Amie Goins' chemotherapy regimen for Stage 2 breast cancer was, as her primary oncologist Dr. Dawn Klemow says, "the most difficult of all the regimens we give."
The fatigue is debilitating, the nausea overwhelming, the hair loss a given. Bone pain can be excruciating. And while the success rate is high, there's a caveat: The class of drug, called anthracyclines, can cause heart damage, even years after the last dose has been administered.
"It's tragic when you see someone a year later who is still in their 40s or 50s and are in heart failure because they got a drug with their chemotherapy that cured their cancer, but they can't have normal quality of life because they have heart failure," says Klemow, an assistant professor with the Harold C. Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center.
Which is why Goins had to have an echocardiogram even before chemotherapy began — to make sure, she says, her heart was healthy enough to undergo chemotherapy in the first place. And why her health team at UT Southwestern included Dr. Vlad Zaha, a cardiologist who specializes in heart problems caused by cancer treatment.
It's also why Goins, an avid runner, could face what was in store by focusing on four words.
"As soon as he said, 'You can keep running,' " says Goins, who learned she had cancer two days before Christmas last year, "I was like, 'OK.' "
Zaha told her she'd be slower, but she didn't care. He told her the drugs will tell her she's tired, "but if you push through," he told her, "it will help you a lot."
"He was so right," Goins says.
That's not to say it was easy. But when Goins got the go-ahead to keep exercising, she and her husband, Chris, made a pact: They would walk for 30 minutes every day, no matter what. Some days, that was no problem at all. But there were others when he'd come home and she'd be sitting on the couch, exhausted.
"Let's go," he'd say. "Put your shoes on."
"That became our time together," says Goins, 47. "There were days we walked and I put my arm in his and closed my eyes because I knew he wouldn't let me wander into the street or trip over a crack in the sidewalk. Those days were pretty rough. I might have been like that one day and then run five miles a few days later."
She kept going because she could. Because she knew it was good for her. Because she was always glad she did. And because — in a medical maze of being told where to be and when to be there, and what heretofore unheard-of medications would be coursing through her body — running gave her a sense of direction.
"You give up so much control," Goins says. "You feel vulnerable. As soon as the cardiologist said, 'You can keep running,' I seized on that."
Whatever your basic personality when starting cancer treatments, she says, "That will take over. I'm a rip-the-Band-Aid-off person, mostly when things are a little difficult. I assume it's going to work, and it has."
At UT Southwestern's Clinical Heart and Vascular Center, Zaha focuses on helping cancer patients who receive chemotherapy or radiation that can potentially affect their hearts.
"Looking at the cancer spectrum, survival has increased because of earlier diagnoses," says Zaha. The corollary, though, is that "the patient will be having cancer or leukemia in remission, but then will have to survive with the consequences of those treatments."
The lifetime risk of a person developing heart failure increases with cumulative doses of anthracyclines. Zaha recently was awarded a $2.3 million grant from the Cancer Prevention and Research Institute of Texas to study metabolic changes in the heart that occur with such treatments.
"Some of the outcomes are really severe," he says. "Once patients have a degree of severe heart failure, the chance of survival becomes less than 50 percent after a year."
But, he says, "there's a pretty strong component of preventative care. Having a cardiologist on the oncology team has the potential to change the outcome for the patient in a favorable way. Our approach is to help them get through their cancer treatment and optimize their cardiac health."
Patients like Goins are already ahead of the game.
"The heart becomes less likely to lose function severely in a patient who is starting from a much higher level of fitness," Zaha says. "What I find very inspiring is Amie's dedication. She understood it; she got it: Exercise is good. The point was to continue the exercise, even if one of the side effects of treatment is tiredness."
This past January, Goins had her first of eight chemotherapy infusions — one week on, one week off — to shrink her tumor before undergoing surgery. A couple of treatments in, Klemow remembers asking Goins about her energy level, and how much time she was having to spend in bed or if she was resting half the day, like most patients do. She was pleasantly surprised by Goins' response.
"She told me she wasn't going to let chemotherapy get in the way of her continuing to run," Klemow says. "She would not give it up. I came to notice she was not spending nearly as much time in bed as most patients. I was blown away by what a difference it made in her and that her side effects were minimal."
Especially, Klemow says, because though Goins' regimen included three of the best drugs for breast cancer treatment, they're also some of the toughest to deal with.
"A lot of patients by the end are pretty worn out and sickly appearing, for lack of a better word," Klemow says. "I tell you, I was especially amazed the day she came in and told me how hard her run had been, and that she had wanted to quit but her husband cheered her on. Her family was a real team for her, rooting her on."
Goins' determination has made Klemow rethink what she tells patients, she says. "My prior approach was to tell them, 'Rest, rest, rest. Don't push yourself. If you want to spend a week in bed, do it.'
"After seeing the difference it made in her, that made me rethink: You still need to listen to your body, and if you need to nap or take a break, do it. But the whole idea of giving in to the fatigue factor of chemo maybe isn't the best advice."
Giving in to fatigue also means not allowing the heart to work, Zaha says. "When you feel tired, intuition would tell you to go and rest," he says. "Resting when you have treatments for two months in a row means you're not doing anything for two months. You're not just resting; you're becoming sedentary, and that builds itself into a risk factor."
But Goins, with her inner strength and supportive family, wasn't going to let that happen, Klemow says. "We tell patients to move around as much as you can, but most don't go out and run a 5K," says Klemow. "She's an amazing girl."
Her last infused treatment was May 10. She underwent a lumpectomy on June 13 and, for the record, went home the same day. A few weeks later, she started the first of 28 radiation treatments. Her doctors have pronounced her "free of detectable disease" and encourage Goins to think of her disease in the past tense. As a preventative against recurrence, she's now taking oral chemotherapy.
Through it all, Goins keeps running, completing 11 5K races since January and planning for another six by year's end. After just about every one, she'd email Zaha her finishing times. That was, she says, "kind of a way to say, 'Look, I'm really doing this because you said I could!'
"It's very interesting to see. I sent one the day before my first chemo infusion and five days before the next one, and I was four to five minutes slower. While I'm not back to my pre-chemo speed yet, I am faster than I was a few months ago. It's not the most scientific method in the world, but it's one source of information Dr. Zaha is using to say I'm not quite back to normal."
Not yet, anyway. Step by step, though, she's getting there.
"Running gives me clarity," Goins says. "It's something to hang on to: I'm still running the same path I used to go. It feels good to be able to run."