Bowel obstructions

I haven't been eating well. On New Year's Eve I bought a bunch of snacks to eat while we waited for midnight, but after a couple slices of pizza around 7 o'clock I was full and my appetite didn't return in time to enjoy all the munchies.

A few days later I had terrible abdominal cramps. I've had them a few times in the past several years and found they were caused by intestinal blockages. What happens is that some stool in my colon gets too dry and hard, digested food backs up behind it and the cramps are failed attempts by the intestines to push it all out. Those episodes were solved with saline enemas, so I tried that again, got things moving, and felt better.

But a few days later it happened again. I'm afraid that it's harmful to do frequent enemas (and it's tricky to do enemas without a rectum), but I administered another one and cleared the problem again.

The obstructions kept repeating. Now I didn't have feelings of constipation, just bloating, intestinal gurgling, and nausea. Rather than ending with a stubborn bowel movement, these episodes ended with vomiting.

Such problems are common with patients like me. Abdominal surgery, chemotherapy, and radiation can all lead to scars and inflammation that prevent the intestines from moving normally and resulting in obstructions. My doctors recommended managing the problems through diet – low fiber, low residue, stool softeners, avoiding bulky foods like raw vegetables or nuts.

Yet the obstructions continued. I went to the emergency room, and after a CT scan they diagnosed me with a small bowel obstruction. They put in a nasalgastric (NG) tube to suck out the stomach contents so the bowels could rest for a few days. During five days in the hospital, they transitioned me back to soft foods and sent me home. Then just a day later I obstructed again.

I was getting desperate since I was losing weight rapidly and wasn't accomplishing anything in my life except struggling to eat, feeling sick, lying on the couch, watching TV, and waiting to get better. So I contacted the abdominal cancer specialists who did my big surgery in December 2008 to see if they had any solution.

They were reluctant to operate since they said it's very risky to operate on someone with such an extensive history of treatment as me. If the root cause is scars from previous surgeries, then another surgery is as likely to cause new problems as to fix existing ones. And the doses of radiation since my previous surgery could change the tissues and prevent them from healing properly.

But I couldn't simply continue failing to eat and losing weight, so they admitted me to their hospital to prepare for surgery. I went on a clear liquid diet plus Ensure (a nutritional supplement drink) while we did some gentle bowel preparations over the course of a few days. We also tried putting me on total parenteral (TPN) intravenous nutrition for three nights. During that week I didn't obstruct again, so the surgeons decided it was better to send me home on a diet of Ensure and go searching for an effective chemotherapy. From their perspective, if I could live without surgery it was better not to risk it.

So I continued that diet at home (without TPN) yet continued to lose weight. I added some simple foods like crackers and low-residue cereals which certainly helped stimulate my appetite. But then I began having episodes of obstruction again and continued to lose weight.

My radiation oncologist doubted that these obstructions were symptoms of his radiation treatment, so the prime suspect has become cancer itself. I met with a team of doctors at NIH about enrolling in clinical trials, but most of their drugs are oral so my inability to eat reliably makes me a poor candidate.

December 2009

April 2010

In April my medical oncologist finally decided that we had to do something other than let me continue to starve and wither, so we started chemotherapy with continuous intravenous 5-FU.

So far I've received two weeks of chemo and tolerated it okay, but I'm continuing to suffer obstructions and lose weight. I fear that we'll have to take more drastic steps to get nutrition if this continues. We might set up for home TPN, receiving intravenous feedings at night. But that sounds like a lot of work and inconvenience, making me even more homebound and preventing me from engaging in the travels that are so important to my happiness.

Currently I'm trying the medication Reglan to try getting my intestines to push in the right direction and allow me to get enough nutrition the old-fashioned way.

I want to eat.

The face of cancer – 2 years

Two years ago I began taking daily photographs of myself to track how my appearance changes as I battle with cancer. During that time I started a different chemotherapy, treated a bone tumor with radiation, knocked the cancer back into remission, finished chemotherapy, diagnosed a recurrence, started another chemotherapy, and found that these drugs that helped before are no longer stopping the cancer's growth.

I previously posted time-lapse movies of these self portraits at the 6 month and 9 month marks. Now I present two years of self portraits as a high resolution download or as a streaming video.



The early months were marred by the severe acne and hair loss from the previous ineffective chemotherapy. Since then I think my appearance has continued to improve even through the latest months of recurrence and unsuccessful return to other drugs.

