Dec 28 - Blood Transfusion Successful

I was able to get 2 pints of blood at the hospital on Thursday. Although it took all day, we were there until 8:30pm, I had better color and a little bit more energy with the two new pints of blood. Now lets hope that I can keep my red blood cell count up high enough to get chemo next week, January 3rd. I'm still in agonizing pain during the evenings. I hope to get a new pain management plan next week as well. Well, I'll be leaving for the Ritz on the 31st, will be back on the 2nd. Happy New Year Everyone! Thank you all for your prayers. Please continue to pray for me in 2007. Let's hope for a cure this time. Yeah.. I realize it is not likely, but everything I have done in life until now has been against all odds. Why should this be any different?


Love ya for reading my posts.... that means you care!!!

December 27 - Dose #2 of Topetecan Not Successful

A small set back today. My hemoglobin was very low today, 7.5 as well as my platelette counts, 73. I need a blood transfusion. However, there were no rooms available for the rest of the year. So, I will be admitted tomorrow to MD Anderson Hospital for the blood transfusion. I'll probably spend the whole day there, but I will be able to come home at some point. Lovely way to spend my holiday, isn't it? The set back is disappointing, because they will not attempt to give me the Topetecan before my next scheduled appointment which is next Wednesday. This just delays the entire process and gives the disease more time to grow, but I am trying to stay positive (although it's getting harder to find any positive points of view in this ordeal).

My pain has also escalated dramatically to the point that I can't get more than two hours of sleep at a time. My meds were upped considerable today, so hopefully I will be able to get some sleep. Still planning on spending New Year's Eve at the Ritz. They can't take that away from me (at least I hope not).

December 26 - Port Placement Surgery

All went well today. Surgery was a success. Have to keep padding on and can't take a bath for two days, so I don't know what it actually looks like, but at least we know the surgery was successful.

12/21/2006 - Blood Work/PET results

Never a dull day. I received disturbing news today. I had another PET scan on Monday 12/18, partly because the 11/3 PET was vague, but also to have an accurate baseline before starting treatment. Since my pain has increased dramatically over the past several weeks, I suspected that there might be a spread. Unfortunately, my suspicions are correct. The cancer is spreading like wildfire. I have three new lesions on my liver and something around the pancreas as well since 11/3/2006. I see my doctor's PA tomorrow to get a better explanation of the PET findings. My nurse assures me that I am doing the only thing that can be done at this point. It is a good thing that I started the chemo this week. Hopefully the Topetecan will slow down the progression of the lesions. I also have to hope that this new drug, Avastin, is truly a miracle drug and can at least stop the rapid progression and possibly reduce some of the current tumor impact.

12/20/2006 Topetecan Treatment #1

1st Treatment went well. Arrived at 8:30am, was done by 11am. I slept most of the day, but no nausea. Although the chemo went well (I tend to tolerate chemo pretty well) my blood work is questionable. My hemoglobin is very low (they don't know why. they asked if I have had any excessive bleeding, but I have not. maybe there is internal bleeding. I'm not sure, but I'm going to have another CBC on Friday.). My liver enzymes are out of whack and my PT/INR is way high (3.8) . I'm having surgery on Tuesday, which is worrisome with such a high PT. Hopefully I won't have massive bleeding for a 15 minute port placement, but I am nervous, nevertheless.

Finally a Treatment Plan

Dr. Shah has finally written order for me to start Topetecan (cytotoxic chemotherapy) on Wednesday, December 20th. Topetecan will be administered weekly for three weeks, then I will take a one week break. This will be scheduled for 6 cyles (so that means at least 6 months of chemo). I will also be given Avastin concurrently. The Avastin will begin after four weeks (I believe this is because I have to have a port put in and Avastin cannot be administered within 4 weeks of any surgery).

Dr. Ramirez from MDA Houston finally called to give me the opinion of their Review Board. Believe it or not, the Radiologist still has not read my PET films. Interestingly, one of my radiologists here in Orlando felt that the PET was not definitive as to the metastasis and he suspected that MDA would want me to redo the scans, but here I am beginning treatment and the Radiologists out in MDA Houston have no had the decency to read my films and offer their opinion. I am disgusted with them.

