Cancer Chronicles: A Son's Journey with His Mother

History:

My 66-year-old mother has been battling osteoarthritis for 22 years and hypertension for 17 years. In May 2022, she noticed a lump in her left breast while sleeping. The lump, located in the upper outer quadrant, was mildly tender. Both a consultant surgeon and an ultrasonologist assessed the lump and deemed it benign, suggesting a trucut biopsy. After undergoing two biopsies that showed no signs of malignancy, the lump seemed to vanish after the second procedure, potentially due to antibiotics and anti-inflammatory treatment. However, it reappeared deeper after a few weeks. A subsequent mammogram revealed concerning features, categorizing it as Berad 4, and also identified enlarged axillary lymph nodes.

Consequently, my mother underwent breast-conserving surgery with lymph node dissection (17 July 2022, 54 days after first noticing the lump, with two trucut biopsies performed in these 54 days that had not showed anything). Pathology results of the excision biopsy indicated invasive breast carcinoma with no special type (ductal), grade 3, measuring 4cm. The surgical margins were clear, but some lymph nodes (2 out of 15) tested positive for cancer cells. The tumor showed strong staining for estrogen receptors (80% of tumor cells), was negative for progesterone receptors, and HER2-negative (Ki67 index 15).

Following the healing of the surgical wound (45 days after surgery), my mother received chemotherapy (started on 30 Aug 2022), first Epirubicin and Cyclophosphamide, followed by Docetaxel (4+4 cycles). Subsequently, she underwent radiotherapy (18 cycles with boost, starting from 20 Mar 2023 till mid-April 2023). After completing chemotherapy (8th cycle on 8 Feb 2023), she began taking Anastrozole, an aromatase inhibitor, and was advised to continue this treatment for seven years. Regular follow-up tests, including CT scans, blood work, and DEXA scans, initially showed no signs of metastasis.

However, in a scheduled bone scan on 21 August 2023 (one year after a pre-chemo normal bone scan), an unexpected and extensive metastasis was discovered in the skull, ribs, and appendicular skeleton. This surprising turn of events has raised concerns about the chosen treatment approach and the accuracy of the initial histopathology report. It appeared as if the tumor continued to progress to the bones while she was undergoing chemotherapy and radiotherapy, leading to concerns about the effectiveness of the treatment.

I asked several key questions from different oncologists: Could the choice of chemotherapy be a factor in the rapid metastasis? Was there any discrepancy in the initial histopathology report that might have impacted the treatment plan? The unforeseen progression highlighted the necessity of a comprehensive review of the treatment strategy.

The oncologists replied that while it is rare, distant relapse during or immediately after treatment can occur. Although it is mostly seen many months to years after completion. Targeted therapy with Palbocyclib along with Anastrozole is a recommended option for ER positive HER2 negative MBC. Since 24 Aug 2023, she has been on these two drugs. Neutropenia was noted as a side effect of Palbocyclib, initially managed with GM stimulating factor injections. However, as the side effects progressed over three months, the oncologist Dr. W. reduced the Palbocyclib dose. After the dose reduction, she went fine for another three months before developing other problems like anemia and weakness. Despite this, the rapid decline in her hemoglobin levels (Hb) has been concerning, starting around two months ago (it is unclear whether it was due to metastatic progression or drug-induced).

In the last two months (Feb to Apr 2024), she was given erythropoietin 10000 IU twice, with an interval of 5 weeks. (The first injection was given when her Hb was 10gm/dl, which rose to 10.9 after 10 days with erythropoietin. Then after 5 weeks, her Hb was found to have dropped to 9.4gm/dl. The rapid decline velocity in her hemoglobin levels made me bewildered, so I gave the second injection of erythropoietin after consultation with the oncologist). On 24th April 2024, she had root canal treatment for her broken tooth (the dentist told that dental extraction is contraindicated because of the risk of osteonecrosis of the jaw as she is on zoledronic acid 2 monthly for her bone metastasis), and the dentist told she had significant bleeding so he couldn't do proper dental filling, just filled the cavity temporarily to give some tamponade effect. After dental treatment, my mother was uneventfully back home but looked slightly pale.

On 28th April 2024, she had a fall because of a syncope attack. She says she had a blackout after standing from the sofa for a few seconds and didn't remember anything. Luckily, she didn't strike anything during the fall, and the family was there to witness and rescue her. At that moment when I checked her BP, it was low (80/40 mmHg). So I immediately rushed her to the nearby hospital - Jinnah Hospital Lahore emergency CCU after advice from Dr. Usman Butt Sahib, who is a consultant cardiologist. There, she was given a saline bolus, leg elevation, and an ECG, which was found normal. Troponin I also came back normal, suggesting that it was not a cardiac event. I told her cancer treatment history and dental treatment history to the duty doctor, and he got her CBC test, which came back very worrisome. Hb was 6.7gm/dl, significant neutropenia, leucopenia. He advised packed cell transfusion which was done in JHL emergency CCU. BP rose to normal, and we were discharged with advice to avoid dehydration and continue Aspirin as a safety measure as he told anti-cancer therapy had pro-coagulant effects.

Feeling trapped in a dilemma. If I stop my mother's cancer treatment, particularly Palbocyclib, I fear the metastasis might advance unchecked. On the other hand, continuing the medication comes at the cost of severe side effects, greatly diminishing her quality of life. Additionally, there's the agonizing uncertainty about whether the medication is effectively slowing down the progression of the metastasis. As per advice of Prof. Abu Bakkar Sahib, who is our consultant oncologist, MRI brain with contrast was done which showed dural thickening, one small dural lesion, and a lesion along the left inferior orbital rectus muscle suggesting potential metastasis. Professor suggested she might need cranial radiation after a second opinion from a radiologist. On 6 May 2024 Monday, MRI brain DVD was submitted to the radiology department of INMOL hospital for a 2nd review to formulate a subsequent treatment plan.

On Saturday, 11th May 2024. I am currently awaiting a reply from the INMOL radiology department regarding the review report. Last night, she developed a headache and fever, which began with an earache. Considering her dental problem, immunosuppression, and the findings on her brain MRI, I administered an antibiotic and discontinued Palbocyclib due to concerns about meningitis.