Thursday, November 24, 2005
As people with CLL, we are often pigeonholed by society’s stereotypes and expectations about cancer. The media reflexively uses various terms, without thinking about them much, and we have all encountered friends, family, and coworkers who see us as something different than what we were before we were diagnosed.
There is no doubt that the diagnosis of a life-threatening illness can change us, sometimes even for the better. But people who aren’t walking in our shoes may have a tendency to play fast and loose with labels, slapping them on us when they don’t always fit. There is a danger in mindlessly accepting them, in subtly becoming what others expect us to be.
So what should we call ourselves?
I don’t really like the description “patient.” There is a certain loss of individuality in that appellation, a cow-like aspect that implies being a member of a rather passive herd of unfortunates managed by personnel bustling around in white coats. It makes me a set piece on the medical stage, one player in a long row of sufferers tethered to IV poles, and it brings with it all the notions of powerlessness that one ascribes to such an image: less power over disease, and less of a voice in the “doctor-patient” relationship. Medical care is part of the CLL experience, but not everything about it (though I certainly prefer “patient” to “medical consumer”).
Despite my reservations, “patient” is not inaccurate, but it is just one of the hats we wear. And perhaps we need to dust it off and change the way “patient” is perceived, make a transition in public perception from “poor things” to “hell-raisers." (Movie trailer for Bone Marrow Biopsy II: Aspirate This!: "Their white cells make them see red!”)
It should also be noted that the word "patient" does have an unintended meaning: With CLL, one must learn to be patient. That’s not the usage intended, though.
“Victim” is bad on so many levels. You can be a victim of anything, if you choose to see life that way. As a child, I was a victim of candy manufacturers, consumption of whose products required multiple fillings in my teeth. When I was 16, I was the victim of not having a car. You get the idea –- “victim” is overused, which tends to dilute its meaning for those who are genuine victims, such as babies killed by bombs. The decline of the human body is part of living -- I have been heading toward destruction since I left my mother’s womb one autumn day in 1956 -- and while this is an unfortunate progression, I do not see myself as a victim of the natural order of things. Yeah, I feel sorry for myself sometimes. But I have the power to fight back. Victimhood is not empowering, and I have always found it to be a most unpleasant way of getting by.
“Survivor”? Sometimes you see a CLL person who is rather proud of this title, and I can see why. Some people go through a hell of a lot, they surprise themselves, they prove something to themselves, and perhaps to others. I take nothing away from their accomplishments and they deserve to wear the title proudly. For some people, those with aggressive disease or other complications, CLL is a hard struggle from the start.
But, taking a broader view, we are all survivors until we die, whether we have leukemia or not. To me, unless I have truly earned my stripes, been to the edge and back, it is not right to adopt it as a label, because survival is just part of the act of living. Anyone alive is a survivor, really. And a philosopher I know suggests to me that since CLL is chronic, do we really survive it? Or do we survive along with it?
Speaking of “Survivor,” one cannot help but think of the CBS TV reality show of the same name. The motto of the show, in which contestants are pitted against one another in a remote place, usually a tropical island, is “Outwit. Outplay. Outlast.” In a strange way, that just about sums up the battle many of us have with CLL. A few false moves, a streak of bad luck, and you can get voted off the island, which is not a pleasant prospect. Play it right, choose treatment wisely, get a little lucky, and you just might make it to the end. There’s no million dollar prize, but life itself is infinitely more valuable.
That leaves us with “dude.” I like the blend of serious and casual that comes with “leukemia dude.” It is unexpected; it is impossible to conjure up a stereotype of how a leukemia dude looks or acts, and it breaks through the fog of negativity that others can mentally impose on those with our condition. If “dude” implies a somewhat looser, going-with-the-flow approach to life, even someone who’s cool, then maybe we need to add that element to the picture that others have of us.
Of course, you can just be a little less trendy and say “person.” That is what I still feel that I am, something whole and unbent, not a stereotype or a role or a sound bite. I have hazel eyes and a brown cat and a silver car and some extra white cells.
The phrase “CLL’er” has been used on occasion. It’s a bit flip, perhaps, but rather neutral. I don’t mind it. Taking a page from ethnic descriptions, there’s also “Leukemic-American,” or “Leukemic-Canadian,” and so on. And at times I feel like one of the “Leukemically Challenged.”