At any rate, Dr. Ramirez claims that the board suggests the standard treatment of Topetecan weekly for three weeks and off one week, as Dr. Shah suggests, but to recheck after three months. Whereas Dr. Shah is suggesting to go for 6 months of treatment. Dr. Ramirez does not support adding Avastin. He claims that he can see how Dr. Shah, being a medical oncologist, would find that Avastin has credence, but they (in the field of Gynecological Oncology) have not seen any supporting evidence of Avastin working for cervical cancer. I mentioned that there is a GOG Phase I clinical trail going on right now all over the country for Avastin for recurrent cervical cancer. His response is that only 1% of Phase I trials result in successful findings.

He was stern in his recommendation. I am more excited about Avastin than Topetecan for that matter. In fact, I wish I did not have to take the Topetecan. I wonder if there is some improvement after 6 cycles, if they will discontinue Topetecan but continue Avastin?

Another disappointment is that I had a trip planned to drive up to North Carolina to take my kids to see snow (the little ones have never seen snow). I had plans with two other families. However, now that my chemo will start on the 20th (I was planning to go from the 18th to the 23rd), I have to cancel the trip. Dr. Shah said that it would be ok to push everything out a week and start on the 27th, but my husband and I feel that it would be irresponsible of us to push off the treatment. The CT/PET that showed my recurrence was 11/1/06. At that time, I had no symptoms. Now I am in constant chronic pain requiring pain meds around the clock (it gets a little worse each day). So really.. I think I need to get started. Of course, they are allowed to be irresponsible in taking so long to find me a treatment plan, but it's my life after all. Hopefully I will have other opportunities to take the children to see snow.

Testing

Testing

A glimmer of hope

Good news...finally. I received verbal authorization today that my insurance company will cover one of the drugs that is currently being trialled for Recurrent Cervical Cancer. Although it is still on trial, and not proven for Cervical, this drug has proven to be very successful in controlling the spread of disease in other cancers such as Colorectal and Breast. Now I am just waiting for Dr. Shah to schedule me to start. It may still be a couple of weeks because it is a very expensive drug, so it has to be special ordered and written authorization from the insurance company must be received before the pharmacy will order it. The drug name is Avastin. This is similar to the drug that is being trialled at SKM in NYC. This is the type of drug Dr. Shah was wanting me to trial. Now I can receive it here in Orlando under her supervision. This makes me much happier. It's too bad it took this long to figure this out though, because I have spent weeks calling the different trial sites trying to get in to one. At least I am that much more knowledgeable now regarding the different types of cancer fighting agents that exist and feel good about this choice.

12/06/06 - Still no word from MDA Houston

More crap from MDA Houston again today, believe it or not. The Patient Advocate called me at 3:30pm (mind you their review board meeting that they are supposed to be reviewing my case in this afternoon is from 3-4pm) to tell me that they did not receive the CD. I saw the nurse on Tuesday while I was there with the CD in her hand, on the way to mail it via FED Ex. So I called the nurse to tell her that they did not receive the CD. Faye (nurse at MDA Orlando) said that she had already received that message and that she was able to track it and verify that it had in fact arrived Wednesday morning at 9:18am. I called Kimberly the Patient Advocate to give her Faye's number so that they could communicate.

Within 30 minutes, Kimberly called to tell me that she now was in possession of the CD and would put an expedite order on the reading of the CD. Can you imagine how outraged I am at this point? I totally laid in to her, and she had the nerve to tell me that she just found out about my case two days ago. Nobody had let her know about the complaint I opened when I was in Houston last week. Had I called her, she would have ensured that the reading of the films would have been expedited. Mind you, I did open a complaint with the office manager, who was sent in by the doctor I saw, who also told me he was putting an expedite order on the reading of my PET scans 9 Days ago. So I asked her, was it my responsibility to call her to let her know that I opened a complaint or was it the office manager's role? how is it that 30 minutes ago she didn't even know she had the CD that had been delivered the morning before? She said that they attempted delivery on Wednesday morning to her, but she happened not to be at her desk. Since there was no one to sign for it, it went back to the mail room. So I guess you don't get messages when you have a FEDEX delivered and you are not there to receive it?

Any way you look at this, it is horribly inept, unprofessional and beyond words.

I'm sure you can imagine how livid I am. She complained that I was venting to her when she was just trying to help me. She acknowledged that there was a lot of negligence in the handling of my case, but all she can do is ensure that the matter is handlied properly from this point forward.