The best plan of attack now is a big surgery to go after the tumors directly. So I am preparing myself through eating, exercise, relaxation, and planning for months of recovery. The break from chemotherapy at this time might show in the extra twinkle of energy and clarity I feel.

Chemotion

Last week I took a week off from chemotherapy to celebrate Easter and regain strength for the last few weeks of chemotherapy. I noticed that I've been feeling more emotional lately, about the experience of cancer, toward personal relationships, and even in response to television shows and news stories.

Other cancer survivors have warned me that the period after treatment can be harder emotionally than treatment itself. The common belief, I think, is that one has to act strong and determined to tolerate the stress of treatment. After treatment, patients let their guard down and all the repressed feelings resurface. My increased emotion could be anticipation of finishing treatment and greater openness from discussing the experiences in support groups.

But this week as another dose of chemo builds in my system I feel the emotional numbness and detachment returning. I think now that it may in fact be another aspect of chemobrain. Just as memory, concentration, and agility are gummed up by therapeutic poisons, maybe emotion is too.

I have been looking forward to regaining my full intellectual abilities after two long years of chemotherapy. It will be interesting to see how my emotional state could change with recovery too.

Clean

My latest PET/CT scan and blood CEA were excellent. Everything is normal; no evidence of disease.

My doctor is considering three more months of chemotherapy just to be aggressive. But chemo also carries risk of further damage to my organs and more lost time from leading a normal life. The problem we have is that there is no medical evidence to say what to do in my situation.

Few stage IV cancer patients survive as long as I have. Of all the ways that people get colon cancer, mine is in the fraction of those that are hereditary, in the sub-fraction that's nonpolyposis, in the sub-sub-fraction that's not caused by one of the known genes for hereditary nonpolyposis. There's not much medical research available on such a rarity, just educated guesswork. The Xeloda + Avastin therapy that has worked so well for me was expected to just slow or shrink the tumors temporarily, not eliminate them completely.

I am hoping to finish chemotherapy by my 35th birthday in May. In the past four years, that is the one month that has always brought improvement and a break from treatment.

But I'm not as excited I might be expected to be right now. I'm very happy to stop chemotherapy and get back to some normalcy. But I'm still afraid that something bad will happen before I get there. Or maybe as soon as I go off chemo some hidden cancer cells will come zooming back.

I've been in remission once before, so I know better than to expect that I'm cured. I just hope for a long break from cancer and time for medical science to catch up. Maybe some months or years down the road I'll feel ready to celebrate, for now I'm just happy to get some time as my normal self.

On the cusp

My cancer treatment is nearing a milestone. In November I had PET, CT, and bone scans that were complicated but mostly clear. My CEA also reached normal levels. With clear tests and no symptoms my doctor declared the cancer to be in remission. Our plan was to continue chemotherapy and then scan again in a few months to see if any suspicious activity arose. If not we planned to finish chemo and hope for good health.

That next set of scans will be in two weeks. My CEA has bounced around a little between 1 and 3 ng/mL but is still in the normal range. I went in for an infusion of Avastin today and started another week of Xeloda. There's a chance that this is my last dose of chemotherapy and I can go treatment-free for months or years. A welcome and long prayed for life change.

Or the blips in my CEA could be regrowing cancer and the scans could show that the questionable spots in my liver from last time are in fact new tumors. That would probably mean that my current treatment has stopped working and it's time to consider something else. A darker change that could make the past year of chemo seem pleasant.

My career is also on a cusp. I am now unemployed again since the grant that paid for my part-time work ran out. My boss is seeking funds for another year, but that depends on budget decisions which are out of our control. I expect a decision any day and it could mean returning to work in my research field, especially if I get off chemo and have a return to normalcy. Or it could be time to seek fresh work.

I'd like to stay in science since it's something that I enjoy, am good at, and am highly trained for. But it's been discouraging to make so little progress while I've been ill, during the very postdoctoral years when a young scientist should be rapidly growing and flourishing. I see other researchers accomplishing work on the ideas I had three years ago but haven't had the time and health to do myself. Maybe science just isn't compatible with unstable health and I should move to a field where results come quicker and without such deep investment.

Cancer quantified

Since starting treatment more than three years ago, our main measurement of its effectiveness has been the level of carcinoembryonic antigen (CEA) in my blood. CEA is a protein involved in cell adhesion that is normally present in a developing fetus but not in an adult. A plot of CEA versus time shows the history of my cancer's ebb and flow.


