In a perfect world

In a perfect world, the weather would be in the 70's and sunny year-round.
In the real world, we get to experience the change in seasons, which is okay too.

In a perfect world, I would never have had to experience cancer.
In the real world, I have learned a lot about myself and others and have met some extraordinary people. 

In a perfect world, the women who have children they don't want or have abortions to kill their babies, would just give their children up for adoption.
In the real world, Mark and I get to help some of those babies.  And that is amazing.

In a perfect world, Mark and I would have a seven-year-old boy, a six-year-old child and a two-year-old child.
In the real world, I got to experience pregnancy, which is something many women with PCOS don't have a chance to feel.  And we have memories.  And I have my life thanks to baby Angel.

In a perfect world, everyone would have a place to live and a person who loves them.
In the real world, I have a roof over my head and people who love me and I love the people in my life.  In the real world, we try to show others that they belong and they are loved.

In a perfect world, there would be no need for foster care, for humans or animals.
In the real world, we have been able to meet some of the most awesome humans and animals!  And the Three Stooges would only be one.  And how boring would life be for us and Barney?

In a perfect world, there would be a happily ever after.
In the real world, until we take our last breath, there is always a chance for a happily ever after.  

DREAM BIG

Today was a good day

Mark and I met with our social worker and an 18 year old girl today who needs respite a couple times this summer.  We liked her.  She'll come here on Friday and leave on Sunday this week.  She's going to be celebrating our 10th wedding anniversary with us.  Not a real romantic evening, but she chose going out to dinner to a Chinese buffet.  So that's where we're going!

I met with my psychiatrist today as well.  He seems to think that I'm relatively normal, surprisingly!  Still taking my Trazodone in the evenings and that's helping with sleep and anxiety.  We talked politics mostly.

Today and tomorrow the woman running our Tastefully Simple party is offering a "match that sale" deal.  Whoever spends the most in the next 48 hours will be able to purchase whatever they want, for whoever they want, at the same amount as they spent.  Great deal!

TASTEFULLY SIMPLE

Happy Father's Day

As I watched Mark with our little three-year-old visitor this weekend, I realized what a great Dad he is, could be, should be.  It makes me sad that I couldn't give him a child.  There's a reason we're doing this fundraiser to help us adopt, and if you know Mark at all, you know he would make and HAS made an amazing Father.

Happy Father's Day to both my Father and Mark's Father, both gone now but remembered.  Tom, Mark's Dad was a great Dad to his kids and to me.  I miss him every day.  If wishes could come true, he'd be back here with us.

Here are the two fundraisers we are doing to help us adopt.  If not for me, please consider giving and/or ordering....for Mark, on Father's Day.  Every little bit DOES help.  Please help.

GOFUNDME

Tastefully Simple

Happy National Cancer Survivor's Day

Today is National Cancer Survivor's Day. Thanks for informing me, Noell Erwin Healy!

I have survived bladder cancer.

2010 pregnant at 42. Had ultrasound, found tumors in bladder, lost baby, stage (depending upon who you asked) 2 or 3 muscle invasive bladder cancer. Chemo of Gemzar and Cisplatin winter 2010/2011, bladder removal March 2011.

To make a long story even longer!

My hope is that there comes a day when there are more survivors than not.  For now, I unfortunately know of more people who have not survived cancer.  A little bit uneasy celebrating my survival when so many have not.

What IS an Indiana Pouch?

I have an Indiana Pouch.  I had my bladder removed back in 2011 due to a large amount of cancerous tumors in my bladder.  Prior to the removal, I had a few months of chemotherapy, to shrink the tumors and make for an easier removal.  I was supposed to have surgery via the Da Vinci method, which is a robotic surgery.  I had too much scar tissue from my previous emergency appendectomy and they ended up doing open surgery, with a scar from the staples going from my chest area to below my belly button.  But in the end, there was zero cancer found in pathology.

Recovery from the surgery was crazy long, with setbacks galore.  I still somehow end up in the hospital a time or two every year, mostly from abscesses and hematomas near my right kidney.  I am hoping to have surgery to remove my basketball sized hernia in the near future.  Hopeful and scared.  The initial 12 hour surgery almost did me in.  It was horrific.  I wanted to die.

