Disappointing Test Results

Thursday, May 27, was the end of Cycle 29 of my pomalidomide (CC-4047) trial at Mayo Clinic. Unfortunately, my IgG and M-spike were both up about 10%, which is not good news. Every myeloma regimen fails eventually, and this could signal the end of my rather easy ride on pomalidomide. Furthermore, the neutrophil count is 920 (tiny buggers per microliter) and if it stays below 1000 I can't continue on the pomalidomide study until it goes back up. Otherwise, in theory at least, I'm a little too vulnerable to bacterial and fungal infections.

Neutrophils:

My Mayo blood draws are usually ay 6:30 am, and the neutrophil count was below 1000 at the end of both of the previous two cycles. In an afternoon blood draw a few days later, in both cases, the count had jumped up well above 1000 and I was able to continue on the study. This time, though, I was heading out of town to run a marathon, so we did another blood draw at Mayo before I left, still in the morning but not so early, hoping that it would show 1000 or above. But the vaunted Mayo Clinic screwed up! They did the CBC, but failed to do the differential which shows the actual absolute neutrophil count. By the time we discovered this, the test could not be repeated and we were almost halfway from Minnesota to Idaho. So the next day we stopped in Billings, MT, and had blood drawn there. I do not yet know the results of that CBC, so I can't be sure of continuing on the study. I'll assume the best unless I hear from Mayo.

Genistein:

I have been taking genistein, a soy isoflavone, throughout the pomalidomide trial, about 50 mg/day. It is supposed to have some anti-cancer effects by "supporting" the immune system. However, since myeloma is a cancer OF the immune system, there is a question whether it should be "supported," and in addition there are other questions about any estrogen-simulating supplement. So I decided to stop it for a cycle, to see what might happen to IgG and M-spike. I guess I got my answer. Back on genistein!

Hand Infection:

Three months ago I whacked the back of my left hand against something and got an infection, either bacterial or fungal, and the hand eventually got quite warm, swollen, and painful. It has healed very slowly, but it's almost better now.

Some current test results:

Test		Mar 04		Apr 01		Apr 29		May 27		Remarks
M-spike g/dL		1.0		1.0		1.0		1.1		Best tumor measure
IgG mg/dL		1130		1070		1010		1110		Variation is normal
L FLC mg/dL		2.10		1.82		2.41		2.58		L Free light chains
Calcium mg/dL		10.1		9.8		9.7		9.9		Below 10.2 is best
Creat mg/dL		1.0		1.2		1.3		1.3		Kidney, normal
HGB g/dL		14.2		14.7		14.6		14.1		Hemoglobin, normal
RBC M/uL		4.17		4.39		4.21		4.36		Red cells, normal
WBC cells/uL		3400		3300		3300		3600		White cells, low
ANC cells/uL		1290		940		730		920		Neutrophils, LOW!

ASCO Conference:

I have been invited to attend the annual meeting of the American Society of Clinical Oncologists next week, and I will be blogging in "real time" about the presentations that I see there. Here are a few of the topics that seem interesting to me:

• Studies of Carfilzomib, a Velcade-like drug which has far fewer side effects;
• Post-transplant maintenance therapy with Revlimid or another drug, versus no maintenance. We're going to hear that maintenance prolongs lives!;
• Denosumab versus Zometa for bone problems;
• More about pomalidomide (when will they get this FDA approved?);
• Doxil, Velcade, and dexamethasone as front-line therapy; and
• LOTS more. I can't hope to cover it all.

Related links:

My Myeloma		A discussion of my myeloma, not very technical.
My Treatment History		Not technical.
My Test Charts		Graphic displays of several key test results over time.
My Test Result Table		Best with a wide browser window. Somewhat technical.
My Supplement Regimen		With links to where I buy them.

I haven't had time to update the charts, test results table, and other documents (see links above) that go with this post, but wanted to get this posted now while I have a few minutes. I'll get around to the rest later, but there is really not a lot of change except the increase in IgG and M-spike.

P.S. June 2, 2010: The blood test (CBC) at Billings Clinic showed 1890 little guys per microliter (how can it go up that much from 920 in one day?) so I'm still on the study!

Breakfast:

Mom Is 100!

MY MOM IS 100 TODAY!

We had a heckuva party over the weekend, people coming to Minnesota from as far away as California. She's lovely, and I'm so proud of her. Go MOM!

