeling pessimistic about it. He also mentioned that the radiation they used wasn't very good at causing cancer, and that usually when people get cancer from radiation, it's because radioactive sources themselves have collected inside the person for some reason, and those sources cause constant exposure. The chances that the radiation treatment I got would cause problems down the line were on the order of 1/1000 – 1/10,000, but seeing as how the probability that the cancer is not in remission now is 1/4 – 1/3, I'll take those odds. On the up side, lymphomas in general are one of the more responsive cancers to radiation, so instead of needing a higher intensity dose for a shorter duration, they could use a lower intensity dose for a longer duration. The dosage is measured in “gray” (Gy), and the usual dose is 1.8 – 2.0 Gy, but for lymphomas, they can get away with 1.6. The doc said that higher energies wouldn't really do anything extra, and it'd just be like shooting a guy with two bullets instead of one when the one would kill him just as dead. Side effects depend on where the treatment is targeted, but generally include some fatigue. Since my treatment was to the chest, the other main possible side effect would be irritation to the esophagus, since the esophageal lining (and gut in general) is made of rapidly dividing cells.
After the consultation, there was a planning session, although this wasn't for another couple of weeks. The planning required another PET/CT scan so the oncologist would know exactly what areas to target. I got the idea that radiation treatment is very much an art as well as a science; he said that after he got the images, it would take him a few days to decide exactly what the best course of action was. It turned out that the scans didn't show as much detail as they wanted, so I had to do another CT scan with contrast (where they put the dye in your blood to make things show up better), but that wasn't a big deal. The up side of getting the PET scan was an update on how the cancer was doing. The bottom line from the hematology oncologist was that he thought we were still “on track”. Even though there was still a little bit of above-average uptake and a newer spot on the sternum showing, the doc said that at this point the images are very open to interpretation, and some of it could be from the drug they give me to stimulate the marrow into replacing lost blood cells. He did say that the most important and telling thing at this point was that the tumor was still shrinking, so I'm just holding on to that “still on track”.
So when the radiation doc gets the images and decides what to do, they basically use the scans to build at 3D model of the inside of my body, and they write a program that tells the radiation source where and how long to shoot the beam. The rooms with the scanners and treatment machines all have lasers in the wall that shoot fans of laser light along three axises: across the front of my body, down the front of my body, and down the side. Marks are placed on me along those axises where the lasers land, and they are covered with tape to keep them from coming off (although they have to be redrawn every few days; I thought at first they were using some special ink, but the first time they were redrawn, I saw that it was just a Sharpie). Also, small dots are tattooed (yes, the permanent kind) on those marks just in case; I have three: one on the center of my chest, and two on either side of my body. They stopped putting ink marks where the tattoos were, but still required a mark lower down on the sternum. I kind of wish they'd just have put a dot there as well so I didn't have to worry about it coming off throughout the whole treatment. Now, every time I went in to get zapped, my body was aligned with those lasers, then they used x-rays to fine-tune the position of my body to match where the machine thought I should be. Then the machine could move its x-ray source around me and administer the radiation according to its internal model, which matched up with my actual body position on the table. A couple of times in the treatment room I saw a plastic mesh mold of someone's head and top of the torso which the patient would lie under. I asked if that was for someone being treated in the head, which is was; you really have to be in the same position every time.
My first day of actual radiation, I soooo wanted to take in a spider or a popcorn kernel and put it on my chest. Just in case. ;) [The popcorn kernel of course would have purely been a joke, as microwaves and x-rays are way far apart on the spectrum.] Everything after I actually started the radiation was pretty rote. I had to have twenty-seven treatments, where I'd get one every week day, so it took five weeks and two days. (Well, actually, five weeks and three days since I didn't get treated on the 4th of July since that was a holiday, so that one just got tacked on to the end.) Once a week I'd meet with the doc, and they'd get my weight, temperature, and blood pressure, ask how I was doing, and then look at my back and chest (the exposure areas) to make sure my skin wasn't getting all funky or anything. The radiation basically reddens the skin, akin to a mild sunburn, and then it fades to brown for a few weeks, like a tan. The actual treatment just took a few minutes. After I went into the room, I laid down on the table with “the machine” looming over me. They'd line me up with the lasers, leave, and then line me up with x-ray images, then do the actual exposure, which was about eight seconds from the front and back (maybe nine or ten on the front; I was having to just count in my head), so sixteen to eighteen seconds' worth in all. If nobody was ahead of me, I was in-and-out in ten or fifteen minutes. I started on June 6 and ended July 13. Not too bad at all.
The side effects for me were actually really mild. I had a little fatigue at first, but that faded, and around treatment ten, I could feel some sensitivity in my esophagus, like it was clenching up a little when I ate sometimes, but it never got any worse, for which I am very thankful.