Here is the best description I could find of the Indiana Pouch.  Like they say, I now catheterize through my belly button stoma, maybe 6 times a day and once through the night.  It's embarrassing sometimes, especially when I have to go to the bathroom in a public bathroom and my feet face the wrong way for a girl!  But, again, I am alive and currently cancer free.

Indiana pouch

From Wikipedia( View original Wikipedia Article )Last modified on 24 January 2013 at 14:31.

An Indiana pouch is a surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed as a result of bladder cancer, pelvic exenteration, bladder exstrophy or who are not continent due to a congenital, neurogenic bladder. This particular urinary diversion results in a continent reservoir that the patient must catheterize to empty urine. This concept and technique was developed by Drs. Mike Mitchell, Randall Rowland, and Richard Bihrle at Indiana University.^[1]

Description

With this type of surgery, a reservoir, or pouch, is created out of approximately two feet of the ascending colon and a portion of the ileum (a part of the small intestine). The ureters are surgically removed from the bladder and repositioned to drain into this new pouch. The end of the segment of small intestine is brought out through a small opening in the abdominal wall called a stoma. Since a segment including the large and small intestines is utilized, also included in this new system is the ileal-cecal valve. This is a one-way valve located between the small and large intestines. This valve normally prevents the passage of bacteria and digested matter from re-entering the small intestine. Originally, it was thought that removing the ileal-cecal valve from the digestive tract would likely result in diarrhea, but this has not shown to be the case. After a period of several weeks, the body adjusts to the absence of this valve (from the digestive tract) by absorbing more liquids and nutrients. Importantly, this valve, in its new capacity, will now effectively prevent the escape of urine from the stoma.

Recovery and function

Patients can usually expect a hospital stay of between seven and ten days for this surgery. The abdominal incision for this surgery may be up to eight inches in length and is typically closed with staples on the outside and several layers of dissolvable stitches on the inside. After surgery, patients will have three drainage tubes place while tissues heal: one through the newly-created stoma, one through another temporary opening in the abdominal wall into the pouch, and an SP tube (to drain non-specific post-surgical abdominal fluid). In the hospital, the SP tube and external staples will be removed, after several days. The remaining two tubes will each be connected to collection bags worn on each leg and the patient is usually sent home like this. After sufficient healing, and another doctor's visit, the tube will be removed from the stoma. The patient will now begin to catheterize the pouch every two hours. Since one other tube will still be in place, patients can still sleep through the night, since a larger collection bag is attached to that tube at night time. After approximately one month, patients will return to the hospital for a special x-ray. Dye will be instilled into the pouch to verify that there is no leakage of urine. If there is no leakage, this last tube will be removed. Emptying time now may be increased to 3 hours, however, now the patient will need to wake up during the night (every 3 hours) to empty the pouch. Over time, emptying time can increased up to 4–6 hours. The pouch will continue to expand and will reach its final size at approximately six months. The pouch will then hold up to 1,200 cubic centimeters (cc). Each day, the pouch will need to be irrigated with 60 cc of sterile water. This removes mucus, salts, and bacteria. If consumption of liquids is reduced in the evening, patients should be able to sleep through the night after approximately six months.

Advantages of the procedure

In contrast to other urinary diversion techniques, such as the Ileal conduit urinary diversion, the Indiana pouch has the advantage of not using an external pouch adhered to the abdomen to store urine. This can result in a better body image and broader clothing options. Also, there will not be the worry of an external appliance coming loose and leaking. Additionally, the cost of urostomy appliances can be significant, and is usually not covered in full by most health insurance plans. Nor will there be the need to monitor how many appliances are left or ordering more and waiting for them to be shipped.

Treatment

Indiana pouch surgery can be done in very young patients, as long as they understand how to catheterize the pouch and can empty the pouch on a schedule. Indiana pouch surgery also has been successful in patients of advanced ages, also as long as they are able to empty and irrigate the pouch on a schedule. Some patients, after having had an ileal conduit, requiring an external appliance, have opted to have the Indiana pouch, as elective surgery. Such a surgery is usually recommended, if possible, since it has been documented that the Indiana pouch may reduce the possibility of kidney damage because the ureters are repositioned lower in the abdomen. This positioning reduces the possible back-flow of urine to the kidneys. After having an Indiana pouch surgery, patients may choose to wear a medical alert medallion indicating they have an Indiana pouch.