Ho Hum, Cancer Is Still Stable

Stable but not ho-hum, actually. Thursday, April 29, was the end of Cycle 28 of my pomalidomide (CC-4047) trial at Mayo Clinic. M-spike is still 1.0 g/dL, IgG is actually down 5%, and light chains are normal. That's great! The fly in the ointment is the neutrophil count, which is down to 730 cells per uL, where the reference range is 1700 to 7000. In theory, at least, this leaves me a little too vulnerable to bacterial and fungal infections.

Neutrophils:

The trial protocol requires that the pomalidomide dosage be reduced if neutrophils fall below 1000. Last month, neutrophils were 940 per uL, but another CBC performed four days later at a local clinic showed a count of 1500. When that result was faxed to Mayo, the study was continued unchanged. This time the neutrophil count was even lower, but Dr L again suggested a re-test in four days, and by golly the count on Monday afternoon was 1700. Huh. No change in pomalidomide dosage for at least another month.

How can the neutrophil count change that much? More than double! I'm surprised that it can, actually, but:

• Exercise can affect the count. Both Mayo doctors have mentioned this, and Dr LL, my primary care physician, explained that exercise pushes the neutrophils out of muscle tissue into the blood. Learning of this, I have done a few flights of stairs and a set of pushups before each of the Monday blood draws at the local clinic. On the other hand, I also did those exercises before last Thursday's blood draw at Mayo, and that time the count was the lowest ever.
• Dr L explained that neutrophils do follow the body's daily circadian rhythm, and they are higher in the afternoon than in the morning. In both cases, the Thursday blood draw at Mayo was done at about 6:40 am soon after a 90-minute drive, and the Monday blood draw at the local clinic was done in the early afternoon. Perhaps this accounts for much of the gain in count.
• Could food make a difference? Something in the stomach? I don't know a reason why food should affect the count, but results have been low on an empty stomach and high after two meals.
• Do you suppose there is a difference in the way that the two laboratories count neutrophils? Of course there is a difference, there is always a difference, but I doubt it is enough to double the count.

Hand Infection:

• Two months ago I whacked the back of my left hand against something and got an infection, either bacterial or fungal, and the hand eventually got quite warm, swollen, and painful.
• Over time, three different doctors have prescribed four different antibiotics. Whether or not the antibiotics helped, the infection eventually started to turn around after getting steadily worse for more than five weeks. It's still getting better, very slowly.
• I've babied that hand, keeping it extra warm and even applying a little heat for much of the time.
• The last antibiotic ran out 10 days ago, and the infection is still slowly getting better even without it.
• Here's what I think:
  • It's a fungal infection, because the speed of recovery didn't seem to change when the antibiotic ran out;
  • The speed of recovery is reduced by the shortage of neutrophils, which are important in battling either a fungal or a bacterial infection;
  • If I do nothing more, it will probably, gradually, heal itself. I hope; and
  • I sure am glad that I have nothing more serious to whine about!

Other Discussions with Dr L:

• I asked which test, M-spike (serum protein electrophoresis) or IgG (immunoglobulins), was more accurate. She took the question to mean "which is a better indicator of tumor burden" I think, and responded that IgG is better when numbers are quite high, and M-spike when numbers are quite low. For me, she said, with IgG and M-spike both near 1000 mg/dL (1.0 g/dL), they may be equally good indicators.
• Dr L is OK with my decision to NOT start taking Fosamax yet.
• She also doesn't know what's going on with the hand, and seems pleased that Dr LL, my PCP, is taking care of it.

Some current test results:

Test		Feb 04		Mar 04		Apr 01		Apr 29		Remarks
M-spike g/dL		1.0		1.0		1.0		1.0		Best tumor measure
IgG mg/dL		1180		1130		1070		1010		Variation is normal
L FLC mg/dL		2.78		2.10		1.82		2.41		L Free light chains
Calcium mg/dL		9.8		10.1		9.8		9.7		Below 10.2 is best
Creat mg/dL		1.1		1.0		1.2		1.3		Kidney, normal
HGB g/dL		14.2		14.7		14.6		14.1		Hemoglobin, normal
RBC M/uL		4.00		4.17		4.39		4.21		Red cells, normal
WBC K/uL		3.8		3.4		3.3		3.3		White cells, low
ANC K/uL		1.22		1.29		0.94		0.73		Neutrophils, LOW!

Related links:

My Myeloma		A discussion of my myeloma, not very technical.
My Treatment History		Not technical.
My Test Charts		Graphic displays of several key test results over time.
My Test Result Table		Best with a wide browser window. Somewhat technical.
My Supplement Regimen		With links to where I buy them.

Sore left front paw: