Dr. Sara Hurvitz
Dr. Giuliano referred us to Dr. Sara Hurvitz, a medical oncologist at UCLA in Santa Monica. Initially, the soonest her assistant Diane would schedule us was next Monday, which seemed like an unacceptable delay. However, Diane called this morning and said that Dr. Hurvitz could fit us in at 1:00 this afternoon. We had been preparing to try to push buttons and pull strings to get in sooner, so we were elated to get the call.
Dr. Hurvitz, like Dr. Miller, is a young woman who I immediately felt comfortable with and found easy to talk to. Consistent with the other doctors' recommendations, she said neoadjuvant therapy, then surgery, then postoperative therapy are necessary. (As an aside, she explained that the point of neoadjuvant therapy is to be able to monitor the tumor shrinking. If surgery happened first, no one would ever know if the postoperative treatment was effective. This is completely logical, but I hadn't thought of it that way before.) She explained the following options:
Of course, as soon as Dr. Hurvitz finished explaining the trial, I was ready to sign up. She made me read the 37-page consent form before I did, but there was nothing in it that gave me pause, so I signed it and the ball is officially rolling. We will find out if I have been admitted to the trial in 5-7 days - my biopsy cores have to be analyzed by pharmaceutical maker Roche in Germany first - but Dr. Hurvitz didn't seem to have any doubt that I would be. Assuming that I am, we will find out which arm I am assigned to (as the trial is not blinded) at the end of next week or early the following week - the odds are 50/50 for each. It's hard not to get our hopes up for Arm B - though I've discovered that keeping my hair is not a huge priority for me, I do love the idea of not having other side effects, or having them much less. But the fact is that even Arm A is a significant improvement over the Standard of Care, so I will be extremely fortunate either way. The only downside of the trial is that I will have to provide two extra needle core biopsies, but I figure that I'm going to be poked and prodded and cut up so much during the next year, I'll hardly notice two more biopsies.
Under any of these three regimens, the neoadjuvant therapy will consist of six three-week cycles, so the time period from the first treatment to the last is 15 weeks. The drugs would be administered on a Thursday each cycle, and according to Dr. Hurvitz, I'll probably feel tired over the weekend but by the following Monday or Tuesday should be myself again. This was incredibly encouraging news to me, as I had been preparing for four months of continuous and increasing fatigue. Dr. Hurvitz said not only could I continue working throughout my treatment, but that I should - a big relief to me, as I was really looking forward to returning to work in October.
Another big relief was the question of Ike's care. Having heard so much about how chemo compromises the immune system, we were very concerned that Ike might not be able to attend his daycare once I start treatment, as he - and therefore I - will inevitably be exposed to many nasty bugs there. I was also concerned that if he got sick I wouldn't be able to be around him, which would be both emotionally distressing and logistically challenging in our small house. Dr. Hurvitz dismissed those concerns with confidence. Under the Standard of Care or Arm A, 24 hours after each treatment I will receive a shot of a drug called Neulasta (Pegfilgristim). Neulasta stimulates the growth of healthy white blood cells in the bone marrow which help the body fight infection, so my immune system will function as normal. Even better, under Arm B, Neulasta won't be necessary because no healthy cells will be impacted by the treatment. In any case, though I should take precautions like frequent hand-washing, I don't have to be afraid of every sneeze and doorknob and shopping cart the way that chemo patients were in the past.
There are still a lot of things that need to happen before I can start treatment, including my PET scan and brain MRI this Thursday, a "chemo teaching" session on Friday, electrocardiogram and echocardiogram (yet to be scheduled), and installation of my chemo port (a minor surgery, yet to be scheduled), as well as all the administrative approvals. More than likely, I will have my first treatment on September 18. This gives us a little more breathing room for Ike's weaning, so I don't mind the wait.
I continue to be amazed by the timing of all of this. That there is a trial being conducted a few minutes from my home that is studying the effects of these very new drugs on my exact type of cancer seems incredible. That these drugs have only been brought to market for any use in the last year or two is also amazing. Dr. Hurvitz said that Perjeta was actually invented over ten years ago but wasn't approved until 2012. It's tragic to think how many women have suffered and died waiting for this drug, but I suppose you can't think that way - you have to think of all the women who will benefit from it in the years to come, including me.
Dr. Hurvitz, like Dr. Miller, is a young woman who I immediately felt comfortable with and found easy to talk to. Consistent with the other doctors' recommendations, she said neoadjuvant therapy, then surgery, then postoperative therapy are necessary. (As an aside, she explained that the point of neoadjuvant therapy is to be able to monitor the tumor shrinking. If surgery happened first, no one would ever know if the postoperative treatment was effective. This is completely logical, but I hadn't thought of it that way before.) She explained the following options:
- Standard of Care - The term Standard of Care means the recommended treatment process within the bounds of current FDA approvals. In my case, the Standard of Care is neoadjuvant therapy consisting of two chemotherapy drugs (docetaxel and carboplatin) and two antibodies (trastuzumab (Herceptin) and pertuzumab (Perjeta)), which in combination are called TCHP, followed by surgery, followed by Herceptin for the balance of the year from my first treatment. I was surprised and pleased to learn that the chemo drugs would not be needed after the surgery.
