Friday, 6 November 2015

Looking for advice to get cocktail started for my mom with recurrent GBM

Hi everyone. First off thank you all for your thoughts, information and advice. You guys keep hope alive. I'm here to try and figure out what else we (my sister, brother and I) could be doing for my mom.

I'm hesitant to make this post because I do not know the make up of my moms tumor(s) however, I do know that we need to do more for her now, before it's too late. I can try to get the pathology report from UCLA and post more on that when I do. I couldn't tell you what methylated or IDH-mutated mean but I do know my moms situation seems to be getting worse.

Without a pathology report I will try to give a brief backstory so you get a picture of what's going on here. I hope this is the right place for this and I will try to keep it as brief as possible. 

Jan 2008: Ended up scraping off side mirror on the car and realized peripheral vision was gone. Eyes checked, no problem. MRI showed brain tumor. Surgery Jan 11, 2008 at UCLA with Dr. Daniel Kelly (Now at St. Johns Santa Monica) with complete (or as close to complete) resection as possible. Diagnosed at age 51 with Stage 4 GBM and received all the scary statistics about her being lucky to make it a year. She bounced right back from the surgery as if nothing every happened. Up and about within a day or so back to her normal routine. 2 years of Temedor 5 days out of the month and around 60 rounds of radiation later, life was good and stable MRI's became the norm although every MRI was never any less scary awaiting results. We thought perhaps she was in the clear. Her vision also came back :)

My dad, her caretaker passed away unexpectedly in June 2012. I only bring this up because I believe stress may have played a big factor in the next update.

Jan 2013 MRI was clear. In fact, we celebrated 5 years remission. She then missed a scan in Feb '13 due to an insurance mix up, and finally had a scan in March '13 which showed a pea sized recurrence in the original tumor location. Prior to this she was doing so well that the doctor was going to allow her to get MRI scans less often. She was off Temodar for 3 years before this recurrence. So she went right back to several more radiation treatments and another year of Temodar (one week each month) and MRI scans monthly. Her scans showed the tumor to be shrunken and the site to be stable with no new growth.  

March 2015 MRI showed new but small growth in a new location close to the original tumor site but a bit deeper in. Oncologist tried new chemo, CCNU and were to follow up in one month. We were told she has had her lifetime max of radiation so that was out. Next scan showed the Tumor almost tripled in size. Options were try another chemo, surgery if the Tumor Board deemed it appropriate and a clinical trial going on at UCLA, Toca 511 where they inject a virus into the tumor cavity directly after resection. The remaining virus was to infuse itself in remaining cancer cells later to be killed by pills she took. We got word that surgery was an option and were able to enroll in the clinical trial. Surgery was performed at UCLA on May 14th, 2015 with Dr. Linda Liau. MRI before surgery showed more growth. Surgery was as successful as possible and Dr. Liau was somewhat surprised as she said so much of the tumor she pulled out was "dead." My mom had more trouble recovering from this operation. Memory loss for a few days, permanent vision loss and basically a big blow to her spirits because she didn't bounce back. She was still very much interested in recovery and getting stronger. As part of the study every 6 weeks she got an MRI and she took pills that were I guess anti-fungal in nature however, they were to head to the implanted virus, that had infused itself in remaining tumor cells and form a chemotherapy to destroy left over cancer cells. My mom began recovering, walking more normal and getting back to normal life minus navigating differently due to a permanent visual field cut from surgery. 

Things were looking great until October 8th 2015 when a scan showed some "changes." We were told it was nothing to be concerned of yet and that they weren't sure what was going on actually. Not the most comforting news. We were to follow up in a month or sooner if things got worse. My mom began to walk more poorly (always veering to the left) and crashing into walls, her memory became worse, most scary she just started acting odd like throwing away her fork and knife and looking for things around the house that were in completely different areas like the telephone for instance. She is aware that she is getting worse and is depressed and spends most of her awake hours crying. (We saw my grandma die from a metastatic brain tumor from lung cancer and it was not pretty) We tried to get my mom in for a scan, this time they wanted to do a DOPA-PET scan, which we were told might be the future of monitoring brain tumors. Insurance went back and forth for around 2 weeks on approving and denying and then approving only to have UCLA "run out of the DOPA injection dye."

