The Key to Happiness

My friend and fellow stage IV lung cancer fighter Jessica Rice has had a very rough road throughout her treatment. She is two years into this journey and has been through numerous chemo cocktails, Xalkori, a clinical trial, CyberKnife, and whole brain radiation.

When I found out I had lung cancer, I was desperate to find other young people dealing with this terrible disease. When I came across her blog, I read it from start to finish. I look up to her as a sort of expert who has already tread the path that I am on, someone who can be a beacon in these unknown waters.

I was looking through her "Frog List" (things to do before she croaks) and I noticed that one of her dreams is to see a Cirque show. Suddenly, I had an idea for how I could try to pay back some of what she has offered me.

I contacted the three people I know who have worked with Cirque du Soleil and, being the lovely people that they are, they all replied promptly with thoughts on how to help my friend. Much scheming ensued, and we were able to contact the Artistic Director of La Nouba (the resident show in Orlando's Disney World) who not only granted two free tickets, but also coordinated for Jessica and her fiance to meet some of the cast members.

How cool is that?

The funny thing is how happy this has made me. Being able to help out someone else feels amazing. I have been the beneficiary of so much support since my diagnosis, it feels nice to help someone else.

I saw La Nouba many years ago, and it is a great show. Over a decade later, this scene still brings a huge grin to my face.

Source: Orlando Sentinel

Take a moment and look over her Frog List. Perhaps there is something on there that you can help with. If not, do yourself a favor and help out someone else today. You just might end up feeling great in the process.

World Prematurity Day

I am taking a break from talking about lung cancer to write a post in honor of my amazing daughters. These little fighters came into the world at 32 weeks, after several almost-deliveries (and almost-miscarriages) in the preceding few months. Mikaela pulled the ejection cord, as Jason likes to put it, and they were delivered by emergency c-section (like, SUPER emergency c-section) on March 8, 2011.

I had been in the hospital on bed rest since 28 weeks because of placenta previa. I am very thankful that I was in the hospital that night, since I had a massive bleed and the doctors got me from my room, into the surgery suite, and got both girls out in under 10 minutes.

Man, I just can't do anything the easy way, can I?

The girls spent the next 4 weeks in the NICU, hooked up to tubes and monitors. I remember looking at their tiny arms and wondering how in the world the nurses got an IV into those veins. To this day, when I am getting poked (often repeatedly) to put in an IV, I think back on what my little girls went through when they were too small to understand what was going on. If they endured it, who am I to complain?

Thank you, Mikaela and Autumn, for teaching me how to fight, how to thrive, and how to beat the odds. You are growing into such fabulous little people who keep me laughing and bursting with love everyday. I am so lucky to be your mom.

PS - I really didn't want to talk about cancer stuff in this post, but I would be remiss if I did not mention that I got my scan results and they were stable. No more shrinkage detected, but no growth either. As I explained in An Exciting Time to Have Cancer, stable is one of the good results of a scan. And if you had forgotten that I was waiting for scan results, then just forget about this PS and go back to admiring my wonderful little girls.

Stage IV is No Time to be Timid

I've been rather giddy about my ROS1 mutation news. When I met with my oncologist on Tuesday, she told me that I am the first person at the University of Michigan Cancer Center EVER to test positive for ROS1. She said the technician ran out into the hall screaming when he got the results. The tumor board couldn't stop talking about it. "We finally got a ROS1!"

How cool, I'm Patient #1.

My oncologist wrote my prescription for Xalkori (the brand name for crizotinib), then paused as she handed it to me:

We may run into some problems, because this is considered off-label for ROS1.

Urg, I didn't even think of that. Because the ROS1 group is so small (only about 30 cases), there have been no clinical trials specifically for us. We have tagged along with the ALK mutation trials because, thankfully, the mutations are similar enough that their targeted drugs also work for us. But technically, there are no drugs approved specifically for ROS1. My oncologist assured me that if insurance turns me down, we can appeal directly to Pfizer to get compassionate use of their drug. But all of this will take time.

