Mid Course Guidance

Or choose your own adventure?

Let's take stock. Immunotherapy was a bust for me. My disease has progressed stealthily, and the side effects were severe enough to see me hospitalised. One door closes and hopefully another opens.

Since coming out of hospital a few weeks ago I've been waiting for some lab results¹ and talking with my oncologist to help clarify remaining treatment options.

One characteristic of modern warfare is precision strike², the capability to hit specific high value targets from long range with extreme accuracy, to ensure success while minimizing unintended damage. The opposite is a large-scale, indiscriminate attack over an area, where success depends on mass rather than accuracy of weapons.

Precision medicine³ is an emerging approach that uses recent advances in genomics, data analysis and artificial intelligence to finely tune and optimise treatment to each individual patient and the specific genetic and molecular attributes of their disease. The result is personalised treatment and higher efficacy with lower risk of adverse side effects. Targeted therapy.

Chemotherapy by contrast is a ‘one size fits all’ approach, using standardised treatments based on models of the response of the ‘average’ person. Systemic rather than precise. The equivalent of carpet bombing.

My lab results came back negative. No targetable markers detected. The most promising treatment door remained locked.

Back to indiscriminate attack with a high chance of collateral damage. In a few weeks I'll be resuming chemotherapy, this time with a different cocktail of poisons.

The FOLFOX⁴ regimen consists of eight fortnightly cycles of infusion of folinic acid, fluorouracil, and oxaliplatin. The fluorouracil is administered over a 46 hour period via a take home wearable portable pump⁵. Used across a range of digestive tract cancers, for advanced biliary tract cancers such as metastatic cholangiocarcinoma FOLFOX is a standard second-line treatment⁶, applied after completion of first-line treatment using cisplatin/ gemcitabine⁷. Common side effects include low white blood cell count, anemia, diarrhea, nausea, and peripheral sensory neuropathy (tingling, burning, numbness, or pain in hands and feet).

After that there are few remaining doors left to try. There is no cure, only slowing of disease progression, if that is even possible. This lab result was hard news to take. Another of those painful reality checks.

Thanks Declan MacManus for helping me get my energy levels back up.

1. https://www.petermac.org/patients-and-carers/tests-and-diagnosis/genetic-testing-including-familial-cancer-centre

2. https://researchcentre.army.gov.au/library/land-power-forum/precision-strike-growth-regime

3. https://www.chiefscientist.gov.au/sites/default/files/Precision-medicine-final.pdf

4. https://www.eviq.org.au/medical-oncology/upper-gastrointestinal/pancreas-and-biliary/3875-biliary-and-gallbladder-advanced-folfox6-mod

5. https://spiritmedical.com/products/dosi-fuser/dosi-fuser-chemo-2-5

6. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00027-9/fulltext

7. https://www.eviq.org.au/medical-oncology/upper-gastrointestinal/pancreas-and-biliary/1200-biliary-and-gallbladder-advanced-cisplatin-an