A normal CEA level is below 2.5 ng/mL. Higher levels can be produced by gastrointestinal cancers, and levels above 20 ng/mL are associated with metastatic tumors. Note that the vertical scale is logarithmic, not linear, so each major tick is ten times higher than the one below. My CEA was at 23 when diagnosed in August 2004.

Colectomy (removal of the lower colon) and FOLFOX chemotherapy reduced my CEA to normal. A laparoscopic examination showed that I still had many small tumors remaining, so in May 2005 surgeons removed my peritoneum (a membrane covering organs in the abdomen) and diseased parts of many other organs. Then they applied direct, heated chemotherapy to kill any remaining cancer cells.

The surgery seemed successful, but in early 2006 my CEA shot back up to worrying levels. CAT scans and PET scans confirmed that tumors were growing in several spots, particularly around the pelvis. We started chemotherapy with Erbitux and Camptosar, but the cancer kept growing.

In November 2006 we tried the oral chemotherapy Xeloda plus Avastin. The cancer responded well, and my CEA has dropped from a high of 160 ng/mL down to normal. We are continuing chemotherapy since a normal CEA does not necessarily mean that all the cancer is gone. I'll get scans again in a few weeks to see if those have cleared.

The face of cancer - 9 months

It has been three years since my diagnosis with Stage IV colon cancer. Three years since my first surgery and three years since my first chemotherapy. And it has been nine months since I began taking daily photographs to chronicle the changes in my appearance.

Three months ago I posted my first Face of Cancer video, and now I have an update. It is available in high resolution or as a low resolution stream from YouTube.



I am still in my third round of chemotherapy, nearing a year on that treatment. I'm feeling pretty well, walking normally, traveling more, and being productive. It's hard to believe that in January I was bald, had a broken pelvis, and was about to go through several months of pain and bleeding due to radiation treatment.

In my eyes the video shows me feeling better as the cancer and treatment effects subside. I hope to continue in that direction and have another, even healthier update at the one year mark.

The face of cancer

In November of 2006 I came across a fascinating video on YouTube called Everyday: Noah Kalina Takes a Photo of Himself Every Day for 6 Years. Since I was in the midst of chemotherapy, I became interested in seeing how my own face changed during my fight with cancer. I have compiled six months of my daily photos into Face of Cancer in high resolution or as a streaming movie from YouTube below.



The concept of daily self-portraits is not original to me nor to Noah. An article in the Boston Globe tells the story of a photographer who has been taking his own picture for twenty years. But I felt that the technique would be particularly well suited for chronicling how cancer affects a person's appearance.

Would I grow visibly sicker as chemotherapy took its toll or as the cancer progressed? Is appearance really a better indicator of health than blood tests and X-rays?

This movie begins with the start of my third round of chemotherapy. The second round had made my hair fall out and gave me terrible acne. I also had great pain with walking, which we would later learn was due to a tumor destroying my pelvic bone. The second and third months of this movie include a period of radiation treatment targeted at that tumor.

As an artist I regret not having photographs of earlier periods in my treatment such as hospitalization and recovery from surgery. But I had not yet conceived of addressing my cancer with art and daily photographs are not the sort of thing that family members usually think of when visiting a sick relative.

Exploratory surgery

In March 2005 I finished my six-month round of chemotherapy with FOLFOX. One way of measuring effectiveness was blood tests for carcinoembryonic antigen (CEA). It's a protein that is normally found in the blood of a developing fetus but is also produced by certain cancers, especially those in the digestive tract. A normal CEA level is below 2.5 nanograms per milliliter. Mine was around 24 when I was diagnosed, 13 after my first surgery, and less then 2 by the time I finished with FOLFOX. That was good news, suggesting that my metastatic tumors had shrunk or disappeared.

During chemotherapy I also went for scans every two months. Computerized tomography (CAT) scans looked for tumors by measuring physical structure. My CAT scan before surgery only showed the primary tumor — the other tumors throughout my abdomen were too small and flat to show up. Later scans were clear, which was good news since it meant that nothing big had grown but didn't necessarily mean that small tumors didn't remain.

I also had positron emission tomography (PET) scans which look at the metabolism of tissues. After fasting for several hours I would be injected with radioactive glucose and sit quietly for an hour. Cancer cells would be particularly hungry for glucose, so it would become concentrated in those tissues. Then I was slowly scanned through a radioactivity detector to map where the glucose had gone. High concentrations in the brain, heart, and bladder were normal. Bright spots elsewhere could be due to cancer. My PET scans were clear, meaning that my tumors were either too small to be detected or gone.