I survived a weekend without Mark!

Not by choice.

My doctor wouldn't allow me to travel over 30 minutes in a vehicle, and it is four hours from our home to Mark's Mom's home.  And we had no one to watch the Three Stooges.

I learned just how much Mark does around here, because I had to do most of it while he was gone.  He did come home to garbage that had to be emptied (I cannot lift) and laundry that had to be done (I cannot go down the steps into the laundry room).  But just taking care of the Three Stooges is WORK!  Feeding all three, two different meals, plus medicine for Mrs.  And walking them.  I got a workout this weekend!!

So glad he's home, even if he didn't take care of just about everything here at home.  I missed him.

His Mom is selling the family house and moving, and so Mark brought back a van FULL of things....a cooler chest full of food, a couple bags of boxed and canned food.  Food from the graduation party yesterday, salads, steaks, cake, candy.  All of his Dad's ladders and tools.  And a nice little table that Mark's Grandfather made for his daughter (Mark's Mom) years ago that fits perfectly into our nursery.

I'm sad that I won't get to see the house for one last time, as she is moving next month and I still won't be able to travel.  Honestly, it's been very tough going into the house since Tom (Mark's Dad) passed away in July of 2011.  I see him there, remote in hand, laying on the couch, when you first enter the house.  Still miss him a lot.  He was the Dad I never had.

For now, I have four UP Pasties in the oven for Mark.  I'll eat the inside but not the crust.

Our old house

This is the house we lived in when we were in the car accident. We had to stand across the street to wait for the school bus. There was a curve right before our house. That is where the car slid on black ice and pushed me across the street, and landed on top of my two sisters. My little sister Kathy Jo had every bone in her body broken and didn't survive.

I have heard through the years that the house is now "haunted". 
http://www.vhscommunityhistory.org/pages/projects/chester_andover/pages/simonsville%20.html

Do NOT like being alone

Mark has gone to Gwinn, MI for the weekend.  Our niece is graduating from high school and they have individual graduation parties in the Upper Peninsula...for every graduating child apparently.  When I was in school, our class had one BIG graduation party for all of us....band, kegs, food, fun.  So Miranda is graduating, and her party is today.

I don't think that I've ever spent two whole days and nights alone in this house.  The Three Stooges are here, creating havoc for me because they miss their human Dad.  Yesterday they all spent hours in the kitchen, staring at the door to our attached garage, whining and crying.  Today, Mrs. pooped on the kitchen floor and won't eat, and Mister Petey Picard will not stop crying.

Despite the whining and crying, the house is so quiet without Mark here.  Odd really, because he's not really a loud person and he doesn't talk much.  Maybe I'm just imagining because I'm missing him?  We've had days apart before, but it's usually been when I'm in the hospital.  Almost two weeks so far this year, and more to come when I have my hernia surgery.  But Mark has promised to try to stay in my room in Milwaukee for that.  Or at least nearby.

When I was first separated from the bad Mark ex-husband, I LOVED being alone!  I had a tiny little one-bedroom apartment and had only myself to take care of.  It was so nice after 12 years of being yelled at, hit, shoved, ignored and given lists of my "chores" to do on a daily basis.  But now that I'm in a good marriage with the good Mark, I don't like it when he's gone!

He's coming back tomorrow afternoon, so less than a day to go, thank goodness!

Today is a special day

Today is the 12th anniversary of when Mark and I first met.  I wrote up a little story about it.  I knew from first sight that I would marry him some day.  On June 21, 2003, I did just that!  Mark and I met online, he saw my profile at "Love @ AOL" and responded!

He had emailed me and we'd been talking for a few weeks. We decided to meet in the middle between our homes in Morrisville, VT and Milton, VT. So we met in Jeffersonville. Just me, and Mark, and my over-sized Bull Mastiff and Rottweiler mix puppy, Bubba. He brought me flowers and a box of treats for Bubba. So, Bubba was hooked, love at first sight. We went for a drive over the Notch. Didn't talk much, as Mark is not a talker. But by the end of the drive, he asked me out again. And before we said goodnight, Mark asked permission to kiss me. And then he asked "tongue or no tongue". I knew that night, when I saw him in his nice black Levis in his beautiful Black Dodge Dakota Sport truck, that we would be married some day.

