The Cocktail Bar

A middle-aged woman and her companion walk up to the building, the bright neon sign flashing “Cocktail Bar”. She feels a little out of her comfort zone. The last time she set foot in a bar was when she was in grad school, 10 years in the past. She timidly places her hand on the door handle, takes a deep breath, and walks in. The bar is surprisingly full, people crowded around tables, some with food, others with drinks, and still others wrapped up in blankets. The one common denominator, the far away look in all of their eyes.

The young woman walks up to the bar tender and says, “Uh, I guess I need a cocktail. I’m not sure which cocktail would be the best for me, though.”

”Well, tell me a bit about yourself and I can find the best one for you.”

“I, uh, I have breast cancer, of the pleomorphic lobular version, despite nursing four children for over 12 months each. The cancer has spread to at least 2 lymph nodes. I think my Oncotype score was about 18, but I don’t really remember. Um, I’ve had a bilateral mastectomy but did not have further lymph node dissection, opting instead to have radiation to the axillary region. I guess that about sums it up.”

“In that case, I think you should have the ACT cocktail. You’ll get four cycles of AC, Adryamycin and Cytoxan, with each cycle being delivered every two weeks. After that, you’ll get twelve weekly cycles of T, Taxol. Why don’t you step on over here and I’ll have you talk with my assistant bar tender to get you all of the details.”

As the young woman is following the bar tender, another person rushes into the bar frantically waving a piece of paper shouting, “Wait! Wait! Don’t start anything yet! I have new information!”

He hands the slip of paper to the bar tender, who reads it and then wrinkles up his nose. “Hmmm, this changes things. Ma’am, were you aware that you have an issue with your heart?”

The woman nods.

“Your left ventricle is not squeezing quite hard enough. Now it’s possible that the issue could be an artifact from pregnancy, but I’d rather not take any chances. Adryamycin and Taxol both are what we call cardiotoxic drugs. Since you are already starting with a slightly decreased heart capacity, I’m going to give you a different cocktail that will not put you at risk for further heart damage. This will be called CT: cytoxan and taxotere. You’ll get this every three weeks for four cycles. If you are tolerating it well, then we’ll push on to 6 cycles so that we can treat the disease as aggressively as possible.”

“Okay, that sounds reasonable. So do I still need to meet with the assistant bar tender to get more specifics?”

“Yes. She will be going over the side-effects of the cocktail and give you some tips on how to manage it all. Do you have any other questions?”

”No, not right now, thanks.”

“Alright, then. I just want to add that you will be losing your hair. Probably around week 3, you’ll feel your scalp getting tight and then your hair will start falling out. It will grow back after the treatment is ended, but you’ll definitely be losing your hair.”

“Okay, I’m prepared for that, thank you.”

The young woman meets with the assistant bar tender in a private room, where she is informed of all of the various side effects of the cocktail and is given a handy chart to help her keep it all straight in her mind.

Symptom	Management
Alopecia (hair loss)	Wear a wig or a scarf
Fatigue	Take frequent naps, but don’t be a couch potato
Nail discoloration and changes
Appetite changes	Eat 5-6 small meals a day, don’t use hunger as a cue for when to eat
Nausea	Take the medication and stay ahead of the nausea
Constipation	Call the office as soon as you notice changes.  Don’t wait until you’ve gone 5 days without a bowel movement. Drink lots of fluids.  Add greens to your diet as well as prunes, flax seed and apple juice.
Metallic taste	Use plastic silverware
Dehydration	Drink at least 64 ounces of water per day.  Stay hydrated!
Decreased white blood cells	Neulasta injection.  Stay away from large crowds, wear a mask if you will be around sick people.

“The day after your cocktail, you’ll need to come in to get a Neulasta injection. This will create more bone marrow, which is where the white blood cells are housed. The injection itself isn’t too painful, but you will likely experience bone pain as a result of the new bone marrow being created.”

“Great! One more thing to have to deal with!”

“I know. I’m sorry!” The assistant bar tender places her hand on the young woman’s hand and gives it a squeeze. “You can take Claritin and Tylenol to help mitigate the bone pain.”

“So basically, I’m going to become a druggie. I’ll be alternating Compazine and Zofran every four hours for the nausea. For two days after the cocktail, I’ll be taking Decadron, also for nausea. For constipation, I’ll be taking Miralax and Senecot. For bone pain I’ll be taking Claritin and Tylenol. And this is in addition to the iron pills I have to take post-surgery. How in the world do I keep this all straight?” The young woman’s brain was starting to swim with all of the information that was being given her.

“I would recommend keeping a log of when you have taken each drug and what time you are supposed to take each drug. The most important ones are going to be the anti-nausea medications. You really want to stay ahead of the nausea. Once you get very nauseated, it’s very hard to manage, and then you run the risk of dehydration and malnourishment. So you really, really want to stay on top of the nausea.”

The young woman lets out a huge sigh. “Okay, I’ll see what I can do about that. Anything else I need to know?”

“Nothing comes to mind. Let’s go find the bar tender and make sure we haven’t missed anything.”

The two women go in search of the bar tender, who is just finishing up with another patron.

“So if  I understand correctly, you are wanting to get started today?”, he says.

“Uh, well, um, ah, er, I guess.” The young woman looks at her companion, who had been quietly following her around and had been taking mental notes of all of the information. His eyes were as big as saucers at the thought of beginning immediately, but he shrugs his shoulders and says, “Sure, go for it.”

And so she does.

They find her a private room for her first infusion. The bed is horribly uncomfortable, so the young woman opts to sit in the chairs. The nurse comes in and accesses her port, which is a sterile process. She puts gloves on, making sure to only touch the port accessing items once the gloves were on. The port site is cleaned with some anticeptic for 30 seconds and then the access needle is inserted. The young woman is overjoyed to discover that this is a practically pain free process. No fishing around to try and get an IV started!

Ah, finally! she thinks, Something positive in my day!

The nurse then hooks her up with a liter of saline fluid to make sure the young woman is well hydrated. After that, the first drug is set up to run for an hour. The young woman is given specific instructions to call the nurse if anything feels different. (Itchy, tired, sudden nausea, etc.) The first drug is administered without any problems and the second drug is set for an hour along with a half liter of saline fluid.

Four hours after getting started, the young woman is finished and gets ready to head home. It has been a busy day for her and she is tired, but happy that she is feeling so good. So far, the cocktail hasn’t produced any of the dreaded side effects. She knows this likely won’t last, but for now, she’ll take the good feeling.

Tomorrow will be another day.

With that, the young woman and her companion step out of the cocktail bar into the beautiful, sunny day.