Mistake. Give me my steroids, NOW!

Sick as a dog, thank you Chemo.  I am meant to be on top form tomorrow.  It’s hubby’s very special birthday and we have a full day of fun planned.  Thanks, thanks a million for deciding to be ‘a bad Chemo’ day.  Team, my wonderful team, I feel let down.  There has been a mistake.  You forgot to give me my steroids.  I trusted you.  I felt safe.  I wasn’t safe today.  It made a difference, a huge difference.  I let myself down too. I forgot to do my own checks.  I forgot to ask for my steroids.  Consequences.  There are always consequences in this Cancer game, some big, some small, some easily remedied, others drastic and most, a right pain in the arse.  Consequences, you can rip the rug right out from under my plans.  A plan to; feel good, not have to go near a hospital and not have to be in, manage my mood mode because something unexpected and unhelpful has triggered me.

Monday, you didn’t start out a bad day. In fact, you were brilliant until 6pm.  I went for my morning blood test, at 8.30, later than usual after a wee welcomed sleep in and a fab, fun, friends packed day, on Sunday.  Then, I moseyed to a café near hospital to do Italian language practice before my lesson with the fabulous C from Sardegna.  I wandered back to Macmillan to a meeting with my therapist who helped me think about my recent test results, the meaning I was adding and my plans to up the ante on the work front.  As usual she was a great help.  My pink smoothie, a nutri-bulleted beetroot and green salad was yummy.  My call with friend and coach M, was great.  Even Chemo went smoothly.  Or so I thought.

I got home and started feeling wretched.  More wretched than I have in ages after a Chemo day.  Even drinking water was difficult.  Pain, everywhere.  Nausea, constant.  Stuck close to the bathroom.  The Dom anti-nausea pill wasn’t doing its thing.  Sweat, cold, sweat, cold.  Aaargh.  Why?  Why today? This is sh*t.  Will I function tomorrow?  Hubby’s birthday is so important to me.  He has even taken the day off work which is so rare.  10.15pm rolls around and Chemo you bit*h, you have me sitting on the couch, head in hands and between my knees.

Steroids

Then it dawns on me.  I didn’t receive my steroids today.  Dexamethasone, I wasn’t given it and I was so busy watching Americans on Prime to distract me from any pain of the cannula going in, that I didn’t do my own checks.  Bugger.  Now what.  Now, I’ll have to telephone the Haematology Registrar on-call and see if I can take my day 16 (tomorrow’s dose) of Dex now.  It’s not a great time of day to be taking a steroid, they’ll keep me up all night…but hopefully I’ll feel better.  Priority right now: feel better.

Then I realise.  Pissed off.  If I take the dose I have at home, I’m going to have to go to hospital tomorrow now, the very day I didn’t want to go and normally don’t have to go near it. And on your birthday, darling Man.  I don’t know how long it will take, to pick up a steroid on a day I am not usually there.  VERY PISSED OFF.  My feeling wretched, my having a problem, my having to go into problem solving mode, my having to deal with the impact, accept the consequences, pissed off…it was all so preventable.  Annoyed.  Sad.

I ring the hospital, ask for the Haematology Reg on call.  Operator says she‘ll page him and he’ll call me back very soon, often straight away.  I wait. 40 minutes later, I’m still waiting.  I’m so sick, I can’t get angry.  Hubby calls.  The operator is surprised I haven’t heard. She pages him again.  He calls back in 5 minutes.  No apologies, no explanations (e.g on another call).  He runs through the usual questions – have a vomited? Not yet. Do I have a temperature?  No, just the sweat, cold combo.  Do I have diarreah or constipation? No.  Just pain, a lot of pain and nausea that pills don’t kick.  Finally, he confirmed I should take the Dex I have at home and go up to hospital for another dose tomorrow.

I take the steroids and Hubby manages to find another stronger anti-nausea tablet amongst my large array of pills in ‘the pill box’ (a large bread bin, works a treat).  I cuddle up to Hubby, focus on his breathing and wait for drugs to kick in.  By the time we move it’s 1am and despite the steroid, I feel like my body is now desperate for sleep.  Good.  Happy to oblige.  I drag myself upstairs to bed.

Hubby’s birthday day.  I feel a whole heap better but very drained.  He drives me to hospital.  I go to get my steroid and my fear about how the day may unfold starts to be realised.  Cancer, you bit*ch, you don’t make life easy.  My steroid isn’t ready. I don’t get to drop in, collect it and get out again (my hope).  Despite having an email back from my specialist in the morning, acknowledging that a) my Chemo, carfilzomib is hard to tolerate without the steroid and b) containing his request that I be dispensed the steroid today, directly from the Chemo Day Unit (CDU) and c) that the clinical trial nurse should call the CDU nurses to make sure they have the steroid ready for 9.30am – it’s not ready.  I even get there about 10.40am, figuring I’d give everyone a bit more time to communicate and prepare.