I told her that I could not believe MDA Houston could be ranked #1 in the nation or that they were in the business of saving lives. I told her that the doctor himself acknowledged that I am currently on borrowed time, as I have already outlived the average life expectancy of someone with Recurrent Cervical Cancer, and yet no one has considered my case urgent.

I also asked her how they could not have made an exception and found someone capable of reading a paper film rather than one copied on CD (or realized that they did not have the correct format in less than 7 days). Surely someone in MD Anderson was capable of reading the film the old fashioned way.

Anyway.. as you can imagine I am disgusted with them.

And.. they have me scheduled to go visit their Phase I clinic on Dec 21st. As if I have the luxury of waiting until then to discuss possible trials. I guess they knew when they made that appointment time that it would probably take the Review Board this long to discuss my case.

Beyond frustrated.

December 4th - Met with Dr. Shah (MDA Orlando)

If you tuned in last week, you would know that I was supposed to receive a phone call today from Dr. Ramirez, who I saw last week in Houston, regarading the MDA Houston recommendation for my case. While I was sitting in Dr. Shah's office today, MDA Houston happens to call them.

Would you believe that MDA Houston was supposed to review my case today in their Tuesday Review Board (they were supposed to have discussed it last Tuesday, but the Radiologist had not read the PET report or seen the films, which I hand delivered that day; they could not review it on Thursday because they had canceled their Thursday meeting; so today, at 1pm, they call my onc in Orlando to request the PET on CD. They claim that they cannot read the PET in the format that was provided to them; what the heck is up with that? what did they do before they were able to copy them on CDs? Why didn't they say something sooner, like last week when I was there and hand delivered the films to them? This is outrageous and pathetic. They had me open a complaint and speak to their Case Manager. He said that they were putting the Radiology reading on a fast track to make sure that the films were read and reported on prior to Tuesday's meeting. Today the nurse calls me to tell me that this now has top priority. Are they in the business of saving lives or what? OK.. I"m just venting because there is nothing I can really do about it. I'm just outraged that they could be so unprofessional. I do not even care what they have to say anymore. I'm proceeding without their advise.

So... about my meeting with Dr. Shah... She seemed to think that my best option would be to get into any VEGF inhibitor trial that I could get into; however, the only one that is even open and possible at this point is the VEGF Trap at SKM in NY. My onc needs to confer with their research nurse to see if they can work around my need to be on blood thinners.

She did not think it was worth going to Tennessee for the Topotecan/Pemetrexed trial. She felt I would be better off taking Topetecan here, by itself, in the weekly format. She said that there is no proof that combining with Pemetrexed would work any better, so it isn't worth going on trial. The only reason she feels that going on a VEGF inhibitor trial is worth it is because the drug is not commercially available for my cancer type (although it is being trialed all over the place).

I talked to her about petitioning the insurance companies and pharmaceutical company. She said that she has tried this for her breast cancer patients and not had any success. The only time she has been able to get it approved is if the treatment was started out side of Florida (because in Florida they apparently don't have to pay for it). Sounds like she is strictly taking about the insurance companies though and didn't get what I was trying to convey about going directly to the pharmaceutical company.

I don't think that they are willing to administer the drug unless they have pre-approval from the insurance company because the drug costs about 10K a month. Some how they have to pay for those clinical trials.

I happened to call Sorono again today about R763 - Aurora Kinase Inhibitor, and the trial is now recruiting again. So, I called my onc and left a voice mail for her to get me in on the evaluation process.

So here are my possible options, in no particular order:

(1) If SK agrees to allow me to be on blood thinners, VEGF Trap in NYC, requiring travel to NYC every two weeks

(2) R763. This is a pill taken for three days in a row, every 21 days. Would require travel to San Antonio TX every 21 days

(3) Topetecan weekly here in MD Orlando

November 28th Appointment in MDA Houston

Nothing eventful came out of this appointment. We went over the history of my disease. Next the Radiologists at MDA Houston will review the Radiology Reports and Films and provide their own opinion of the films. The GYN group in Houston will then review my case in next Tuesdays meeting. Dr. Ramirez will call me after the meeting to let me know what their recommendations are.