Going through treatment for cancer is of course unpleasant, but one thing that made it easier for me is the curiosity about how all the tests and treatments work. I am a scientist by education and I'm always curious about how things work, why certain things are popular, and human nature. Studying medicine through the eyes of a patient kept me interested and my abilities as a scientist kept me thinking about how barbaric some modern treatments are and how much better we could do in the future.

Chemotherapy had worn me down a bit physically, I'd lost several pounds, and I was tired of dealing with my colostomy. But in some ways I was actually feeling better than before diagnosis. I hadn't realized that I was feeling sick before since the onset was so gradual. But as surgery and chemotherapy cleared the cancer I began feeling better. And once I finished chemotherapy and recovered for a few weeks I started feeling great.


The doctors gave me two months of rest to recover from chemotherapy and let the side effects clear. I took a trip to Michigan to visit my family, attend my brother's college graduation, and celebrate my 32nd birthday. It was nice to be back, feeling better, and spending happy times with family and friends. Just six months earlier my future was grim and my relationships had gloomy undertones since it seemed that I was dying. It was a triumph to see those people again, feeling better than ever.

Still, we needed to know if there was any cancer left in my body. The surgeon who took out my primary tumor had told me that advanced colon cancer that has spread throughout the body is nearly impossible to cure. It was beyond his ability to remove the metastases, but he knew of a clinical trial at the National Institutes of Health (NIH) on a radical surgery to remove widespread abdominal tumors followed by direct application of heated chemotherapy drugs. The best hope was to shrink the tumors with chemotherapy and then go for that surgery.

Since my CEA was low and my scans were clear, the last step to check for disease was visual examination. So I checked into NIH for exploratory surgery. They sedated me, made a couple small incisions, and put a laparoscope into my belly. When I awoke I was told that, yes, there were still tumors in there. In particular there were a few on my liver and on the bottom of my diaphragm. That was somewhat bad news: colon cancer typically kills not by infiltrating the colon but by migrating to the liver, lungs, or brain. But the doctors were optimistic because the tumors were only the size of grains of rice rather than the size of quarters as seen in my first surgery.

With my otherwise good health and the assistance of chemotherapy, I was a prime candidate for the clinical trial. So I stayed in the hospital and prepared for the big surgery to hopefully get rid of the remaining cancer and cure me.

Chemobrain

One side effect of chemotherapy that I never knew existed until I experienced it myself is chemobrain. I noticed after receiving a few doses that along with feeling physically sick I also felt different mentally. My mind was functioning slower as if the gears in my head were getting gummed up with molasses. The effect would be worse for about a week after each infusion and then gradually improve.

I have experienced chemobrain to varying degrees from all three of the chemotherapy regimens that I've received and from a special chemotherapy dose given during my biggest surgery. The main symptoms are:

• Impaired memory
• Difficulty concentrating
• Reduced intelligence
• Diminished creativity
  
• Lack of ambition
  

During my FOLFOX chemotherapy I felt crappy from infusion on Wednesdays until I started recovering on Sundays. Fridays and Saturdays were the worst -- I would mostly lie on the couch listening to the TV and eating very little. So when I felt a little better on Sunday I liked to get out of the house to see a movie with my girlfriend. But I discovered that I couldn't remember what I saw! I would see the same movies in the video store a few months later and not be sure whether I had seen them already. When my girlfriend reminded me that we had seen them together then I could recall the outing but still not remember much about the plot.

Failing memory is also a problem with relationships. Family and friends will call to check how I'm doing and I won't be able to remember what events we've already discussed or who has called recently. When presented with evidence I will vaguely recall the conversations but I often forget about events without reminders. I've probably done damage to my credit rating by forgetting that I had received bills in the mail and not getting around to paying them until I feel more clear-headed weeks later.

Beyond memory impairment I also suffer from other mental difficulties. My job is very mentally demanding (theoretical chemical engineering) and my personality is intellectual and introverted. But on days when chemobrain is bad I can barely manage to read and understand a newspaper. It's hard to concentrate on a subject or reason beyond a superficial extent. Television has become a good friend for giving me enough stimulation to keep me entertained without demanding much concentration or analysis.

I feel as though I lose twenty IQ points when I'm on a dose of chemotherapy. When I had a big surgery at the National Institutes of Health and was given a massive infusion of 5-fluorouracil I felt like I lost sixty IQ points. I could barely read and felt like an imbecile. Even many television shows were too challenging. The old game show The Price Is Right became the highlight of my days.