I asked if I should wait to start the meds until after my scheduled scan on Friday.

Oh, this won't be through insurance by Friday.

Sure enough, when I took the prescription to the Cancer Center pharmacy, they tried to run it and it was declined by my insurance. They will need to get a "prior authorization." This will take several days.

Sigh.

I spend Wednesday hoping to get a phone call from the pharmacy. No luck. So, I go to Pfizer's website and fill out the forms to request the drugs, but notice that the processing time is two weeks. Urg.

I contact the wonderful Bonnie of the Bonnie J. Addario Lung Cancer Foundation. She replies within minutes, and starts working on my behalf. She contacts Dr. Camidge, one of the leading ROS1 researchers, and he advises her what documentation I will need in order to dispute my insurance. (Here is a nice short video of Dr. Camidge discussing ROS1, crizotinib, and the FDA challenges.)

Thursday rolls around, still no word from the pharmacy. I start to get nervous. I would normally be starting chemo on Tuesday, and if we end up needing to go to Pfizer and then wait two weeks for a response . . . this could drag on for ages without me getting any treatment.

So I tweet my frustration.

Tori Tomalia ‏@lil_lytnin
Fighting @BCBSM to get my meds. #ROS1 #xalkori #LCAM2013 #lcsm

Moments later, this appears in my feed:

BCBSM ‏@BCBSM
@lil_lytnin Please email the 800# on the back of your card & contact info to membersupport@bcbsm.com for help getting answers. Thanks. ^GD

Wow, they follow twitter? Incidentally, does anyone know what "^GD" means?

I consider contacting member support, though doubt that they will be able to help me. I decide to first call the Cancer Center pharmacy to see if any progress has been made on my claim. Nope, insurance is refusing it, needs a "prior authorization." The pharmacist said they will work on it and let me know as soon as they know more.

How frustrating that my potentially life-altering medication is being held back by a mess of red tape.

I try to put the girls down for a nap (mostly a failure), I attempt to get some work done (semi-successful), I eat some lunch (success!), and then the phone rings.

It is BCBS of Michigan. They have expedited my claim and approved me for a 6 month supply of Xalkori. They tell me to call my pharmacy and have them re-run the prescription. It will go through now.

!!!!!!!!!!

I call the pharmacist and tell him this.

(Stunned silence) Your insurance called YOU?!? This happens in maybe ... 1 out of 20 cases.

He re-runs the prescription. It goes through. The meds are ready for me.

I tweet a "thank you" about BCBS expediting my claim.

Then I start to feel bad. Had I strong-armed the insurance company by tweeting about them? Had I been inappropriate in airing my frustrations publicly? Should I have just quietly waited and accepted whatever response they gave? Suddenly, the words of a fellow lung cancer warrior ring in my ears: "Stage IV is no time to be timid."

It's true, I am literally fighting for my life.

Tomorrow morning I have a CT scan to see the impact of rounds five and six of chemo (results on Tuesday). I would love to see more shrinkage, and hope for at least stability. I plan to ask for a vanilla/mocha blend for the contrast solution (see my post "Fear" for that story).

Tomorrow night I will start my new adventure with Xalkori. I hope I am one of the lucky ones who show a great response. I plan to stock up on ginger ale and Imodium for what I've heard can be a rough start with this medicine.

I will gladly accept all thoughts, prayers, well-wishes, chanting, etc as I head down this new path. Thank you, as always, for the amazing love and support you have been sending from all over the world. 

Knowledge is Power

This belief has driven how I respond to stressful situations throughout my life.

When I was pregnant with our first child, I took every class I could find, read lots of books, and watched many hours of birth videos (thanks to my midwife sister). I learned and got ready.

When I found out we were having twins, I read books and asked questions of every twin I knew. As the pregnancy progressed and took a complicated turn, we were told that the girls would likely be born severely premature and if they survived they would face a lifetime of challenges. In response, I started reading about raising children with special needs. I subscribed to blogs written by some amazing families with special children. I got prepared.