- Clinical Trial Kristine - Clinical trials study (and therefore allow patients access to) treatments that are not currently approved by the FDA. Kristine is a clinical trial that was designed and is being overseen by Dr. Hurvitz. It consists of 432 (433 with me?) HER2-positive breast cancer patientsdivided into two cohorts, or arms, as follows:
- Arm A - Arm A consists of the same TCHP regimen as the Standard of Care, followed by surgery. The difference is in the postoperative treatment, which would consist of both Herceptin and Perjeta for the balance of the year. Postoperative Perjeta is currently only approved for metastatic breast cancer, but according to Dr. Hurvitz, it is very beneficial for early-stage cancer as well, so it is a big bonus to receive it through the trial (the drug is expensive - Dr. Hurvitz estimated the value at $50,000).
- Arm B - Arm B does not include any chemotherapy drugs; instead, the neoadjuvant therapy consists only of antibodies, trastuzumab emtansine (T-DM1 or Kadcyla) and Perjeta. T-DM1 transports the Perjeta directly to the tumor while sparing healthy cells, which reduces side effects when compared with systemic chemotherapy. The FDA approved T-DM1 earlier this year for treatment of metastatic breast cancer, but it is not yet available for treatment of early-stage cancer. Dr. Hurvitz said that the side effects are so mild, patients don't even lose their hair. The postoperative treatment would also be T-DM1 and Perjeta.
Of course, as soon as Dr. Hurvitz finished explaining the trial, I was ready to sign up. She made me read the 37-page consent form before I did, but there was nothing in it that gave me pause, so I signed it and the ball is officially rolling. We will find out if I have been admitted to the trial in 5-7 days - my biopsy cores have to be analyzed by pharmaceutical maker Roche in Germany first - but Dr. Hurvitz didn't seem to have any doubt that I would be. Assuming that I am, we will find out which arm I am assigned to (as the trial is not blinded) at the end of next week or early the following week - the odds are 50/50 for each. It's hard not to get our hopes up for Arm B - though I've discovered that keeping my hair is not a huge priority for me, I do love the idea of not having other side effects, or having them much less. But the fact is that even Arm A is a significant improvement over the Standard of Care, so I will be extremely fortunate either way. The only downside of the trial is that I will have to provide two extra needle core biopsies, but I figure that I'm going to be poked and prodded and cut up so much during the next year, I'll hardly notice two more biopsies.
Under any of these three regimens, the neoadjuvant therapy will consist of six three-week cycles, so the time period from the first treatment to the last is 15 weeks. The drugs would be administered on a Thursday each cycle, and according to Dr. Hurvitz, I'll probably feel tired over the weekend but by the following Monday or Tuesday should be myself again. This was incredibly encouraging news to me, as I had been preparing for four months of continuous and increasing fatigue. Dr. Hurvitz said not only could I continue working throughout my treatment, but that I should - a big relief to me, as I was really looking forward to returning to work in October.
Another big relief was the question of Ike's care. Having heard so much about how chemo compromises the immune system, we were very concerned that Ike might not be able to attend his daycare once I start treatment, as he - and therefore I - will inevitably be exposed to many nasty bugs there. I was also concerned that if he got sick I wouldn't be able to be around him, which would be both emotionally distressing and logistically challenging in our small house. Dr. Hurvitz dismissed those concerns with confidence. Under the Standard of Care or Arm A, 24 hours after each treatment I will receive a shot of a drug called Neulasta (Pegfilgristim). Neulasta stimulates the growth of healthy white blood cells in the bone marrow which help the body fight infection, so my immune system will function as normal. Even better, under Arm B, Neulasta won't be necessary because no healthy cells will be impacted by the treatment. In any case, though I should take precautions like frequent hand-washing, I don't have to be afraid of every sneeze and doorknob and shopping cart the way that chemo patients were in the past.
There are still a lot of things that need to happen before I can start treatment, including my PET scan and brain MRI this Thursday, a "chemo teaching" session on Friday, electrocardiogram and echocardiogram (yet to be scheduled), and installation of my chemo port (a minor surgery, yet to be scheduled), as well as all the administrative approvals. More than likely, I will have my first treatment on September 18. This gives us a little more breathing room for Ike's weaning, so I don't mind the wait.
I continue to be amazed by the timing of all of this. That there is a trial being conducted a few minutes from my home that is studying the effects of these very new drugs on my exact type of cancer seems incredible. That these drugs have only been brought to market for any use in the last year or two is also amazing. Dr. Hurvitz said that Perjeta was actually invented over ten years ago but wasn't approved until 2012. It's tragic to think how many women have suffered and died waiting for this drug, but I suppose you can't think that way - you have to think of all the women who will benefit from it in the years to come, including me.
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