So right now I'm just waiting. I have a follow-up with radiation doc on August 11, which will probably just be a routine, “How are you feeling? [Fine.] Any lingering side effects? [No.] OK, lets get your temperature, weight, and blood pressure,”-type thing. After that, I have a PET scan scheduled for August 22 with an appointment with the hematology doc on the 30th to get the actual results. I guess he just wants to let the suspense build. :) Until then, I'm just enjoying some time where I don't have to think about it and live normally for a while. If it's ini remission when I get checked again, awesome! If not, then it's back to different chemo treatments. We'll see.
There's a comic I read called XKCD. His fiance was diagnosed with breast cancer about a month before I got my news, so shortly after I was diagnosed, he started putting out the occasional cancer-related comic. I liked one of his more recent ones a lot because it has a really good answer to the, “Did the treatment work?” question [Short answer: don't know] and gives a good idea of the cancer treatment cycle. It's at http://xkcd.com/931/, and after you read it, you should hover the mouse pointer over the image. The one that's two before that (http://xkcd.com/933/) is also good.
Shortly after my last chemo treatment, I was sent to a radiation oncologist, who is basically another cancer doctor that specializes in radiation treatments. My first appointment was for a consultation. They put in all my medical history (that I'd given to other doctors before... not sure why all that stuff isn't linked together...), and then I had a long talk with the doc where he explained all about the process. Now, this guy is as big of a nerd as I am, so at the end, he told me that he went into a lot more detail with me than he usually does, but he figured I'd appreciate it, which was a correct judgment. :) [an aside: Does anyone else think that “judgment” should have an “e” between the “g” and “m”? Either that, or “judge” should not have an “e” at all. In fact, it should be spelled “judj”. No need for all this “soft 'g'” business!]
So to pass along one of the more interesting pieces of information, he told me how the radiation actually kills the cancer cells. X-rays of a certain frequency are shot through your body. At lower frequencies, your body is transparent to them, but bone is not, which is why you can get x-ray images of bone and internal structure. If we increase the frequency of the x-rays (which is synonymous with increasing the energy when we talk about radiation), bone becomes transparent as well. The rays end up interacting with particles in your cells in ways that can break the cells' DNA. Now, your DNA is rather resilient, and it can normally repair itself, but if the cell is in the process of dividing, then the DNA, which is normally in the structure of a ladder, is in an “unzipped” state (picture halving a ladder by breaking all the steps on it), and breaks while it is in this state cannot be repaired. If the DNA can't be repaired, the cell dies. So basically, the radiation has a higher probability of killing cells that are dividing, and since cancer cells divide at a higher rate, they have a higher probability of being in that vulnerable state. You actually use the high rate of division against it. Neat! That of course means that the radiation can still affect healthy cells that have a high division rate, but just not to the same extent, so it's just like chemo in that way.
With regard to my specific case, he went over the pros and cons of treatment, since I could actually opt not to have it. (My thinking there is that the docs know more about it than me, so if they suggest it, I'm doing it!) The radiation is there to clean up what the chemo didn't get. This isn't always the case since sometimes it's used to shrink tumors before surgery. He said that the particular location and the bulkiness when it was found both increase the risk of recurrence, so he was in favor of the treatment. I'll admit, it felt weird going over that stuff again, even though it wasn't anything that I hadn't heard before. I just had to keep telling myself that that increased risk he talked about was already taken into account when I got my original prognosis. Otherwise, you can start feeling pessimistic about it. He also mentioned that the radiation they used wasn't very good at causing cancer, and that usually when people get cancer from radiation, it's because radioactive sources themselves have collected inside the person for some reason, and those sources cause constant exposure. The chances that the radiation treatment I got would cause problems down the line were on the order of 1/1000 – 1/10,000, but seeing as how the probability that the cancer is not in remission now is 1/4 – 1/3, I'll take those odds. On the up side, lymphomas in general are one of the more responsive cancers to radiation, so instead of needing a higher intensity dose for a shorter duration, they could use a lower intensity dose for a longer duration. The dosage is measured in “gray” (Gy), and the usual dose is 1.8 – 2.0 Gy, but for lymphomas, they can get away with 1.6. The doc said that higher energies wouldn't really do anything extra, and it'd just be like shooting a guy with two bullets instead of one when the one would kill him just as dead. Side effects depend on where the treatment is targeted, but generally include some fatigue. Since my treatment was to the chest, the other main possible side effect would be irritation to the esophagus, since the esophageal lining (and gut in general) is made of rapidly dividing cells.