This brings us to now. Nov 3, 2015 new scan shows growth and not just one area. The larger area is the one that appears to be messing up her walking. Our oncologist stated there looked to be a lot of inflammation around the area along with necrosis. He states that surgery on that area is probably not an option and may do more damage than good. We will seek a second opinion of course.

Nov 3, 2015 she had an Avastin infusion and was put back on Temodar 5x per mo. The Toca 511 trial has been put on hold. Her spirits are destroyed.

Throughout the course of this she has taken many supplements (mostly the first few years) Lots of different mushroom powders and something called Ave, some type of wheat germ for boosting her immune system. March of this year she started the CBD/THC Cannabis oil off and on. She can't stand feeling "high."

As of now she's taking:
Temodar 
Avastin 
Keppra 750mg 2x daily 
AHCC mushroom supplements. 

She was taking Wellbutrin but I'm not sure how consistent she is. 

It's probably too early to tell if the new drugs have done anything however, prior to them we were seeing a steady decline. Since getting them a few days ago she at least doesn't appear to be any worse symptom wise. 

We were told if she responds to treatment, great. If not she could be gone in a few months. I'm hoping this could at least buy us some time to get her back on the right track. 

So, what would you guys recommend we add in immediately along with her Avastin and Temodar? 


I'm sorry this is long and thank you. If someone would like to email or talk on the phone I'm sure that could be arranged. 



32 comments:

  1. Hi Andrew

    Welcome to our group. Glad you found us and sorry you need to be here. If you have not looked at Stevens Astrocytomaoptions.com yet that is a good place to start. I would also suggest you look at Ben Williams recommendations for repurposed drugs and supplements. I do not have that with me now, but will post it for you later tonight if someone else has not done so before then. The specifics of your mothers tumor are important and will likely impact recommendations. The cocktail approach utilized by those on this blog vary from person to person, with many similarities and some differences. In essence we are all running individual clinical trials with the components we have selected for our cocktails. You can get a look at what others are doing by searching this blog.

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    1. Thanks so much for your response :) I will start with your information and see where it takes me. I'll be on the phone ASAP with UCLA to see if I can get a copy of that pathology report sent my way so there's a better understanding of what exactly we are dealing with. I truly appreciate your advice and am ready to have any supplements overnighted to us here. I believe we also may have access to prescription medications which it looks like some of what most cocktails consist of.

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  2. Yes, please do get a copy of the pathology report. I'd like to see it (see my email address on the User Information page, above).

    Assuming she was taking Wellbutrin for depression, you could try fluoxetine (Prozac) instead, which may be a chemosensitizer and have anti-tumor effects of its own (this was shown in mouse studies).

    I'd rather not make too many specific suggestions until I can have a look at the UCLA pathology report, which you will hopefully have by Monday. Also ask if there is a "Foundation" report. The oncologist will know what that means. It is basically a comprehensive genetic test done by Foundation Medicine.

    http://foundationone.com/

    As Mike said, glad you found us but sorry you have to be here.

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  3. Andrew

    Appears I can't post Ben Williams documents as his document for "Ingredients for a Cocktail Clinical Trial is 6 pages long. You can send me an email at pacm@mtaonline.net and I will send it to you along with his supplement recommendations. Steven, I am certain you have these two documents from Ben, can you post them in the brain tumor library? It would be helpful for people as an introduction to cocktails.

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    1. I'm not sure if I have the same version you have, but yes I can put a copy of that into the Library.

      I'll put his supplements list in there too for reference, and you can also find that by clicking on the "ben_williams" label from the labels list.

      Perhaps I'll make a cocktails folder, and add the CUSP9 documents too.

      Ben, Rich, myself and others are part of a group designing a protocol for a multi-agent clinical trial for newly diagnosed GBM. This protocol is significantly different from Ben's document which was our starting point. It includes many of the drugs we discuss here on this blog.

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    2. An updated cocktail proposal which is the fruit of over a year of work may be found in the Brain Tumor Library, Cocktails folder, along with Ben's original proposal and the two CUSP9 documents.

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    3. Interesting Steven. I am interested in some of the thinking behind this cocktail. But for now a few questions if you don't mind.

