The New Plan

Last week I talked a bit about the MRI results from 2/10 and coming up with a new plan for treatment going forward since the previous chemo was no longer working. 

We met with our doctor at VCS who recommended a few new chemo options: irinotecan and docetaxel are the two main drugs we could consider trying next.  Both are approved by the FDA and have been used in gastric cancer (irinotecan with particularly good response rates of 65%).  I say these are the main chemo drugs because chemo is often give as a doublet or triplet, so there were options that we could combine like cisplatin, carboplatin, or even doing docetaxel and irinotecan together.  My primary oncologist was very supportive of us going back to Hopkins and getting another opinion from Sloan Kettering. 

We went to Hopkins last Thursday (Valentine's Day) to see if they had any clinical trials I might qualify for or had any other recommendations for treatment.  The doctor at Hopkins said he would be fine with either irinotecan or docetaxel in combination with cisplatin.  In the two days between our meeting with my primary oncologist and Hopkins, I had done some research on both irinotecan and docetaxel.  Both have very strong warnings against giving the drugs to patients with hepatic (liver) impairment.  I have pretty significant hepatic impairment.  I mentioned this to the doctor at Hopkins and he said, you're right, you can't get irinotecan with a bilirubin (liver function test) greater than 3 (normal is 0.2-1.0), mine is currently 4.5.  So irinotecan is off the table for now.  Even though there weren't any good clinical trials at Hopkins, I wouldn't have qualified with my liver in this condition anyway.

The doctor from Sloan recommended against both irinotecan and docetaxel given my liver dysfunction, and suggested paclitaxel with cisplatin.  He also recommended that my oncologist talk to the radiologist who reviewed my MRI to see if they could put any stents into my bile ducts to improve the liver function (the assumption being that the tumor were compressing the bile ducts).

So I had an ultrasound to look at the bile ducts more closely - unfortunately there was no easy fix there.  The compression from the tumors is happening all over the liver as opposed to just the bile ducts.

All of this happened in a week and we were back at my primary oncologist to discuss the recommendations.  In the end, we are going with a reduced dose of docetaxel (on its own) given every 21 days.  We are hopeful that this will shrink the tumors enough to improve my liver function so we can slowly increase the docetaxel dose to normal.  Unfortunately the expected response rate for docetaxel is just 30% (but we have to keep in mind that most gastric cancer patients are older and the statistics in younger, healthier patients may be better).  If it doesn't work, we are looking at limited options for what to do next.  Probably a phase I trial specifically for patients with hepatic impairment.

So I start tomorrow with docetaxel and will be praying it works!