I explain again, what has happened.  The CDU nurses won’t give me the steroid and when they call the Clinical trial nurse for information something is lost in translation so they now think they need a prescription before they can give me anything.  I show them my box of Dex with the prescription and dose details AGAIN.  I start to get upset.  Really upset.  I could be waiting for ages for the clinical trial nurse to come to the CDU with a prescription (I’ve been through this before so know how long it can take) and then if I must go to the regular hospital pharmacy for it to be filled, I can write off another hour, it is hideously inefficient.

Tears.  Yep they’re coming.  I cry.  M the wonderful receptionist comes to comfort me and says ‘this is not like you’ and to find out what’s going on.  I fleetingly wonder ‘what is like me, when I’m here?’  I feel bad because I know the team have had someone die today and one of the head nurses has had to race off and manage that.  My tears over impacting my day with my hubby seem trivial in comparison and yet not, nothing is trivial in this Cancer journey.  It’s all bearable for me most of the time, yet it is all sh*t too.  I cry some more.

Nurse L comes to my rescue.  She looked after me all last year and I missed her when she left to do a stint in private practice.  She asks what is going on, I tell her, show her my empty box of Dex and say I just need my day 16 dose because I had to take it last night after not receiving the steroids yesterday. I don’t say which Nurse forgot to give me the steroid.  Nurses are human.  We all make mistakes.  She is usually so so good so must have had an ‘off day’.  AND, it was my mistake too.  It’s not really fair to hand all responsibility and agency of my care over to a Nurse.  After all, I bang on about being the agent in your own health and treatment for as long as you possibly can.  Nurse L goes and gets the Dex dose immediately and finally I get to leave.

Thank you M and L.  You saved my day.  I know my Clinician plans to talk to the nurses about how the steroid was missed but I don’t worry about that now.  I know mistakes happen yet between us, the Nurses and I are usually so good at going through a checklist each time. It’s a shame it went wrong.

On this day of all days.

Psychology Tips – Working with your and others’ mistakes

Admitting mistakes can be hard.  Research shows there are links between our beliefs about whether we can change our behaviour or whether our personality is fixed and if mistakes and admitting mistakes are perceived threats.¹ Cognitive Scientist, Art Markman summarised the research results² and explains when you believe that your behaviour can change, you are more likely to be willing to admit responsibility.  You recognise that by admitting what you have done wrong, you can work to make it better, to grow and so you are not threatened or are less threatened by admitting mistakes.

People who do not believe that they can change, can be stressed by admitting their mistakes, because they believe that those mistakes say something fundamental about who they are as a person.  Understanding that people see their own mistakes as a threat, and have different beliefs about their own and possibly others’ ability to change, can help us to remember to avoid showing unhelpful frustration and anger when managing mistakes.  We can all change our behaviour.  We can all learn from our mistakes.  We can all repair and improve relationships.  It can take some people longer than others, to recognise that change and growth is possible, especially when their starting point is one of: I and others have fixed personalities and mistakes are flaws.

It’s easy to get frustrated with others’ mistakes when we feel something is unfair (it can be completely justified) but does it help the situation to show the frustration?  A compassionate response will get you more powerful results and responding with anger and frustration negatively impacts loyalty^3,4.  In my case, I want the Nurses to like treating me.  I want them to feel we are on the same team, to feel loyal, committed.  Showing my frustration and upset was normal, human, yet unlikely to have been the optimal way to have managed the situation.  Remembering that frustration, anger and stress raise heart rates, make it harder to think, mean that when recognising frustration, a good first step is to pause, be mindful, and then choose a more powerful response.  One of clear communication, compassion, kindness, empathy, forgiveness.  This is more likely to invoke compassion, kindness and loyalty in return.

Recognise too that anger, frustration and upset at mistakes of yours and others are often underpinned and exacerbated by worry and a catastrophising thinking style.  I was worrying that my need to go to hospital on Hubby’s birthday day would ruin our day.  Ruin his day.  Eventually I managed to realise an unhelpful worry and thinking style was probably in play and ask myself, was my hospital visit really the worst thing in the world?  Were my thoughts true, would our day really be ruined?  How much time in our day did it take up really?  Was it more likely that hubby was happy to help and had enjoyed his rare time alone, in a café, doing things he wanted to do, without having to be at work, while I was at hospital?   Regaining perspective enabled me to let my frustration and upset go.  An hour later I noticed I was laughing at something Hubby said and our day was going well.  Yes, it meant we came home earlier than expected because I was really tired yet we relaxed together and the evening was a good one.  I could easily have been very tired anyway.  It’s not unusual for the day after Chemo.