      Some of the OTC supplements that Ben has been supportive of are absent. As I prepare a maintenance cocktail after Jeremy finishes his 12th round of TMZ this month I have been reevaluating many of the supplements. Some seem questionable due to inadequate support for their use, at least in my opinion. Were most of the supplements left off this protocol due to lack of evidence supporting their use, an attempt to reduce the number of compounds being used so the cocktail is more likely to be tried clinically, or some other reason? One that seems important is milk thistle for its hepatoprotctive benefits given the drugs the liver has to process. But I realize only so much can be added. Anyway, your thoughts on supplements are much appreciated.

      Why the lack of DCA? I have come to believe when dealing with a highly adaptive tumor, two approaches that must be a part of our approach is to undermine metabolism and manipulate the immune system so it can recognize a tumor and go after it. The immune component is tricky and I wonder just how well PSK and other mushrooms are because we can have a healthy immune system, but if the tumor is not recognized, the immune system will not go after it. I do know there are numerous cases reported where polysaccharide containing immune stimulants appear to be beneficial for a variety of cancers, and I have included it in Jeremys cocktail, but I wonder just how beneficial it really is. Now back to metabolism. DCA seems to be our best approach at undermining cancer metabolism. There is of course a small human trial with DCA as well. Something we don’t have for much of the cocktail components. Was it left off the list due to is legal status as a “drug” and other regulatory issues? Thoughts please?

      I am not familiar with Telmisartan and Ramelteon. Will you be adding any information on your web site regarding these?

      Thanks for your thoughts Steven.

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    4. I will address these questions in more detail by email. But quite simply, approved pharmaceuticals are much easier to get into trial than supplements. DCA is in the same boat as supplements, not being an approved pharmaceutical.

      Telmisartan is an angiotensin-II receptor blocker. There is retrospective clinical evidence on this class of drug for GBM, which you'll find in the brain tumor Library.

      Ramelteon and agomelatine are melatonin receptor agonists, with improved PK/PD characeteristics in comparison with melatonin itself, according to Richard Kast. Kast has published a paper on these two drugs recently, which I'll add to the cocktail folder.

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4444449/

      Yes, thanks for reminding me, I should summarize the evidence for angiotensin-II receptor blockers on the website.

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    5. I was able to take a look! Thanks, Stephen for letting us know. Definitely some unfamiliar items on the list I'll have to research. Perhaps I could be included on Michael's email or a separate email with a "brief" run down of some of the new components?

      Side note, after a few days of my mom taking the Metformin she reports it's KILLING her stomach, even when taken with a meal. I've read others have had similar experiences. I've also read that others report this less with the "extended release" version. Is the extended release version beneficial to the cocktail? Same medication so I would think so, but I figure I should ask :)

      DCA is also on the way!

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    6. What dose of metformin is she on? Tolerability to metformin increases over time, so I would recommend lowering the dose for awhile until she reaches a dose that is tolerated. In my experimentation with metformin I started at 500 mg once daily, then increased to 500mg twice daily after a few days and stayed there for awhile. But some might need to start even lower, 250 mg daily or twice daily. I would set a target dose of around 1500 mg per day, but it might take weeks or months to get there depending on the person.

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    7. Right now she's on 500mg 2x daily with food. Good advice! I'll see if she can tolerate the morning dose and get her used to it, then increase :) If not I'll request a new prescription for 250mg.

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    8. Andrew,

      When we started, I was using a pill cutter to cut the 500mg pills in half. We did 250mg twice daily (about 2/3 the way through the meal) for about a week and then increased to 500mg twice daily. I hope this makes it more tolerable.

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    9. Hi Kendall,

      Thanks for this idea! Thought never even occurred to me :) Will definitely give this a try.

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  4. Andrew, as Mike suggested, if you want to get a feel for what other people are doing, click on the "cocktail-profiles" label from the list of labels on the right side panel. There are at least a couple pages worth of cocktails that people have posted.