I don't know what the biological mechanism of chemobrain is. Maybe the chemotherapy drugs kill some brain cells along with the cancer, digestive, skin, and hair cells. Maybe it's not the drugs themselves but metabolic byproducts, the chemicals released during breakdown of cells, or changes in body chemistry resulting from the chemical load on the kidneys and liver.

Of course the chemotherapy drugs themselves aren't the only thing in my body during treatment. I take the antianxiety drug Ativan to reduce nausea and apprehension on infusion days and other times when I'm not feeling well. I also take the antianxiety/antidepression drug Paxil to manage associative nausea. I've read that anxiety is a big factor in the conversion of short-term memories to long-term storage. That's why people remember stressful events like the Challenger explosion or September 11th so clearly. Researchers have administered antianxiety drugs to prevent post-traumatic stress disorder in victims of war and accidents. I suspect that the antianxiety drugs that I take for nausea likewise interfere with long-term memory. It can be a blessing, since this aspect of chemobrain dims my memories of hospitalization and sick days.

I feel chemobrain most intensely for about a week after each infusion. It gradually fades away over the next couple weeks, and when I get a break from chemotherapy I start to feel really good as my mental abilities return. I often experience bouts of creativity and ambition as if I've been on vacation and just returned to an old problem with fresh eyes.

From talking to other cancer survivors I've learned that chemobrain can be a long-term problem. Many people experience memory impairment for three years after finishing chemotherapy or never recover completely. Being that my job and personality are so dependant on my mental abilities I was frightened that I would lose my intelligence permanently. But during my period of remission I felt at least as smart as I ever was -- maybe even smarter since I've gained wisdom and coping skills from my struggles. So although I still feel hampered by chemobrain I expect that I'll return to my usual self whenever I can get off of chemo.

What to eat

One of the side effects that everybody expects from chemotherapy is nausea and vomiting. I've been fortunate that in 2-1/2 years and three rounds of treatment I have never vomited from chemotherapy. I have had to deal with nausea ranging from a slight loss of appetite to "ugh I feel sick and can't bear to think of food".

Some of the advice that I was given was to try to stimulate an appetite by preparing my favorite foods. I've learned that that can be a bad idea. My first round of chemotherapy involved 6-hour infusion sessions, so I needed to eat something before and during the infusion. I chose some of my favorite snacks and meals: donuts, bagels, grape juice, applesauce, ham sandwiches. Unfortunately after a few weeks my body began to associate those foods with the sickness that I felt from the infusion. Whenever I saw or thought about them I suffered from associative nausea.

Some of those foods I have managed to disassociate from chemotherapy, but grape juice and applesauce still turn my stomach. I also have strong associations with smells: roasting coffee beans and certain brands of pizza remind me of snacks I ate on the days after chemotherapy.

My advice is to choose foods that you moderately like but not your favorites. For me, this means that if I must eat during chemotherapy I stick to snacks like pretzels, animal crackers, and apple juice. I totally avoid my very favorite foods (sushi, steak, certain desserts) on days when I'm feeling sick from chemotherapy. My current chemotherapy regimen takes only an hour to infuse, so I don't eat anything during that time.

One of the lessons that many people learn from fighting cancer is to enjoy all the little pleasures in life. Eating good food is high on that list, and the threat of weight loss from chemotherapy often means a license to eat as much as you want. Good nutrition is also important for staying healthy, so you should consume wholesome and high-quality foods. When I'm free of nausea, it's nice to be able to indulge in fine meals and desserts. Cost can be a concern, but I economize by getting restaurant meals as takeout (saving on beverages, side dishes, and tips) or learning to cook more myself.

I have also benefited from a couple of medications to alleviate nausea and stimulate appetite on those marginal chemotherapy days: Emend for the severe nausea from Camptosar and Marinol for the mild nausea from Xeloda.

Into chemotherapy

After surgery revealed that my colon cancer had spread throughout my abdomen, I started chemotherapy in September 2004. My expectations were formed by what I've seen in movies: chemotherapy means vomiting, hair loss, and misery.

The mechanics of chemotherapy was biweekly visits to a small clinic in Kensington, Maryland. There an intravenous line was connected to an infusion port that had been surgically implanted beneath the skin on my chest. This port led via a small tube into my aorta where the chemotherapy drugs are rapidly mixed into the blood.