When I was diagnosed with lung cancer, I dove into the research and tried to learn everything I could about this disease.

Actually, that is not quite true. For the first few weeks I actively avoided reading anything about it. I knew enough to understand how dire it was. I couldn't face seeing it in black and white.

Eventually, I took a deep breath and started reading.

Terminal.

Eight month median survival.

Gulp. Well, now I know. Now I will learn all that I can.

So, THEN I started wading through journal articles that were way over my head, desperately trying to understand this thing that was taking over my body.

One very interesting area of research is the driver mutations for adenocarcinoma. By analyzing a sample of the tumor, the doctors can sometimes determine what is causing the cancer to grow. This has been a game changer in the world of NSCLC. Rather that using chemotherapy, which as Jason said is like a shock-and-awe campaign on the body, there are now a handful of drugs that are specifically designed to target a few driving mutations.

Early on in my treatment, my oncologist tested my tumor sample for two common driver mutations with targeted drugs, EGFR and ALK. Sadly, I did not test positive for either. Over the next few weeks, as I gradually started to understand a bit more about this cancer, I learned that there are actually over a dozen known mutations, each that seem to correlate to certain population characteristics (smoking status, age, race). I went to my next appointment with my long list of possibilities and said that I wanted to be tested for all of them. Unfortunately, the sample that they had taken during my biopsy was too small to send off for this full battery of tests. Since the chemo was working, it made more sense to continue on and wait until my cancer started growing again to biopsy more tissue and test for mutations.

But something kept nagging at the back of my mind.

Fast forward to my sixth cycle of chemo. My oncologist was out of town, so I had a short visit with the nurse where she mentioned that I would be starting maintenance with avastin, or alimta, or alimta and avastin. I left feeling a bit unsettled and dove into researching maintenance therapy.

And that nagging feeling came back.

Then it dawned on me: there wasn't enough tissue left to test for a dozen mutations, but I bet there was enough to test for one.

I emailed my oncologist and asked if we could test the sample for the ROS1 mutation. I had a hunch.

I bet you can guess where this is going.

Yes, the test came back and revealed that we have found what is driving my cancer. And even better, there is already an FDA approved drug to treat it, crizotinib, plus several others possibilities currently in clinical trials. 

This chart shows the breakdown of mutations in NSCLC. See that tiny little pink sliver at 1%? That's my tumor's mutation!

Source: Targeting Tumors Early: Trials Push Novel Agents to Forefront

Targeting Tumors Early: Trials Push Novel Agents to Forefront

- See more at: http://www.onclive.com/publications/oncology-live/2013/january-2013/targeting-tumors-early-trials-push-novel-agents-to-forefront/2#sthash.IHaQjWge.dpuf

Targeting Tumors Early: Trials Push Novel Agents to Forefront

- See more at: http://www.onclive.com/publications/oncology-live/2013/january-2013/targeting-tumors-early-trials-push-novel-agents-to-forefront/2#sthash.IHaQjWge.dpuf

This is pretty exciting news, as it opens up a whole new treatment path. I will be meeting with my oncologist on Tuesday to discuss starting crizotinib. I have heard that this drug comes with its own set of challenging side effects, and it can take weeks to months for your body to adjust to it. Most people say that once you settle in, it becomes more tolerable than chemo. Plus, it is administered in pill form, so I will get a break from IVs for a while!

Most importantly, though, it means I have more options. I know that I will be dealing with cancer for the rest of my life, so the more tools I have to work with, the better. I keep reminding myself to temper my excitement, that there is always the chance that I will be in the minority for whom the targeted drug does not work, and cancer can eventually mutate again in response to treatment. For now, though, I am going to revel in my mutation.

Targeting Tumors Early: Trials Push Novel Agents to Forefront - See more at: http://www.onclive.com/publications/oncology-live/2013/january-2013/targeting-tumors-early-trials-push-novel-agents-to-forefront/2#sthash.KPAklSr7.dpuf