At this point, I am still researching the clinical trials provided to me by Dr. Shah from MDA in Orlando. MDA Houston will only be able to offer clinical trials that are being chaired at their facility. They do not have access to all of the clinical trials in the NCI database as I was originally led to believe. So basically, I need to decide which clinical trial is best for me or whether to go with the standard treatment of therapy for recurrent cervical cancer which is Topotecan.

I'm not schedule to go back to Orlando until Thursday night, but I am going to try to get home earlier if I can.

Timeline

12/03

• Diagnosed with squamous cell Cervical Carcinoma, Stage IIB

• Dr. Craig DeFreese, OB/GYN of Devoted to Women performed a laporoscopy, cervical cone biopsy and LEEP surgery following up on abnormal PAP from 10/03 and complaints of chronic abdominal pain.

• Referred to Dr. Finkler of Florida Hospital Cancer Center

12/03

• CT Scan confirms pathology of cervical cancer

• Dr. Finkler stages the cancer at IIB and recommends pelvic radiation, chemotherapy and lymphadectomy

12/3

• Go to MD Anderson for 2nd opinion

• Dr. Castaldo of MD Anderson confirms Dr. Finkler’s finding except for need for lymphadectomy. I choose MD Anderson

01/2004

• Begin pelvic radiation for 5 weeks

• Begin chemotherapy treatment for SQUAMOUS CELL CERVICAL CARCINOMA It is important to note that the protocol for squamous cell cervical carcinoma is different than that of adenocarcinoma. It is less aggressive. The protocol Cisplatin and 5FU is to enhance the radiation which is the main protocol for treatment of cervical squamous cell carcinomas.

05/2005

• Completed chemotherapy.

07/2004

• follow up CT scan shows significant decrease in cervical tumor and No Evidence of Disease.

• Continue to see Gynecological Oncologist – Dr. Castaldo and Chemotherapy Oncologist Nikita Shaw ever 3 months. All check ups is 2004 are negative for disease.

10/2004

• complain of abdominal pain

12/2004

• Colonoscopy performed by Dr. Ferreira of CRC (Colon Rectal Center). Negative for polyps. Some degree of radiation colitis (inflammation)

2/2005

• Regularly scheduled CT scan. Show NO EVIDENCE OF DISEASE.

3/17/2005

• Sharp shoulder pain begins. Need for constant pain relief medication until after liver surgery in October, 2005.

3/27/2005

• See Primary Physician regarding shoulder pain, Dr. Nerness of Lake Mary Family Practice. Dr. Nerness says that since I had clean CT scan 6 weeks ago, there is no point to have another one.

• He runs blood tests which show a slightly elevated liver enzymes. Recommends sonogram

• Liver sonogram shows nothing in liver, but indicates slight level of fluid around the heart; referred to cardiologist.

• EKG shows no problem with heart

4/28/2005

• Pain is consistent and getting worse. Reported to Gynocologist Dr. Castaldo during regular follow up check up. Referred to Surgical Orthopedic – nothing is wrong in cervix; could be scarring from radiation affecting spine.

05/2005

• Go to Dr. Stephen Goll of Orlando Orthopedics. Explained that #1 concern given my history is cancer. Recommends for MRI, EMG and 6 weeks of physical therapy.

• 5/2005 cervical and thoracic spine MRI shows only minimal degenerative bulging disc. However, given my history I felt that the MRI should have been more extensive – perhaps the liver tumor could have been caught at this point.

6/2005

• follow up with Dr. Goll; informed Dr. Goll that therapy did not help at all and in fact pain has become more severe. Told that there is noting he can do for me and referred to pain clinic.

6/2005

• go back to PCP, Dr. Roger Nerness to recap what has been going on. Dr. Nerness agrees that pain clinic is the next step.

7/2005

• go to see Dr. Preganz who puts me on Percocet. Percocet relieves pain only while continuously medicated. Also informed Dr. Pregantz that my main concern is cancer.

8/11/2005

• Regularly scheduled 6 month CT scan

8/14/2005

• Pain is radiating to rib cage

8/15/2005

• Visit to PCP, Dr. Nerness. Told of continuos pain and concern. Recommends to follow up pain doctor. If pain continues may consider testing for Sympathetic Reflex Syndrome.

8/17/2005

• Informed by Dr. Shaw that 8/11 CT scan shows 6X6 tumor in liver.

8/25/2005

• Needle liver biopsy is negative for cancer. Shows necrosis and inflammation, but no cancer.

