Living with Cancer – A Partner’s Perspective

Shiona thought it would be interesting for me to write a guest blog so that you get to hear about things from my perspective. I am always slightly bemused when Shiona refers to me as her rockstar husband in her blogs – I don’t play any musical instruments and my promising early singing career as Joseph whilst at Junior School was subsequently curtailed by a nodule on my vocal cords … however I did still appreciate the card I received from Liz, Johnny and Clem earlier this year!

At the outset of this journey, my knowledge of melanoma was limited to basic awareness only. I recall family holidays in the 80’s when my late Dad used to pride himself on applying his factor 4 piz buin cooking oil whilst I myself had to turn to applying natural yoghurt to the top of my sadly burnt feet to try and cool them down to ease the pain. Whilst awareness of the damage that exposure to the sun can cause has improved since then, much still needs to be done, with the incidence of melanoma continuing to increase here in the UK. Melanoma patient numbers being treated at the Marsden have doubled over the past 12 months alone.

As Shiona’s melanoma has progressed, I have learnt that it is an extremely unpredictable disease and once it metastasizes (spreads from its primary site), it can spread almost anywhere – commonly to the lungs, kidneys, liver, bones and/or brain – the reasons why melanoma spreads to different organs / parts of the body is not yet fully understood.

We both consider ourselves very fortunate that Shiona is being treated at the Royal Marsden and only last week, they announced that both their Chelsea and Sutton hospitals have been awarded ‘Outstanding’ by the Care Quality Commission. A fantastic achievement and recognition for everyone involved at the hospitals and from our experience, more than fully deserved.

Not only do we live in close proximity to the hospitals, which makes our regular visits somewhat easier, we also have good relations with the melanoma team and trust them explicitly. Being a specialist cancer centre and being cared for under Professor Larkin and his team, who are at the forefront of research and clinical trials in melanoma for the treatment of advanced disease, we really couldn’t be in better hands. Having said that we are both acutely aware of how unpredictable the disease can be.

I am fortunate to have discovered that I have the ability for my mind to stay in the present; a stage 4 melanoma diagnosis has too many variables. As a consequence I’m a great believer in there being little benefit in wasting energy on things you cannot control. I am realistic and pragmatic enough to realize that I cannot control Shiona’s melanoma, however, what I can control or should I say influence (!) is my ability to support Shiona along the journey, so that has been my priority throughout.

When I say influence … I have obviously had no influence over Shiona’s impending yoga weekend in Majorca with her friend Jen!

Notwithstanding the severity of the situation, we have had a few laughs along the way …

I have been sat in hospital waiting areas before whilst a nurse has been walking around asking for “David Ramage” … it normally takes a while for me to twig that the nurse is probably looking for me!

When Shiona updates the team about the next challenge for the Shomelanoma fundraising, I am often asked, somewhat sympathetically, “Are you having to do this too?”

My favourite was probably when Shiona was told she was being discharged from her 3 weeks stay in the Marsden Chelsea last summer to “save your husband from bankruptcy”.

As many of you know I joined Shiona in abstaining from alcohol when she started her immunotherapy treatment and I completed a full year without an alcoholic drink in April this year. Many people asked whether I felt better for it … the reality was not noticeably! The real benefit for me was that I’m sure it helped keep me mentally on an even keel with so much going on.

Subsequently, the biggest thing I have noticed is the change in my drinking habits … I rarely have a drink at home now but still enjoy a glass or two when out.

My abstinence from drinking was however a source of amusement to our CNS (nurse) at the Marsden who loved to point me out to other patients (& their partners) in the waiting area telling them how I was so well behaved and always did as I was told albeit on at least one occasion, I was instructed to “have a drink David, you only live once!”

Throughout it all, Shiona has maintained a remarkable, positive attitude. Of course there have been difficult moments but Shiona has shown tremendous resilience to dust herself down and get on with her life. She is not one for negativity. I am genuinely in awe of her.

I am also acutely aware that it is Shiona who has to deal with her diagnosis and try as I might, I can never fully put myself in her position and/or see things through her eyes. For example, if I think about scans … they are obviously a stressful time but whilst Shiona has to go through the whole worry of the scans, radiologists and results and no doubt must feel like time stops still, I don’t torture myself by over-thinking things that I have no control over.

On a couple of occasions this summer, Shiona has felt that things were not right with the odd pain causing her some anxiety. In such circumstances she monitors things for a few days and if still concerned will contact the team at the Marsden for either advice or a check-up. This has led to un-scheduled scans, which fortunately have been good. My approach to such scenarios is to stay calm and be logical. I was going to say rational but that could wrongly imply that Shiona has irrational thoughts … in her situation, no thoughts and/or anxieties could ever be described as irrational. It is only natural that such anxieties lead to thoughts about self-diagnosis and/or future treatment plans, however I refuse to indulge in such conversations preferring to wait and see what the facts are and/or what her Oncologist says. When I notice that Shiona is getting anxious about things, we will often go for a long walk to talk things through and take her mind off things.