After the consultation, there was a planning session, although this wasn't for another couple of weeks. The planning required another PET/CT scan so the oncologist would know exactly what areas to target. I got the idea that radiation treatment is very much an art as well as a science; he said that after he got the images, it would take him a few days to decide exactly what the best course of action was. It turned out that the scans didn't show as much detail as they wanted, so I had to do another CT scan with contrast (where they put the dye in your blood to make things show up better), but that wasn't a big deal. The up side of getting the PET scan was an update on how the cancer was doing. The bottom line from the hematology oncologist was that he thought we were still “on track”. Even though there was still a little bit of above-average uptake and a newer spot on the sternum showing, the doc said that at this point the images are very open to interpretation, and some of it could be from the drug they give me to stimulate the marrow into replacing lost blood cells. He did say that the most important and telling thing at this point was that the tumor was still shrinking, so I'm just holding on to that “still on track”.
So when the radiation doc gets the images and decides what to do, they basically use the scans to build at 3D model of the inside of my body, and they write a program that tells the radiation source where and how long to shoot the beam. The rooms with the scanners and treatment machines all have lasers in the wall that shoot fans of laser light along three axises: across the front of my body, down the front of my body, and down the side. Marks are placed on me along those axises where the lasers land, and they are covered with tape to keep them from coming off (although they have to be redrawn every few days; I thought at first they were using some special ink, but the first time they were redrawn, I saw that it was just a Sharpie). Also, small dots are tattooed (yes, the permanent kind) on those marks just in case; I have three: one on the center of my chest, and two on either side of my body. They stopped putting ink marks where the tattoos were, but still required a mark lower down on the sternum. I kind of wish they'd just have put a dot there as well so I didn't have to worry about it coming off throughout the whole treatment. Now, every time I went in to get zapped, my body was aligned with those lasers, then they used x-rays to fine-tune the position of my body to match where the machine thought I should be. Then the machine could move its x-ray source around me and administer the radiation according to its internal model, which matched up with my actual body position on the table. A couple of times in the treatment room I saw a plastic mesh mold of someone's head and top of the torso which the patient would lie under. I asked if that was for someone being treated in the head, which is was; you really have to be in the same position every time.
My first day of actual radiation, I soooo wanted to take in a spider or a popcorn kernel and put it on my chest. Just in case. ;) [The popcorn kernel of course would have purely been a joke, as microwaves and x-rays are way far apart on the spectrum.] Everything after I actually started the radiation was pretty rote. I had to have twenty-seven treatments, where I'd get one every week day, so it took five weeks and two days. (Well, actually, five weeks and three days since I didn't get treated on the 4th of July since that was a holiday, so that one just got tacked on to the end.) Once a week I'd meet with the doc, and they'd get my weight, temperature, and blood pressure, ask how I was doing, and then look at my back and chest (the exposure areas) to make sure my skin wasn't getting all funky or anything. The radiation basically reddens the skin, akin to a mild sunburn, and then it fades to brown for a few weeks, like a tan. The actual treatment just took a few minutes. After I went into the room, I laid down on the table with “the machine” looming over me. They'd line me up with the lasers, leave, and then line me up with x-ray images, then do the actual exposure, which was about eight seconds from the front and back (maybe nine or ten on the front; I was having to just count in my head), so sixteen to eighteen seconds' worth in all. If nobody was ahead of me, I was in-and-out in ten or fifteen minutes. I started on June 6 and ended July 13. Not too bad at all.
The side effects for me were actually really mild. I had a little fatigue at first, but that faded, and around treatment ten, I could feel some sensitivity in my esophagus, like it was clenching up a little when I ate sometimes, but it never got any worse, for which I am very thankful.
So right now I'm just waiting. I have a follow-up with radiation doc on August 11, which will probably just be a routine, “How are you feeling? [Fine.] Any lingering side effects? [No.] OK, lets get your temperature, weight, and blood pressure,”-type thing. After that, I have a PET scan scheduled for August 22 with an appointment with the hematology doc on the 30th to get the actual results. I guess he just wants to let the suspense build. :) Until then, I'm just enjoying some time where I don't have to think about it and live normally for a while. If it's ini remission when I get checked again, awesome! If not, then it's back to different chemo treatments. We'll see.
There's a comic I read called XKCD. His fiance was diagnosed with breast cancer about a month before I got my news, so shortly after I was diagnosed, he started putting out the occasional cancer-related comic. I liked one of his more recent ones a lot because it has a really good answer to the, “Did the treatment work?” question [Short answer: don't know] and gives a good idea of the cancer treatment cycle. It's at http://xkcd.com/931/, and after you read it, you should hover the mouse pointer over the image. The one that's two before that (http://xkcd.com/933/) is also good.
Labels: lymphomania
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