8/26/2005

• Referred to Dr. Khaky of Orlando Surgical Group for consult on surgical biopsy. Referred to Infectious Disease Specialist Jose Giron to rule out possible infection. My symptoms included daily fever and I had been out of the country for two weeks in July.

8/2005

• Dr. Giron feels spread of squamous cell carcinoma and no where else is unlikely; it is more likely to be an infection; proceeding with testing for infectious disease; when all tests are negative it was decided to treat me empirically with antibiotic Flagyl. I requested a prescription for pain. Dr. Giron writes me a perscription for Codeine.

8/2005

• Parmacist misinterprets script and gives me Prednisone – 30 g twice a day. I took this medication for 7 days. I found information of the internet about Prednisone that concerned me. When I called my doctor, we discovered that the pharmacist – Albertson’s Pharmacy in Lake Mary – had filled the wrong prescription

8/2005

• coming off prednisone while on flagyl knocked me out. I spent at least ½ of my day of the next two weeks in bed;

Sept 19th

• I notice pain in my right calf. I begin to exercise a little bit each day that week as I grew concerned that the cramping was from too much bedtime. On Friday, Sept 23rd, the pain in my calf is so bad I can hardly step on the foot. Several hours later I realize I have a blood clot and drive myself to ORMC emergency room,

9/23

• DVT to right calf, knee and thigh is confirmed; begin heparin; CT scan shows tumor is now 9 cm

9/??

• Needle liver biopsy is repeated; this time cancer is found; however, origin is unconfirmed because cell type of cancer is adenocarcinoma (it is therefore assumed that this is not a recurrence but a new cancer of unknown origin)

10/03

• Surgery is delayed due to the unknown origin; after tests to rule out stomach cancer; surgery of liver is performed; it is found that the tumor in the liver cause an adhesion to the diaphragm and right lung base – THIS IS MOST LIKELY THE CAUSE OF MY RIGHT SHOULDER PAIN REPORTED ON 3/17/2005 – I HAVE HAD NO NECK/SHOULDER OR ARM PAIN POST SURGERY.

• The surgery takes 6 ½ hours due to complication of adhesion; the entire right lob of my liver is removed;Additionally I suffered from at least two blood clots;

• I spent 7 days in ICU and a total of 4 weeks in the hospital;

10/03

• at some point after the surgery, oncologist informs me that when my original films from Florida Hospital were re-analyzed; it was found that in addition to squamous cell carcinomas I also had adenocarcinoma. Therefore, it is concluded that this is a recurrence of the original cervical cancer.

ISSUES:

#1- I WAS NEVER INFORMED OR TREATED FOR ADENOCARCINOMA IN MY ORIGINAL CANCER TREATMENT; ADENOCARCINOMA TRAVELS THROUGH THE BLOOD STREAM AND IS THEREFORE MORE DEADLY THAN SQUAMOUS CELL; THE TREATMENT PTOTOCAL FOR ADENOCARCINOMA IS MORE AGGRESSIVE THAN THAT FOR SQUAMOUS CELL;
I AM LICKY THAT IT APPERS TO ONLY HAVE SPREAD TO MY LIVER, BUT THEN AT THIS POINT IT IS UNKNOWN HOW MANY MICROSCOPIC CANCEROUS CELLS EXIST.

HAVING NOT KNOWN ABOUT THE ADENOCARCINOMA CAUSED DELAY IN RECURRENCE DIAGNOSIS. THE DVT SEVERELY COMPLICATED MY SITUATION. HAD I BEEN DIAGNOSED SOONER, THE DVT COULD HAVE BEEN AVOIDED.

#2 - CT SCAN/ MRI SHOULD HAVE BEEN ORDERED SOONER THAN 8/11 BASED ON CHRONIC PAIN IN SHOULDER AND CANCER HISTORY.

#3 - PHARMACIST ERROR MAY HAVE LEAD TO THE FATIGUE CAUSING ME TO BE BED RIDDEN AND ULTIMATELY CAUSING THE DVT.



11/05

• Begin 6 treatments of taxsol/carboplatin on 11/15.

• Tumor markers are down after first treatments

12/05

• Second treatment is given 3 weeks later.

• Third treatment is delayed 1 week due to low platelet counts. Subsequent treatments are given at 4 week intervals at the low platelet counts becomes a patter.