References:

¹ Who accepts responsibility for their transgressions?  Schumann, K and Dweck, CS.  Who accepts responsibility for their transgressions?  Pers Soc Psychol Bull. 2014 Dec;40(12):1598-610. doi: 10.1177/0146167214552789

² Markman, A. (2014) What makes some of us own our mistakes and not others?

³ Sara B. Algoe & Jonathan Haidt (2009) Witnessing excellence in action: the ‘other-praising’ emotions of elevation, gratitude, and admiration, The Journal of Positive Psychology, 4:2, 105-127

⁴ See Adam Grant, Psychologist and author of Give and take: A revolutionary approach to success.  See also work by Emma Seppala, Center for Compassion and Altruism Research and Education.

Acknowledgements:

Shadow and Dex pictures by Me

Dog Photo by Matthew Henry on Unsplash

Shattered plate Photo by chuttersnap on Unsplash

Failed it Photo by Estée Janssens on Unsplash

© 2018 Janine Hayward www.psychingoutcancer.com.  All rights reserved.

Posted in Chemotherapy for Myeloma, Myeloma Treatment, Psychology for Cancer, Symptoms and Side Effects Tagged with: Cancer, Carfilzomib, Compassion, Consequences, Dexamethazone, Frustration, Mindfulness, Mistake, Mistakes, Myeloma, Nausea, Psychology, Sick, Steroids, Sweats, Tears, Worry

Treatment – We need to know NOW.

Most people take more time over choosing a new sofa or hairstyle than I was given to decide on my treatment pathway for Myeloma Cancer.  There was no time to waste; my back vertebrae were in danger of fracturing and causing cord compression so treatment needed to start asap.  I seal my fate within the week, a time frame Dr R and I could live with.  I frantically researched global treatment options versus UK treatment options, NHS versus private care, compared treatment side effects, managed queries in phone calls with Dr R in the evenings, spoke to experts, trawled the internet and discussed pros and cons lists with Hubby.

I had a flash of realisation that no one could make this choice except me.  All the other big choices in life recently had been joint decisions; which house to buy, whether to move to Cambridge, when to move back to London, whether we could afford for me to start a business, whether to get a cat, how each clinical psychology course could work for us if I was offered a place.  Joint decisions, because they impacted both of us.

Yet, here was the decision that could turn both of our lives completely upside down and I ultimately had to make it alone. A decision impacting my health, my body and what I was going to let someone else do to it. What if I chose the wrong thing and I shortened my life unnecessarily?  What if I chose something that turned out to have gruesome side effects for me?  What burden was my choice going to cause for Hubby?  How long will it be before I am in excruciating pain, breaking bones left, right and centre, paralysed or need full time care?

Pause, breath.  I remind myself that survival rates in myeloma are increasing at one of the fastest paces among all cancer types in the UK¹. Pause. Breath.

In the end four things kept zooming around my head:

1. There is some evidence (though better and more research is needed) that people have better outcomes when they participate in clinical trials^2,3.
2. Standard care involves Thalidomide. I know it has improved since the old days but the side effects can still be nasty and I just don’t like the sound of it.
3. The main trial drug Carfilzomib has had great results for people at relapse stage and it and its side kick Cyclophosphamide have been much better tolerated than Thalidomide.
4. I will be monitored like a hawk if I sign up to the trial so reactions and adjustments are likely to be more timely.
5. I can always withdraw if I feel the trial is no longer serving me and move to standard care. I don’t want to withdraw yet I can, if I feel it’s necessary.

You guessed it, in the end I chose the trial.  It’s called CARDAMON and is being overseen by a partnership between University College London (UCL), Cancer Research UK and Amgen Ltd (Pharmaceutical company).  Participant recruitment is taking place at UCL and Kings College Hospital (KCH) and several other UK hospitals.

So, what will be done to my body and its overzealous Myeloma para proteins?

For four months, in one month cycles, I will receive a chemotherapy cocktail of three drugs nicknamed KCD.  KCD comprises of:

Carfilzomib (Kyprolis)^4,5.  This has been used to treat over 4000 myeloma patients world-wide with both relapsed and newly diagnosed myeloma, is licensed for use in the US and approved by the Food and Drug administration (FDA) but is yet to be approved in the UK, hence the trial.  It is a proteasome inhibitor that prevents breakdown of abnormal proteins in cancer cells, causing the cells to die.  It has only rarely been reported to be linked with the side effect of peripheral neuropathy (pins/needles/numbness in extremities) which can be painful and which has been associated with the drug used in standard care, Velcade (Bortezomib).  I will get Carfilzomib by intravenous infusion, through a cannula in my vein on 6 days out of the month.  Doesn’t sound so bad…