We are in the middle of fostering and having a fundraiser in the hopes of adopting.  It can be quite expensive, which makes me sad when there are so many children who need a good home.  We're considering a special needs adoption, an older child, which would be virtually free through the state.  The waiting just stinks!!



And finally, what would a Mindi blog post be without some sort of sales pitch?  My friend is currently having a Tastefully Simple party for our benefit.  Please take a look, share the link, invite friends.  Thank you!

Mindi and Mark are doing fundraisers to help raise funds so they can adopt a child. Mindi's story is remarkable and her's to share. She is a fighter and has a heart of gold. Mindi and Mark deserve to see their dream come true.

Tastefully Simple offers a wide selection of convenient, easy-to-prepare foods designed to help people spend less time in the kitchen and more time enjoying the rest of their lives. Please visit my website at www.tastefullysimple.com/web/kdehartto see the spring/summer products and catalog. Place your order there as well, please make sure you search for Mindi Piasecki in the hostess search at check out so she will get credit. 

The party will be open until June 30. I will be donating my full commission (30%) at the end of the party to Mindi and Mark to help make this dream come true! Please feel free to contact me with any questions! Happy Shopping!

https://www.tastefullysimple.com/secure/pomm/SpecialInvitation.aspx?pxid=3421410&key=3c987021-49eb-4e81-8f8e-06fac5441f66

Desiderata

Desiderata

Go placidly amid the noise and haste, and remember what peace there may be in silence.
As far as possible without surrender be on good terms with all persons.
Speak your truth quietly and clearly; and listen to others, even the dull and ignorant; they too have their story.
Avoid loud and aggressive persons, they are vexations to the spirit.
If you compare yourself with others, you may become vain and bitter;
for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans.
Keep interested in your career, however humble; it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs; for the world is full of trickery.
But let this not blind you to what virtue there is; many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be critical about love; for in the face of all aridity and disenchantment it is as perennial as the grass.

Take kindly the counsel of the years, gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with imaginings.
Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself.

You are a child of the universe, no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you, no doubt the universe is unfolding as it should.

Therefore be at peace with God, whatever you conceive Him to be,
and whatever your labors and aspirations, in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery and broken dreams, it is still a beautiful world. Be careful. Strive to be happy.

© Max Ehrmann 1927

Things to remember

You don't know what another person is going through.  EVERYONE has a battle in their life to fight.  Be understanding and have some empathy.

While I was in the hospital, I met, and cried with, a mother who had been pregnant with twins and lost one of her sons while in labor.  Today, I met another foster Mom who had lost her boy/girl twins at 22 weeks.  Many of us are members of the child in Heaven club.  It's a sad club but honestly, knowing that others have gone through similar heartaches makes you feel not as alone.

You go on because you have no other options.  I have hope for the future and wonder in what each new day will bring.  I am blessed.  I have Mark.  I have the Three Stooges.  Knowing that the Three Stooges will, more than likely, become the Two Stooges soon, makes me sad.  But knowing that we saved her life, we took her in when her only other option was being put to sleep, and we gave her a good life, makes it all worthwhile.

Snuggle with your babies.....human or fur.

Take the time to say "I love you" to the people you love.

Offer a shoulder to cry on, an ear to listen.  Helping others helps you survive.

Never leave someone you love with angry words.  They might be the last words you use with them.

Appreciate what you have.

Mourn your losses.  Don't be afraid to talk to others about their losses.  It helps.

Be understanding.  We all go through some kind of Hell in our lives.  It's okay to lose it once in a while.

It's okay to ask for help.  Friends don't mind.

No one's battle is worse than another's.  A battle is a battle, big or small.

Help when you can.  Help as much as you can.  It feels wonderful.

Say thank you.  And mean it.

