The Radiation Oncologist

It’s Thursday, three weeks since The News.

For once today’s appointment was in the afternoon and there were no sunrise calls or messages. Maybe someone at PAMF finally updated my chart. Sadly I was awake at 7:45 anyway.

The Radiation Oncologist

JT mentioned earlier in the week she most likely couldn’t make today’s visit with the radiation oncologist due to other commitments. Having her at the previous consultations with the surgeon and medical oncologist was invaluable, both as moral support and because she brings a different perspective and asks different questions. In other circumstances I might have given thought to rescheduling the appointment to a time she could attend. But she’d previously made some comments that made me think radiation therapy was less of a concern than chemo and surgery, and when we touched base last night she said she thought it was rather straightforward. I trust her assessment as she’s been down this road before. So I wasn’t concerned about going to this particular appointment alone. And besides, the show must go on!

Like the medical oncologist visit, this one was in the basement of PAMF Palo Alto. Why is it that oncologists like to hide out in basements? There’s a much better way to avoid sunlight: work at night. Their nocturnal patients would appreciate it too.

Before meeting with the oncologist the nurse asked me to watch a video on radiation oncology. This was great, and answered the majority of the questions I had scribbled prior to the visit. I wish the other other specialists provided pre-visit “homework” – their time is busy and it helps to digest the information at your leisure. If you’re interested you can find the radiation oncology video on this page. Look for the one under General Radiation Oncology.

In the context of the overall treatment plan the radiologist described the same process as the medical oncologist – total neoadjuvant therapy. He clarified that radiation therapy would follow systemic chemotherapy; they wouldn’t be concurrent. There’d be a 6-8 week break between the end of radiation therapy and surgery, and the tumor would be re-staged after radiation therapy. While it seems unlikely in my case, I’m still keeping my fingers crossed that the total neoadjuvant therapy will eradicate the tumor 🙂.

Radiation therapy will span five weeks with five sessions each week, for a total of 25 sessions. I wonder if I could just board at the clinic and avoid the commute…that’s what Caper did when she had radiation treatment. She’d check in on Monday and come home on Friday. I rather think she enjoyed her stay at Sage Veterinary, and the staff apparently enjoyed her company as well. At one point her oncologist mentioned they’d thought about sending me home with a stuffed rat terrier so they could enjoy her company bit longer and just hoped I wouldn’t notice. I don’t know…I probably would’ve called in to report that Caper seemed unusually lethargic and wasn’t eating.

The chemotherapy drug Xeloda will be used in conjunction with the radiation treatment. Xeloda sensitizes the tissue to radiation and makes it more effective.

Apparently side effects are minimal. More to do with fatigue, cramps, and things along those lines. I won’t lose any hair (at least not any on my head.) The one thing I was looking forward to in cancer treatment was not having to cut my hair. Isn’t losing your hair one of the classic side-effects? I struck out with the medical oncologist who said the chemo drugs wouldn’t do the trick. And now with the radiation oncologist. Maybe I can request that the surgeon do a haircut while he’s at it. The surgical robot he’s going to use must have a pre-programmed haircut mode, right? (If not…I know some people at Intuitive Surgical, the folks who make the Da Vinci surgical robots. If PAMF is using those I’ll have some special software installed…)

One topic I raised with the radiation oncologist – something another friend going through cancer diagnosis brought up – and something I need to raise with the medical oncologist the next time we speak, is if I’ll end up immunocompromised. With the COVID delta variant running around the Bay Area it’s something I’m concerned about, even though I’m fully vaccinated. The last thing I’d want is to be cured of cancer and end up with long COVID! The radiation oncologist wasn’t concerned – so far they haven’t faced a COVID issue with patients. They would do periodic bloodwork and monitor my white blood cell count in any case.

I assume most people who are looking at radiation treatment have a lot of concerns, like will there be collateral damage from the beams? Will they glow in the dark? For whatever reason I just assume that radiation therapy is safe, and frankly don’t care if I become bioluminescent. One of my greater concerns was a practical one: could I take a shower while undergoing therapy? See, before therapy you’re marked during simulation. Simulation is done in preparation for treatment and basically aligns a patient’s body with the equipment so that the beams get delivered to the right area. The body marks are done so that the alignment can be done easily each day. An article I’d read earlier mentioned to avoid bathing to prevent the marks from being washed off. Not bathing for five weeks would be a bit much – and I doubt either I or the radiation oncologist or technicians would find it pleasant. Fortunately the radiation oncologist said the not-quite-indelible marks didn’t apply in my case.

To finish off the visit the radiation oncologist pulled up the MRI and CT scans. This is the first time I’ve seen the images – I only have access to the text reports in PAMF’s online system. It’s quite interesting how they can navigate through the scans, but to be honest I couldn’t really make out the tumor even after he pointed it out. (It’s occurred to me that this whole cancer business is a sham concocted to try to get me onto a diurnal schedule. If I really suffer no side-effects during chemo and radiation, and if the tumor is “cured” by neoadjuvant therapy I’ll know for certain this was all a ruse!)

The radiation oncologist also pointed me to an excellent source of information – the National Comprehensive Cancer Network. The NCCN is an alliance of cancer centers, and among other things they publish guidelines for treatment of various types of cancers. These get updated periodically as technology and knowledge advance. Each type of cancer has its own guidelines, which you can find by going to Guidelines->Cancer Type from their home page. (You may need to create a login to access some of the documents.)

For rectal cancer I found the Guidelines for Patients most useful. A lot of it I already knew from talking to the surgeon and medical oncologist. But those conversations could’ve been a lot more productive had I read the patient guidelines first. For example, the guideline described the various chemotherapy regimens (FOLFOX, CAPEOX, FOLFIRI, 5-FU/LV, etc.) that are commonly used and their potential side-effects. Knowing this I could have discussed the pros and cons with the medical oncologist, as well as which regimens might be used if the cancer doesn’t respond to the preferred regimen. I think the medical oncologist is recommending FOLFOX for my case. But looking at the descriptions, I see FOLFIRI has a hair loss side-effect (yeah! Though along with abdominal cramping nausea, and diarrhea – small prices to pay for not having to cut my hair.) FOLFOX only has a risk of (temporary) peripheral neuropathy. I wonder if I can convince the medical oncologist to try FOLFIRI first, at least until I go bald?

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