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  5. Hi Stephen and Michael, I was able to obtain a copy of the pathology reports today from UCLA pertaining to surgeries from 2008 and 2015. Stephen I'll email them to you as soon as I get to work and can use the scanner to upload them. I was also able to get the Foundation Report. I'll also send that to you. One thing I did notice was that for the Foundation Report it looks like they used a sample of tumor from 2008 to test in 2015. I would have thought they would have had a sample from the 2015 surgery sent to test. What I can say right without really knowing how to read a pathology report is that it looks like the tumor was MGMT Methylated but did not have the IDH1 mutation which I guess can be associated with responding better to treatment :(

    On my way home, (we live about 2 hours from our doctors depending on LA traffic) I dropped off the 2 most recent scans (October and November) to my moms first neuro surgeon who we've kept in contact with over the years who now works at St. John's in Santa Monica for a second opinion. (He also removed a pituitary tumor from my brain over 10 years ago!) Before I got home his oncologist called me and spoke about getting my mom down there to talk about additional treatments that could be combined with Avastin and perhaps Temodar. He mentioned some immunotherapy called Nivolumab that I guess is used to treat malenoma but has had some success with gliomas? He also said by looking at the Foundation Report there is something else she could be on. That part went over my head of course. Then he said he would definitely like to order a Foundation Report from the tumor sample from May 2015. Also said that he wanted an MRI of her spine and maybe a spinal tap to see if the cancer has reached her spinal fluid.

    My mom seems to be doing ok since I last wrote with symptoms staying around the same. She has her moments where she has episodes of confusion and then mental clarity for most of the day. The Temodar really wiped her out this time around by day 4 and 5 she was pretty beat.

    Thanks again to you guys for responding and providing some knowledge. If there's one thing I'm learning it's that you can't let up on this thing for a minute. The moment you do it gains ground on you.

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    1. Thanks Andrew. I will have more to say after I look at the reports. But definitely if insurance will cover another Foundation test on the new tumor sample, would be great to have that done too.

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  6. Hi Stephen. I hope you received the pathology reports and Foundation Report I sent you yesterday :)

    We just got home from meeting with the other oncologist and I'd say it was a pretty positive meeting. He's pretty open to different ideas. He prescribed Metformin 500mg to be taken 2x daily. He's also pretty set on trying to get her into some immunotherapy trials if we choose to work with him.

    From the Foundation Report he states my mom should be on a drug called Trametinib, some type of tumor growth inhibitor that I guess is compatable with my moms tumor. Of course that's from the sample from 2008. He is ordering another report from the 2015 surgery.

    He mentioned some clinics in Tijuana that are able to do some pretty amazing things for the immune system without being regulated by American standards. (the FDA I assume) They also cost a great deal of money.

    Then he scared us a bit by requesting MRI's of the spine as he wants to check to see if the tumor has invaded the spinal column and therefore the spinal fluid.

    Symptoms seem stable at this time and she's no longer feeling sick from Temodar. Guess that's all we can hope for at this point.

    Thank you very much again.

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  7. I did receive the Foundation report, thanks for sending.

    It seems strange that the Foundation testing was done on the original tumor sample from 2008, rather than on the May 2015 sample. It's not a very safe assumption that the tumor would be showing the same genetic alterations 7 years later, especially with all the intervening therapy in between the two surgeries. It also seems strange to suggest trametinib based on the KRAS mutation from a 7-year old tumor sample. Best to wait to get the new results. You need to treat the current tumor in its current manifestation, not the tumor from 7 years ago.

    Will she be receiving repeated Avastin injections. If so, chloroquine and DCA would be worth considering. These drugs combined with Avastin have worked well in mouse models. Metformin is also a good start. See the pages at the top of this blog for information on drug sourcing, dosing, toxicity etc.

    Definitely let us know when the next FoundationOne results come in.

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    1. Hi Stephen,

      Thank you for taking a look at the Foundation report and your response :) I'm glad I wasn't alone in thinking it was strange to assume the tumor from 7 + years ago is the same that we are dealing with today. I'll feel much better once we have the new report and can determine if we need to modify or change treatment. I'll be sure to send that over to you.

      My mom will be continuing the Avastin and Temodar. Looks like Avastin will be every 2 weeks or so and her next infusion will be 11/17. Therefore, I am trying to order the chloroquine and DCA. The link from this blog led me to a Canadian pharmacy where it looks like I can purchase the chloroquine however the link for the DCA looks like a dead end at this time. Do you know where I might be able to order the DCA? Should I make a new post asking others where they have been able to order some? After reading your material I would agree, we should get her on these in combination with Avastin as the mouse model results show some promise.