Things I have done during my lifetime:

( ) Tip-lined

( ) Swam in Underground Caves

( ) Swam with Seals

(x) Went to college

( ) Hand Fed a Tiger

(X) Been to Canada

( ) Been to Mexico

( ) Been to Europe

( ) Been to Hawaii

( ) Been to California

(x) Been on a plane

( ) Been on a helicopter

( ) Visited Egypt

(x ) Survived a loss and can still be thankful for my blessings

(x) Helped a homeless person

(X) Swam in the ocean

( ) Swam with Stingrays

( ) Been sailing in the ocean

(X) Cried and laughed in the same moment

( ) Played silly games for hours with my kids

(  ) Spent an entire summer camping as much as possible

( ) Ran a marathon- i walked in one

( ) Sang Karaoke with out apologies

(x ) Volunteered at a shelter

( ) Tried Sushi of many varieties

(  ) Been to the St. Louis Arch

( ) Seen the Northern Lights

( ) Scuba Diving

(x) Been on TV

(x) Done something you told yourself you wouldn't 

( ) Met my children and found the meaning of love and life

( ) Been down Bourbon Street in New Orleans

(x) Laughed until some kind of beverage came out of your nose

(x ) Fed an elephant, and petted an elephant

(x) Caught a snowflake on your tongue and pretended I didn't hate the cold weather

(x) Fired a gun

(x) Danced in the rain

() Been to the Opera

(X) Written a letter to Santa Claus with a heart full of hope and wishes

(x) Been Serenaded by someone

( ) Seen a U.S.President in person

(x ) Been kissed under the mistletoe

(x) Watched the sunrise with someone

(  ) Driven a race car

(x) Been to a National Museum

(x ) Been to a Wax Museum

(x ) Eaten something I thought I never would

(x) learned a new language (I know a lot of it)

(x ) Gone ice-skating

(x) Gone to the movies successfully with a toddler

(x) Been deep sea fishing

(  ) Driven across the United States

() Been in a hot air balloon

( ) Been sky diving

(x) Been capable of saving someone in danger

(  ) Gone snowmobiling

(x ) Found my forever home

(x) Lay down outside at night and admired the stars while listening to the crickets

(x) Seen a falling star and made a wish

(x ) Swam into and under a waterfall

( ) Seen the Grand Canyon

(  ) Seen the Statue of Liberty

(  ) Gone to the top of Seattle Space Needle

(x ) Been on a cruise

(x) Traveled by train

(x) Kept my closest friends forever

( ) Been horse back riding

( ) Ridden on a San Francisco cable car

(x) Been to Disneyland OR Disney World

(x) Truly believe in the power of prayer

( ) Been in a rain forest

(x ) Seen whales in the ocean

( x) Been to Niagara Falls

(  ) Ridden on an elephant

(  ) "Swam" with manatees

( ) Been to the Olympics

( ) Walked on the Great Wall of China

( ) Saw a glacier

(x) Been to the desert

(x ) Taken a honeymoon

(x ) Been snow-skiing

(  ) Been to the house I was born in again

( ) Been to Alaska

( ) Swam with dolphins

( ) Been to a Major League Baseball game

(  ) Been to a National Football League game

( ) Been to the Indy 500

( x) Been in my siblings wedding(s)

( ) Swam with sharks

(  ) Been White Water Rafting

(x ) Written a book or screen play

(x ) Fallen in love at first kiss

( ) Swam in a coral reef

( ) Prayed in Saint Peters Basilica

( ) Seen the Sistine Chapel

( ) Touched the Berlin Wall

(x) Met the person I idolize

Feeling too much?

Is it possible for a person to have too many feelings?  Waving arms in the air volunteering to be the first if necessary.

My guilt is my own.  Hardly ever brought on by someone or something else.  I feel guilt over many things.  I feel guilty, first and foremost, for not saving my little sister Kathy Jo's life, way back in 1979.  Yes, I have felt that guilt every day over the past almost 34 years.  Even though I KNOW that I couldn't have done anything, the fact remains that I told her I wished her dead the morning of the accident.

I feel guilty for having a great marriage.  I am SO blessed with Mark.  I have so many friends in bad relationships, that I feel guilty for the privilege of having Mark in my life.  Silly really.  But I truly feel that I haven't really put into the marriage what I've gotten out of it.  It certainly feels that I have put Mark through hell, what with my miscarriages and cancer.  He's always gotten the short end of the stick.

I get down in the dumps when someone passes away.  Doesn't matter if I know them or not.