03/06

• Sixth treatment received 3/06

05/06

• Follow up tumor markers on 05/06 are slightly elevated

06/06

• Follow up CT/PET show activity in Solar Plexus lymph nodes; inoperable

• Dr. Shah informs me that I will most likely not be cured at this point

07/06

• Dr. Bucholtz administers 6 weeks of tomotherapy to para-aorta;

• Severe pain in abdominal area; feels like rib cage is being crunched; cannot sleep; taking 120 mg oxycontine every 12 hours and up to 30mg oxycodone for breakthrough pain

• Pain starts to subside after about 4 weeks of therapy; natious throughout radiation therapy; throwing up daily; lost 30 pounds

09/06

• Neck/shoulder pain begins; not sure if I just slept on it the wrong way

• Pain intensifies in October

11/06

• Begin physical therapy for neck/shoulder pain

• CT scan 0f 11/01 shows new area of focus on edge of liver and soft tissue in Celiac region

• PET scan confirms metabolic activity in both areas noted in the CT scan

• Pain intensifies greatly to include upper and lower back; taking 40 mg of oxycontin every 12 hours and 15 mg for break through pain

11/27/06

• trip to MDA Houston

Friday, November 17, 2006

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Clinical Trials

These are the clinical trials provided to me by Dr. S that I am considering. If anyone knows anything about any of these drugs, please comment!!!

(1) ISOTRETINOIN, INTERFERON ALFA-2B
(2) VELCADE AND IRINOTECAN
(3) 852A
(4) VEGF Trap
(5) ABI-007
(6) Sunitinib
(7) Bevacizumab
(8) TM - copper reducing compound
(9) R763

November 15, 2006 - Visit to Radiation Oncologist

Dr. B, my radiation oncologist was in a conference when my PET/CT results came in last week. Therefore, he was not part of the conference with Dr. S. His opinion is slightly different from Dr. S's. In fact, his opinion is that the CT/PET results are highly inconclusive. Now, you all know that I have been on this roller coaster ride before. However, I'll take any glimmer of hope that I can get at this point.

It turns out that there are two areas of concern on the CT/PET. First is the previously radiated area. The area of concern happens to be right in the middle of the area that received the highest dose of radiation. While an experienced, although conservative, radiation oncologist reviewed the films and concluded that the new area of concern could not be radiation damage. Dr. B could not agree with 100% certainty. Although possible, it is highly unlikely that cancer could grow in this recently radiated area. The bad news is that if in fact it is cancer, then it is a very tough cancer.

The second area of concern is on the outer edge of the liver, where my liver was resected last year. This is typical behavior of the cancer coming back (to come back to where the incision was made). Nevertheless, the surgery I had last year had clear margins. This means that if the tumor was 6cm, they actually cut out 6cm + x and the x portion was not cancerous. Therefore, the tumor was encapsulated in the mass they removed.

Because my tumor markers are also all slightly elevated, everything is leading to a recurrence; however, the recurrence may be limited to the outer edge of the liver rather than the celiac where I recently was treated.

My next step is to go to MD Anderson at the University of Texas in Houston, which has the #1 Gynecological Cancer Clinic in the nation. They may want to redo all the scans. More than likely, they will make a recommendation for a treatment plan. There are lots of chemotherapies that have not yet been tried for me. Although they used the ones with the highest probably of success, they have not been successful for me. Hopefully the next one will be. Alternatively, I may be going into a clinical trial. There are a lot of anti-angiogenesis drugs out there that have demonstrated remarkable ability to inhibit tumor angiogenesis (the process of forming new blood vessels required for cancer to spread)

Houston Here I come

Robin will be traveling to Houston the week after Thanksgiving for a consult with MD Anderson (November 27th-30th). Anybody want to come along for moral support?

11/8/2006 - Review CT/PET Results

I had a CT performed on 11/1/2206 and a PET scan on 11/3/2006. There is a new area of concern on the outer edge of the liver. Also, the area radiated August/September 2006 shows an area of concern with hyper-metabolic activity. Dr. S suggests that I start looking into clinical trials. She provided me with a list of 7. I have been researching the trials with my dear friends Kathi and Magda. For the most part they look promising; however, I definitely feel that I need some direction in making a choice.

Dr. S has referred me to MDA in Houston where they will review all of my records from the past three years and make a recommendation.