The drugs used for chemotherapy vary from cancer to cancer and stage to stage. My regimen was FOLFOX-A: 5-fluorouracil (poison), oxaliplatin (mucks up DNA replication), and Avastin (stops blood vessel growth). I started each infusion session with saline and powerful antinausea medication to prepare me for the toxic drugs. Then the chemotherapy drugs were infused, one by one, over the course of a few hours. Finally I was fitted with a portable pump to continue infusing the 5-fluorouracil for the next 48 hours.

Seeing the other patients in the clinic made me realize that getting cancer at my age really was unusually bad luck. In the 2-1/2 years that I've been going to that clinic, I've seen only one other patient within ten years of my age -- a young woman also on the same treatment for colon cancer. Otherwise about half of the patients look to be in their fifties and the rest are older. It's sometimes uncomfortable feeling the extra attention that I draw as a youngster, and I'm less social with the other patients during my hours of infusion than I would be if they were my peers.

The infusion clinic is a surprisingly upbeat place. Most of the patients are in good spirits and the staff is very nice. Having dealt with many grumpy nurses in hospitals, it's a surprise to see the different personality of oncology nurses. I guess part of it might be that cancer is seen as a tragic disease and it tends to bring out extra compassion in caregivers.

The patients are probably cheerful because these are the people who are actively fighting cancer. Chemotherapy makes us feel sick in the short term, but we all hope that it's making us better and many people start to feel better as the cancer is reduced. And it seems that an optimistic attitude really does improve one's physical health.

But sometimes I see a patient with death in their eyes. They look sick, worn down by chemotherapy or the cancer itself, and in bad spirits. It makes me realize what an ultimately serious disease cancer is and what I might have to experience before long. I don't know if these patients really are at death's door or whether their just at a low point. I know that I've looked like a sick cancer patient myself at times, but then I've improved and looked like a picture of health.

I wonder what it's like for the staff to deal with such sick people every day. How many of their patients are lost to death each year? How does that affect their own lives? I know that we all die eventually, but it's exceptional to know that a person is facing death with immediacy and suffering in the meantime.

Oh the pills, pills, pills, pills, pills, pills, pills

I've been in my third round of chemotherapy since November 2006. When I was healthy the only pills I regularly swallowed were daily multivitamins. My intake of medication changed drastically when I began my battle with cancer. These are the pills that I had to take last week:

Xeloda (pink, elongated): Poison. The compound in these pills is metabolized into 5-fluorouracil (5FU) in the body. 5FU interferes with DNA replication and kills growing cells. The target, of course, is growing cancer cells but it also hits the digestive system and skin. These pills cause pain and peeling in my hands and feet along with slight nausea, fatigue, and chemobrain.

Marinol (brown, sperical): Synthetic THC, the active ingredient in marijuana. These help eliminate nausea and stimulate my appetite. I take one before dinner on the days when Xeloda is making me feel icky.

Prilosec (darker, shinier pink): Acid reducer. Prevents heartburn and related nausea from stomach irritation caused by Xeloda.

Immodium (pale green): Antidiarrheal, necessary when Xeloda makes my intestines unhappy.

Oxycodone (white, circular): Pain killer. I received four weeks of radiation therapy in January and February to treat a tumor on my pubic bone. The radiation also caused external and internal burns nearby, particularly irritating my rectum. I've been taking oxycodone about once a day when that area gets particularly uncomfortable.

Colace (shiny, red and white): Stool softener. Helps counteract the constipating effects of oxycodone and reduces discomfort during bowel movements.

Simethicone (large, white, circular): Anti-gas tablets to reduce cramping when Xeloda upsets digestion.

Paxil (tiny, orange): Antidepressant. I used to suffer from associative nausea; whenever I went to or even thought about my chemotherapy clinic I would feel like vomiting. The antianxiety effects of Paxil make me feel a little calmer and greatly reduce associative nausea. As is typical with serotonin reuptake inhibitors, it also suppresses my ambition and libido somewhat.

Norvasc (white, angular): A popular anti-hypertensive to counteract the high blood pressure triggered by Avastin.

Oh yeah, I also get an infusion and an injection during my biweekly chemotherapy clinic visits:

Avastin: Deactivates the body's vascular endothelial growth factor to prevent blood vessel growth and starve the tumors.

Aranesp: Promotes the growth of red blood cells to counteract fatigue.

Two of these medication are actively fighting the cancer. The other nine are needed to treat the side effects. It's tiresome to take so many pills, but I'm impressed that oncologists have so many tools for minimizing the illness and suffering from chemotherapy.