Mark and I had a discussion way back when, before we were married.  The question on the table was what ONE thing would you change about each other.  Almost simultaneously, Mark said "I'd change how emotional you are" and i said "I'd make you more emotional".  So there you have it.  He's the tit to my tat.

No instant gratification here!

We reached the $1000 mark yesterday!!  Only $9000 to go to meet our goal.

I spoke with a Mother who had adopted her two girls through Lutheran Social Services yesterday.  She said that their total for each adoption was a bit over $17,000.  They took out a home equity for the first and a 401k advance for the second.

I also spoke with the adoption supervisor at LSS yesterday.  There IS a way we can adopt for virtually nothing.  It's called a Special Needs adoption.  Mostly for children who aren't adopted through social services and their foster parents.  Mostly over the age of 7.  Mark and I are discussing.  The problem is, we KNOW how the system can really affect a child, and by the age of 7, it's sometimes not reversible.

My friend is having a Scentsy Party for us and donating 50% of her commission to our GOFUNDME.  If anyone is interested, here's the link to that.  Every little bit helps!

https://rachelmartin.scentsy.us/Scentsy/Buy?partyId=154802436

Please feel free to share this link with your friends.  Thanks so much!!

symptoms typically disappear in about four years??????????

I have chemo brain.  My last chemo treatment was February 2011.  I assumed, wrongly, that my chemo brain would go away within the first year.  While it is getting better, in my opinion and my husband's words, I'm not quite where I was pre-chemo.  And certainly not where I want to be.

I have a hard time with my short-term memory.  I can tell you who ate dirt on the elementary school playground, but not what I had for dinner yesterday.

I have a difficult time with thinking of the right word when I'm speaking.  Sometimes I choose to NOT speak (imagine that!!!), because it embarrasses me when I get mid-sentence and cannot pull the word I want to say out of my mouth.  Sometimes I giggle and say "sorry, chemo brain" and make a joke of it.  It's not so much a joke, unfortunately.  All too real.

I used to read a book a day, or at the very least, a book a week.  I have been having a hard time reading People Magazine as of late.  "Met" a wonderful author of "the Little Book of Pain", through a mutual friend, and read his book, in less than two days!  I actually cried, not only from the content of the book, but because it made me feel almost like my old self, for a bit.

I've always felt that I was a relatively intelligent and at minimum, well-spoken woman.  Today, I feel like an idiot.  This chemo brain has exhausted me.  I have to work twice as hard as the "normal" Mindi, to get half the results.  It's like starting over, to a degree.  I hope to be smart again someday.

Post-chemotherapy cognitive impairment

From Wikipedia( View original Wikipedia Article ) Last modified on 5 May 2013, at 07:32 

Post-chemotherapy cognitive impairment (PCCI) (also known as chemotherapy-induced cognitive dysfunction, chemo brain, orchemo fog) describes the cognitive impairment that can result from chemotherapy treatment. Approximately 20–30% of people who undergo chemotherapy experience some level of post-chemotherapy cognitive impairment. The phenomenon first came to light because of the large number of breast cancer survivors who complained of changes in memory, fluency, and other cognitive abilities that impeded their ability to function as they had pre-chemotherapy.^[1]

Although the causes and existence of post-chemotherapy cognitive impairment have been a subject of debate, recent studies have confirmed that post-chemotherapy cognitive impairment is a real, measurable side effect of chemotherapy that appears in some patients.^[2] While any cancer patient may experience temporary cognitive impairment while undergoing chemotherapy, patients with PCCI continue to experience these symptoms long after chemotherapy has been completed. PCCI is often seen in patients treated for breast cancer, ovarian cancer,prostate cancer, and other reproductive cancers^[3], as well as other types of cancers requiring agressive treatment with chemotherapy. ^[4] [5]

The clinical relevance of PCCI is significant, considering the increasing number of long-term cancer survivors in the population, many of whom may have been treated with aggressive dosing of chemotherapeutic agents, or with chemotherapy as an adjuvant to other forms of treatment.^[6]In some patients, fear of PCCI can impact treatment decisions. The magnitude of chemotherapy-related cognitive changes and their impact on the activities of daily living are uncertain.^[7]

 