      I can't thank you enough.

      Andrew

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  8. Thanks for letting me know about the dead DCA link. I just fixed it so it should be working now. Pharma-dca is the supplier most people here are using for DCA. You can also purchase a digital scale to measure out the DCA from this website, as well as thiamine (to reduce side-effects). Medicor Cancer Centre in Toronto uses benfotiamine rather than thiamine. Some people use both.

    It's likely that Avastin contributes to tumor hypoxia by cutting off the blood supply. Autophagy is one survival mechanism for cells under hypoxia, so it's thought that the synergy observed between chlorquine and Avastin in the mouse studies is due to chloroquine's inhibition of autophagy.

    Hopefully the new Foundation testing will come back quickly. Keep us posted.

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  9. Andrew

    pharma-dca.com is a DCA source many are using.

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  10. Thank you both for pointing the way here. Time for me to piece this all together now and I'm feeling confident thanks to you guys and the Astrocytoma Options website. I'm sure I'll have more questions regarding dosing, scheduling and how to incorporate new drugs into the mix. I'm assuming one wouldn't just start them all the same day however it sounds like they should be combined with Avastin ASAP.

    Once we get the DCA and chloroquine I'll check back in. As soon as the Foundation report gets to me I'll send it over :)

    Once we get the DCA and chloroquine her meds will look something like:

    Avastin infusions every two weeks
    Temodar 5x per month
    Keppra 750mg 2x daily
    Metformin 500mg 2x daily
    Wellbutrin (trying to convince her to give Prozac a try)
    Chloroquine 250mg 1x daily (not sure if correct)
    DCA + thiamine (dosing will be interesting, math was never my strong point)

    Wishlist: curcumin & melatonin.

    Please feel free to let me know if there is anything else I should or should not be doing.

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    1. That's right you wouldn't start everything all at once. Give a day or two to check for any new adverse reactions.

      That is the correct dose for chloroquine phosphate (250 mg chloroquine phosphate equals ~150 mg chloroquine base).

      I can help you with figuring out the DCA dosing once it comes. All I need to know is how much she weighs and how aggressive you want to be with the dosing.

      Melatonin is cheap and easy to find, at least where I live. I take 10 mg before bed every night myself, though the 20 mg dose has been more commonly used in cancer trials.

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  11. Quick question, the site for purchasing the DCA offers sodium or potassium DCA. Is there a preference? I guess the potassium is a "limited" batch. Not sure what the difference is.

    Thank you!

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  12. All research including the 5 patient trail out of university of Toronto used sodium DCA. Stick with that.

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    1. It was actually University of Alberta, but same country :)

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  13. So close. At least I was on the same continent. Actually I knew that. Sometimes I can't be held responsible for what comes out of my mouth or off my keyboard. :) Its 5 degrees (f) here. Thats my excuse and I'm sticking with it.

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  14. Thanks guys! That's pretty chilly. It's 75 degrees (f) out here in Southern CA today.

    The Canadian site to purchase the chloroquine now requests a prescription. Maybe I can ask her doctor to just prescribe it.

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  15. Hi Andrew,

    My daughter is part of the AdV-tk (adenoviral vector trial). One of the things that her NO told me to expect was significant edema as the virus attaches to the remaining tumor and the anti-virals combine with the immune system to fight the virus/tumor -- which was evident on her MRI 12 weeks after injection. She was on Dexamethasone for the edema. I also started giving her 2 High Absorption CURCUMIN TURMERIC Extract (by InnovixLabs) Time Release Tablets at each meal after that MRI. Her doctors were impressed at the significant reduction of edema on the following MRI.

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  16. Hello everyone - I've been reading these posts with much interest. My wife and I just had our first child after years of trying on November 4th but then a few days later, on the 8th, she had her first ever seizure. You already know the story - GBM. We just got out of the hospital today; she's only been with the kid four days.

    Stephen, may I send you our Foundation report for your input? We just started chemo and radiation last Tuesday and I'm looking for every advantage we possibly can.

    And thank you for creating this amazing site; it's a godsend for people like me who suddenly find themselves thrust into this crazy and sad world of brain tumors.

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  17. As we say here, glad you found us, but so sorry you had to. Sure I'll have a look at the Foundation report. My email address is on the User Information page.

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