We have been proactive in educating ourselves and understanding treatment options however this is tempered by the fact that many of the treatments are new and data is still being compiled and conclusions drawn. You also learn more as time goes by.

For example, when Shiona was recommended to have immunotherapy treatment on discovery of a small brain tumour in April 2017, we were thrust into a world that we knew little about. Statistics are bandied about in relation to treatment options and a scary new language is spoken with phrases such as ‘progression free survival’ and/or ‘overall survival’.

On the recommendation of her oncologist and after a few days to consider the options, Shiona opted for the combination immunotherapy treatment of ipilmumab and nivolumab, which apparently has an overall response rate of 58%, and which was comparatively better than if she had opted for single treatment with either nivolumab (44%) or ipilimumab (19%). These statistics are abstracted from the CheckMate 067 trial.

What I have subsequently learnt and now better understand is that the statistics quoted above were derived from clinical trials, and for which all trials have strict criteria to qualify to join in the first place, so in effect the results (& statistics) are to some extent, sanitized. For example, patients could not qualify for this particular trial if they had received prior treatment for their melanoma and/or in the case of patients like Shiona, melanoma that had spread to the brain were excluded from the trial. The sequence in which a patient receives treatment for their melanoma also affects the effectiveness of subsequent treatments.

Back to the statistics, which suggested that some 39% of patients on the combination treatment suffered treatment related adverse effects leading to discontinuation of treatment. With the onset of her autoimmune hepatitis, Shiona joined the 39% club! Whilst in hospital we were advised that having such an adverse effect was considered a positive in terms of the overall response rate … increasing the likely response rate to the immunotherapy to c. 70%.

As you can probably tell, you can become inundated with statistics and in the end forget the context in which they apply. Statistics by their very nature are subjective and whilst medically and/or clinically of interest, for a patient &/or their families, I think you are better off not getting too obsessed about them.

At the time, both Shiona and I were being filmed for our story to potentially be included in a Channel 4 Documentary … with Shiona still in hospital, the producer came to interview me at home late one evening and said to me the statistics were looking good to which I answered along the lines of “It depends upon how you view statistics … for example, if I had ten members of my family and/or friends in a room, 70% means that 3 of them would not respond to treatment.” Statistics in the context of a serious illness and/or human life somehow seems inappropriate.

Recent developments in the treatment of melanoma (and many other forms of cancer) have recognized that the one size fits all approach doesn’t work. As Professor Larkin often remarks … “It’s all about the biology and every patient is different” and this is leading to more personalized treatment and care for patients.

I often say that the subject area is fascinating but I’d rather we were not exposed to it. Some 5-10 years ago, a patient with Stage 4 melanoma would have typically survived for between 6-9 months. Due to advances in the understanding and treatment of melanoma, this is not the case for a number of patients and the team at the Marsden are now able to study and monitor Stage 4 patients to gain further understanding of the disease and enhance/tailor individual treatments.

Much of the current research surrounds trying to better understand immunotherapy and its effects. Immunotherapy treatment harnesses the body’s natural strength to fight cancer, empowering the immune system to conquer more types of cancer and save more lives.

It is a complex area especially when you consider that all patients will be unique in terms of:

• pre-existing immune system/characteristics
• tumour type / genetics
• organ involvement
• micro biome

By studying and monitoring patients throughout their treatment, they hope to be able to develop a panel of biomarkers that could identify patients at risk of immunotherapy toxicity before it occurs and be able to prevent it from occurring.

With immunotherapy being successful in the treatment of melanoma, it is now being applied to many other forms of cancer as an alternative to more traditional chemotherapy and radiotherapy treatments. Therefore the funds that we are raising through Shomelanoma will not only benefit further research in melanoma but also enhance the knowledge that can be applied to the treatment of many other forms of cancer.

Sunday 14^th October 2018 will be our 13^th wedding anniversary; rather than taking Shiona away, I will be undertaking my next challenge in the Shomelanoma fundraising, by running the Royal Parks Half Marathon again. Unlike last year, I will not have the novelty of achieving a personal best for each km I run. Joining me again will be one of my mates, Fraser Brock … we met each other back in July 1995 whilst both working together as graduates at Faithful & Gould in London … and when I asked him earlier this year if he fancied running again he responded in typical fashion “yes, delighted to help you guys” … what a top man!! If you would like to sponsor us, the link is below:

https://www.justgiving.com/fundraising/shomelanomarphm2018

As always, your support is greatly appreciated.