	Table of Contents 1 Incidence 2 Symptoms 3 Proposed mechanisms 4 Treatment 5 Research 6 Prognosis 7 History 8 See also 9 Footnotes 10 External links

Incidence

PCCI affects a subset of cancer survivors,^[7] though the overall epidemiology and prevalence is not well known and may depend on many factors.^[8]

It generally affects about 10–40% of breast cancer patients, with higher rates among pre-menopausal women and patients who receive high-dose chemotherapy.^[3]

Symptoms

The systems of the body most affected by chemotherapy drugs include visual and semantic memory, attention and motor coordination.^[9]These effects can impair a chemotherapy patient's ability to understand and make decisions regarding treatment, perform in school oremployment and can reduce quality of life.^[9] Survivors often report difficulty multitasking, comprehending what they've just read, following the thread of a conversation, and retrieving words.^[10]

Breast cancer survivors who were treated with chemotherapy may find it harder to perform tasks than survivors whose treatment was surgical. One study demonstrated that, a year after treatment, the brains of cancer survivors treated with chemotherapy had physically shrunk while those of people not treated with chemotherapy had not.^[11]

Post-chemotherapy cognitive impairment comes as a surprise to many cancer survivors. Often, survivors think their lives will return to normal when the cancer is gone, only to find that the lingering effects of post-chemotherapy cognitive impairment impede their efforts. Working, connecting with loved ones, carrying out day-to-day tasks—all can be very challenging for an impaired brain. Although post-chemotherapy cognitive impairment appears to be temporary, it can be quite long-lived, with some cases lasting 10 years or more.^[12]

Proposed mechanisms

The details of PCCI's causes and boundaries are not well known.^[6] Two major theories have been advanced:^[3] the direct effect of chemotherapy drugs on the brain, and the role of hormones in nervous system health.

PCCI is complex and factors other than the chemotherapeutic agents may impact cognitive functioning. Menopause, the biological impact of a surgical procedure with anesthesia, medications prescribed in addition to the chemotherapy, genetic predisposition, hormone therapy, emotional states (including anxiety, depression and fatigue), comorbid conditions and paraneoplastic syndrome may all co-occur and act asconfounding factors in the study or experience of PCCI.^[7]

Bortezomib is known to cause reversible neuropathy to the sensory and peripheral nervous systems.^[8] In most cases there is no known way of reducing the effects of chemotherapeutic agents related to taxanes, thalidomide and platinum-based compounds (oxaliplatin is a notable exception to the latter category—though it does cause PCCI its effects can be buffered by infusion of calcium and thought related to PCCI include the ability of the nerves to repair themselves, the ability of cells to excrete compounds, permeability of the blood–brain barrier, damage done to DNA including shortening of telomeres and cellular oxidative stress.^[8]

The importance of hormones, particularly estrogen, on cognitive function is underscored by the presence of cognitive impairment in breast cancer patients before chemotherapy is begun, the similarity of the cognitive impairments to several menopausal symptoms, the increased rate of PCCI in pre-menopausal women, and the fact that the symptoms can frequently be reversed by taking estrogen.^[3]

Other theories suggest vascular injury, inflammation, autoimmunity, anemia and the presence of the epsilon 4 version of the apolipoprotein Egene.^[9]

Fifty-six of the 132 chemotherapy agents approved by the FDA have been reported to induce oxidative stress.^[13] The drug doxorubicin(adriamycin) has been investigated as a PCCI-causing agent due to its production of reactive oxygen species.^[14] It has been investigated in ananimal model with mice.^[14][15]

Research has revealed that neural progenitor cells are particularly vulnerable to the cytotoxic effects of chemotherapy agents. 5-fluorouracilhas been demonstrated to reduce the viability of neural progenitor cells by 55-70% at concentrations of 1 μM, whereas cancer cell lines exposed to 1 μM of 5-fluorouracil were unaffected.^[16] Other chemotherapy agents such as BCNU, cisplatin, and cytarabine also displayed toxicity to progenitor cells in vivo and in vitro.^[17] This is a concern because neural progenitor cells are the major dividing cell population in the brain, giving rise to neurons and glia.