Cyclophosphamide (Cyclo)⁶.   This drug belongs to a group of drugs called alkylating agents. It works by sticking to one of the cancer cell’s DNA strands. DNA is the genetic code that is in the heart of all animal and plant cells. It controls everything the cell does. The cell cannot then divide into 2 new cells.  I will get Cyclo orally by tablets on 3 days out of the month.  Doesn’t sound so bad…

Dexamethasone (Dex)⁷.  This is a strong steroid that can suppress inflammation and the immune response, kills cancer cells and usually induces a better response to the other chemotherapy drugs than when chemotherapy is used alone.  I will get Dex orally by tablets on 4 days out of the month.  Doesn’t sound so bad…

After three weeks in the month of going into hospital every Monday and Tuesday for the above, I get a week off the KCD and don’t have to go to hospital.

I do though have to take a bunch of other meds too, one to protect my kidneys, another to prevent/manage nausea, another to stop a virus outbreak, an antibiotic to prevent infection.  These continue during the non-chemo, no-hospital week.

I’ll also start another drug called Zometa⁸, a biophosphanate with good evidence that it reduces bone loss, fractures and helps to build bones. I will get Zometa by intravenous infusion, through a cannula in my vein on the same day as getting Carfilzomib I think.  I’m yet to understand how often this happens.

After four months, my response to the Chemo will be assessed and if my Myeloma para protein level has dropped by 50% or more, the Chemo will be considered a success.

I will then be scheduled for a heavy-duty med to induce stem cell production ahead of stem cell collection.

After recovering from the stem cell harvest, I will then be randomised to either the;

• branch of the trial that receives an autologous stem cell transplant (ASCT; meaning using my own harvested cells) in the same way I would have received one if I had chosen standard care or
• I will go into the branch that receives a further four months of the KCD cocktail

After this, participants in both branches of the trial receive maintenance medication.

So, what is hoped for from all this medication?  Short term, the hope is that the standard care response of a minimum of a three-year remission is achieved and for the patients in the continued KCD arm that this remission period is achieved without having to undergo an invasive stem cell transplant.  Longer term, the aim is that the treatments, even within the three years of my own remission, will have moved on so quickly (there are already exciting drugs coming down the line in trials) that Myeloma moves from an incurable illness to a chronic illness. A stem cell transplant would then become the final defense at the later stages of the illness.

If this all a lot to take in, I get it.  I thought so too and I’m still getting my head around it all.  There is a massive new language set that goes with moving in this world of cancer and Myeloma.

Have I done the right thing?  I hope so.  I feel that I have, with the research and time in which I had to make the decision.  Psychological cognitive science theory purports that usually you will choose your choice.  It is called choice–supportive bias or post-purchase rationalization⁹.  It is the tendency to retroactively ascribe positive attributes to an option one has selected and it’s a cognitive bias.  Therefore, I am highly likely to have a cognitive bias about my decision to choose the trial because not to do so would undermine my choice…and make it much harder to believe the trial treatment will be successful.  I usually try to avoid or at least be cognisant to my own biases.  In this case, I fully own and embrace my bias about my decision to go with CARDAMON.  BRING IT ON!

Acknowledgements and References:

¹Myeloma UK. www.myelomauk.org

² https://academic.oup.com/annonc/article/22/Suppl_7/vii10/214151/How-may-clinical-research-improve-healthcare

³ https://academic.oup.com/annonc/article/22/Suppl_7/vii2/214043/The-impact-of-the-process-of-clinical-research-on

⁴ CARDAMON Patient Information Sheet; Kings College Hospital; version 4.0; 07Nov16

⁵ https://www.themmrf.org/multiple-myeloma-knowledge-center/myeloma-drugs-guide/kyprolis/

⁶ http://www.myelomabeacon.com/resources/2008/10/15/cyclophosphamide/

⁷ http://www.myelomabeacon.com/resources/2008/10/15/dexamethasone/

⁸ http://www.myelomabeacon.com/news/2010/06/22/zometa-increases-overall-survival-and-slows-bone-disease-in-multiple-myeloma-patients-asco-2010/

⁹ http://changingminds.org/explanations/theories/choice-supportive_bias.htm

Copy Editor: Stephanie Kemp

Image: Photo by Angelo Pantazis on Unsplash

© 2017 Janine Hayward www.psychingoutcancer.com.  All rights reserved.

Posted in Chemotherapy for Myeloma, Psychology for Cancer Tagged with: Cancer, Carfilzomib, Chemotherapy, Choice Supportive Bias, Chronic Illness, Clinical Trial, Cognitive Bias, Cyclophosphamide, Dexamethazone, KCD, Myeloma, Para Protein, Post-Purchase Rationalisation, Response to Chemotherapy, Stem Cell Harvest, Stem Cell Transplant, Survival Rates, Treatment, Treatment options, Zometa