by Vivian W. Bucay, MD
“I have always felt that everyone can define the day in which life changes forever. What I had not realized when I awoke that morning was that May 10, 2006, would be that day for me.” These are the words I wrote for an article published in the October 2006 issue of San Antonio Medicine, which focused on the physician as patient.
The Fateful Call
There is no doubt that being a dermatologist offers certain advantages when you are faced with melanoma, a potentially deadly skin cancer. When I received that call from the skin pathologist, I first thought that he was referring to one of my patients. I had had a skin irritation that had cleared up and then returned, so a few days previously the PA (physician assistant) and I had done a biopsy. I thought I had eczema, or psoriasis.
When I realized that the melanoma the pathologist referred to was mine, I called my husband Moises and then Alexander Miller, MD, director of surgical oncology at the Cancer Therapy and Research Center in San Antonio, TX, where I live.
By 4:30 PM the same day, I was with Dr. Miller, who explained that I would undergo an extensive work-up prior to excision of the melanoma, which was located inside the umbilicus (belly button). It had seemed nothing more to me than an irritation of several weeks’ duration. The only symptom I’d had was a dry, whitish discharge that appeared on dark clothing — no pain, tenderness, bleeding or dark mole that would suggest a cancerous growth.
I was scheduled to undergo blood tests, PET-CT (positron emission tomography-computerized tomography) scans, endoscopy, colonoscopy, and an MRI since it was unclear whether or not the melanoma was a primary growth or had metastasized (spread) from another area. Fortunately, the tests were negative; they did not show that the melanoma had spread.
Fighting the Good Fight
The next step was to undergo a complete excision of the melanoma along with a sentinel node biopsy, in which the lymph node(s) closest to the tumor is/are located by injecting dye around the tumor with an X-Ray taken immediately afterwards. The first area to absorb the dye is the sentinel node (sometimes there are more than one), which is where cancer cells typically spread first. If the biopsy is negative, the melanoma has probably not spread. If the sentinel node is found to be positive, all the nodes in the area are removed; otherwise the melanoma cells might easily enter the bloodstream through the lymph system, thereby spreading throughout the body.
The surgery went very well, and I went home the next day. I spent the next three days recovering at home and “betting” on the results of the sentinel node biopsy. I felt very optimistic, perhaps because all the other tests were negative. When I called my doctor I was told that the results had already been discussed with Dr. Bucay.
“Really? Not that I was aware of,” I said. My husband overheard this conversation and sheepishly confessed that he had obtained the results but had not wanted to tell me before the weekend. Of course, that could only mean bad news, which it was: The sentinel node was positive for melanoma.
I underwent a second surgery on May 30, 2006. This was a radical groin dissection, an almost four-hour surgery in which the groin is explored for removal of all the lymph nodes, which are analyzed for melanoma. Of the 28 lymph nodes removed, another two showed the presence of melanoma. With a diagnosis of stage 3b melanoma and a 50 percent chance for survival at five years, I began to consider myself officially a cancer patient. I even had a regular oncologist, Ronald Drengler, MD, as proof of my new “status.”
Medical R&R – My Trips to Cancer Centers
During the mandatory six-week recovery period, I was able to go to the M.D. Anderson Cancer Center in Houston, TX, and the Hillman Cancer Center in Pitts- burgh, PA, on the advice of Dr. Drengler, who encouraged me to explore all treatment options, including any clinical trials. The physicians at both centers agreed that I should undergo high-dose intravenous interferon treatment for one month, followed by 11 months of home injections of interferon. To date, interferon, a natural immune protein that is mass-produced in the lab for cancer therapy, remains the only FDA- approved medication for the adjuvant treatment of Stage 3 melanoma, meaning that it is used to decrease the chance of the melanoma recurring. Unfortunately, interferon has not been proven to increase survival, just the interval of disease-free survival.
Nonetheless, I began the interferon treatment as a stopgap with the hope that a trial evaluating the efficacy of a promising new immune therapy called anti-CTLA 4 antibody would be under way soon. During this time, when I stayed home from work with the severe, flu-like symptoms caused by interferon, I learned just how fortunate I was. Friends and even my patients made sure that I never went to the daily treatments alone. Flowers and food arrived at my home daily, as did countless cards and phone calls. My office staff was amazing in my absence, and the physician assistant, Courtney Aldridge, who worked with me at the time, kept the office running smoothly until my return in late July.
The Trials Begin
The clinical trial evaluating the promising antibody was approved, and by mid-October, I was commuting to Los Angeles, CA, every two weeks to participate in the study. Often, I took the 6 AM flight to L.A., went to the Norris Cancer Center at USC (University of Southern California) for laboratory tests or for the medication, and was back in San Antonio in time to go to work the next day. Sometimes, there was even enough time for lunch and a little shopping during those trips.
I felt energetic and “normal” throughout this period and was able to go on a cruise with my family in December. Between trips to L.A., my dermatology practice, and making arrangements for my youngest daughter’s Bat Mitzvah, life kept going at its usual hectic pace.
On January 18, 2007, I underwent a CT scan of the chest and abdomen as part of the clinical trial. After the tests, I went back to my office, where I received a phone call from the oncologist. Heat rushed from my head to my toes as I heard the words, “The radiologist has seen numerous spots on your lungs that were not there in October.” Impossible, I felt absolutely fine! Surely there was an error, or perhaps those spots were a side effect of the study drug I was receiving. Nonetheless, both Dr. Weber at USC and Dr. Drengler insisted on a lung biopsy as soon as possible. There was no room for speculation.
My husband and I kept this news to ourselves, and I briefly put off the biopsy. I wanted Gabriela to have a wonderful Bat Mitzvah celebration, which numerous out-of-town family members and friends would be attending. The waiting period was extremely difficult for my husband, but I was so preoccupied with the festivities that the time passed quickly. We all enjoyed the celebration and I am so glad that I waited to undergo the lung biopsy until after the event.
I was nervous as we drove to the hospital for the biopsy, and I made two requests of my husband should the results confirm a diagnosis of metastatic melanoma: first, that he would be the one to tell me as soon as possible and, second, that we would go to the National Cancer Institute at the National Institutes of Health (NIH) in Bethesda, MD, to see Dr. Stephen Rosenberg, a world-renowned melanoma expert. The lung biopsy went smoothly, but when I awoke in the intensive care unit my husband told me that the melanoma had spread to my lungs.
Back to the Drawing Board
Moises kept part two of the promise and, with Dr. Drengler, was able to schedule an appointment on Feb. 27 with Dr. Rosenberg at the NIH. I was seen there by his team of physicians and staff. They recommended that I try another immune therapy called interleukin-2 (IL-2, Proleukin), an FDA-approved treatment for stage 4 melanoma. The treatment is given through a percutaneous central line (delivered through the skin in the arm) in the intensive care unit (ICU) because of its serious side effects and toxicities. Ideally, a dose is given every eight hours, for a total of 14 doses, which is called a cycle. Two cycles (referred to as a course) are given a week apart, and then the CT scan is performed one month later to monitor the patient’s response. A second course of IL-2 is given 12 weeks after the first one. I underwent the first course in March and was able to return to work after each cycle within two days of my discharge from the hospital.
On the night of April 22, I was filled with anxiety and unable to sleep, anticipating the CT scan scheduled for the next day. I had the scan at 8 AM and went to the office to see patients afterward. My appointment with Dr. Drengler was at 3 PM, and I needed to work to pass the time until the appointment. Around 11 AM, my husband came to my office with tears in his eyes and handed me a rose: The study revealed that the tumors had shrunk by around 60 percent. And although the IL-2 treatments had made me feel quite sick, I could not wait for the next course.
I had completed the first course with blind faith and optimism; only around 14 percent of patients show a response to IL-2. But I had a goal now, which was to be in the lucky six percent who show a complete response to IL-2. To date, only the complete responders achieve what is known as a complete and durable remission — that is, many years of survival, in contrast to the partial responders, whose median time of survival is five months.
After my second course of IL-2 in June, I hoped that I was truly on the road to recovery and needed only the confirmation of the next CT scan, scheduled for August 1. To say that I was nervous the night of July 31 would be an understatement — I was terrified. August 1 brought the news of a complete response and the possibility of a melanoma-free life. Additional CT scans on Oct. 24, 2007 reconfirmed the news.
Of course, I will be seen in follow-up and monitored every three months for the next year and twice yearly after that. Nonetheless, I am thrilled to be able to continue my duties as mother, wife, and physician.
Allow me to rephrase that! Not duties, but rather I am thrilled to watch my daughters grow up, my husband “channel surf” and complain about a house full of women, and to have the privilege of caring for others and hopefully making a difference in their lives. Except for the pain that my family has undergone during this time, I would not change any of the events of the last 18 months. Melanoma has given me the gift of a second life and the insight to make the most of it.
Dr. Bucay practices dermatology in San Antonio, TX, where she is a Clinical Assistant Professor in the Department of Physician Assistant Studies at the University of Texas Health Science Center. In 2004, 2005, 2006 and 2007, Dr. Bucay was recognized as a “Texas Super Doctor” in Texas Monthly Magazine.