Due to the critical role the hippocampus plays in memory, it has been the focus of various studies involving post-chemotherapy cognitive impairment. The hippocampus is one of the rare areas of the brain that exhibits neurogenesis. These new neurons created by the hippocampus are important for memory and learning and require a brain-derived neurotrophic factor (BDNF) to form. 5-fluorouracil, a commonly used chemotherapy agent, has been shown to significantly reduce the levels of BDNF in the hippocampus of the rat.^[18] Methotextrate, an agent widely used in the chemotherapy treatment of breast cancer, has also displayed a long-lasting dose dependent decrease in hippocampal cell proliferation in the rat following a single intravenous injection of the drug.^[19] This evidence suggests that chemotherapy agent toxicity to cells in the hippocampus may be partially responsible for the memory declines experienced by some patients.

Deficits in visuo-spatial, visual-motor, and visual memory functions are among the symptoms seen in post-chemotherapy patients.^[20] There is evidence that this may be due to damage to the visual system rather than caused by cognitive deficits. In one study, 5-flouracil caused ocular toxicity in 25-38% of patients treated with the drug.^[21] Methotextrate also caused ocular toxicity in 25% of patients within 2–7 days of initial chemotherapy regimen with the drug.^[22] This evidence suggests that some of the visual-based cognitive deficits experienced by cancer survivors may be due to damage at the ocular level rather than cognitive processing, but most likely it is due to a synergistic effect on both systems.

Treatment

Hypothesized treatment options include the use of antioxidants, cognitive behavior therapy, erythropoietin and stimulant drugs such asmethylphenidate, though as the mechanism of PCCI is not well understood the potential treatment options are equally theoretical.^[9]

Modafinil, approved for narcolepsy, has been used off-label in trials with people with symptoms of PCCI. Modafinil is a wakefulness-promoting agent that can improve alertness and concentration, and studies have shown it to be effective at least among women treated for breast cancer.^[23][24]

While estrogen hormone supplementation may reverse the symptoms of PCCI in women treated for breast cancer,^[3] this carries health risks, including possibly promoting the proliferation of estrogen-responsive breast cancer cells.

Research

Research on PCCI is limited, and studies on the subject have often been conflicting in results, in part due to differing means of assessing and defining the phenomenon, which makes comparison and synthesis difficult.^[7] Most studies have involved small samples, making generalization difficult. There has been a focus on PCCI in younger cancer patients. This makes it difficult to draw conclusions about PCCI in the elderly.^[7]

Several recent studies have advanced the field using neuroimaging techniques. In 2005, Dr. Masatoshi Inagaki used magnetic resonance imaging (MRI) to measure differences in brain volume between breast cancer patients exposed to chemotherapy and subjects unexposed. Subjects were tested at two periods: one year after surgery, and again at three years post-surgery. Results from the first year study found smaller volumes of gray and white matter in patients exposed to chemotherapy. However, in the three-year study, both groups of breast cancer survivors were observed to have similar gray and white matter volumes. Altered brain structure in chemotherapy patients provides explanation for cognitive impairment.^[25]

Another study in 2007 investigated the differences in brain structure between two adult, monozygotic twin females. One underwent chemotherapy treatment for breast cancer, while the other did not have cancer and was not treated with chemotherapy. MRI scans were taken of both twins' brain while taking part in a working memory task. Results found that twin A (exposed to chemotherapy) experienced a broader spatial extent of activation in her brain than twin B (not exposed to chemotherapy). Twin A also reported a greater difficulty than twin B in completing the memory activity. The authors of this study declare that commonly chemotherapy patients will self-report cognitive complaints, although they perform within normal limits on neuropsychological tasks. MRI scans may provide evidence for this occurrence. Chemotherapy patients may require greater volume of neural circuitry to complete neuropsychological tasks compared to others.^[26]

Positron Emission Tomography (PET) is also used to study post-chemotherapy cognitive impairment. In one study in 2007, scans were taken of patients exposed to adjuvant chemotherapy. Significantly altered blood flow in the brain was found, most notably in the frontal cortex and cerebellum. The most significant difference of blood flow was found in the inferior frontal gyrus. Authors report resting metabolism in this area is associated with performance on short term memory tasks.^[27]

Prognosis

While frustrating, the ultimate outcome is very good: symptoms typically disappear in about four years.^[3]