Though I’m not sure quite what to call myself, I do believe in the power of language. We are what we tell ourselves we are. Let us not forget that we are whole, made up of many things, and that CLL may be part of us but it is not everything about us.
Tuesday, November 22, 2005
But when it comes to doctors, otherwise intelligent people sometimes see their good sense fly straight out the window. Doctors may offer the keys to salvation, after all, and some patients tend to be sheepish in their presence, regarding them with the obeisance normally reserved for deities. Religious matters aside, many people simply feel ignorant about the disease and how it works -- not to mention overwhelmed by the shock of their diagnosis -- and therefore embarrassed or at a loss to question what they are told.
Fortunately, the internet provides us with the opportunity to learn, quickly, what we need to know. And that leaves as our only excuse the not wanting to know. Sometimes I hear a patient say: “I let my doctor do the driving because it is too much for me to handle.”
I am reminded here of Toonces, the Cat Who Could Drive a Car. This was a gag on Saturday Night Live in which a gray tabby cat takes the wheel and successfully manages to stick to the road for a few seconds before plunging himself, and his smiling human passengers, over a cliff.
The point I am making is that doctors are people, not gods, and they make mistakes in judgment, especially about tricky diseases like CLL. And they are busy, and not always up on the latest treatments and prognostic tests.
Even CLL experts, at a CLL Consortium institution, can still drive you over a cliff.
So, without further ado, please go to CLL Topics and read the article I wrote there called “Diagnosing Your Doctor.” Here’s the link:
(And for those who want to take a spin with Toonces, go to YouTube.)
Saturday, November 19, 2005
My adventures with Dr. Do-little, or how I narrowly avoided the wrong treatment and learned a lot of big words
Her chemo infusion room, arrayed with oak bookshelves and overstuffed recliners with a magnificent view of the local scenery, even looked like a not unpleasant place to be. I recall, after my first visit to Lippencot in October 2003, thinking: This won’t be so bad. I envisioned bringing my lunch, catching up on my reading as the infusion proceeded, perhaps laying back for a nap as I watched the sun wash across the cliffs in the distance. Of course, I’d have rather avoided the whole thing, but everyone was telling me I had “the good cancer,” and there was nothing to worry about.
The doctor was certainly upbeat. My CLL had been discovered during a routine blood test the month before, and a subsequent flow cytometry test had come back, indicating I had what she called “garden variety CLL.” Sort of like a weed, I guess. Fortunately, I had no “B” symptoms such as fatigue or night sweats, and my platelet and red blood cell production were normal, two important factors that normally argued against starting treatment. Even a fairly high lymphocyte count, 130,000, was no cause for jumping into therapy.
But a CT scan showed a number of lymph nodes throughout my body enlarged up to 3 cm. My spleen was at 18 cm. I didn’t really know what these numbers meant, and only later would I figure out that the swelling, while of some concern, was not nearly as bad as many patients experience.
The doctor was worried, though, that a swollen node could “cut off a kidney” by closing a bile duct. Visions of kidney failure loomed, and therefore treatment was advised, she said. I could take a pill called chlorambucil, which was an older therapy, not exactly on the cutting edge, and would take some time to work. Or I could opt for fludarabine, which she described as “well-tolerated, with an acceptable toxicity profile.” Fludarabine was the “gold standard” of treatment, and it would work quickly and effectively. “I have one patient who’s been coming in every few years for ten years and getting fludarabine and he’s still going strong,” she said, reassuringly.
Dr. Lippencot would have preferred a decision from me then and there, but I asked for a few days to ponder the choices. On my way out of the office I was handed the “leukemia packet” of booklets about CLL and chemotherapy, including one produced by Berlex, the makers of “Fludara for injection,” trade name for fludarabine. On the cover there was a drawing of a woman, one hand resting on her chin, as if she were deep in thought, though not overly concerned.
It was a brave new world, but it seemed as if I would be well taken care of. Indeed, if I had only just gone along, my life would have been easier.
But probably shorter.
The Fludara booklet was written at about an eighth grade level and was filled with cartoon drawings, one of which pictured B cells as looking like the monster in The Blob, a '50s horror movie classic. The booklet addressed issues of hair loss and nausea, which I had always assumed were the worst effects of chemotherapy. I could handle that, especially since I had already been losing hair for years and had gotten past my fears of baldness.
But tucked into a flap in the back was the actual “package insert,” a single page with printing so small that it almost required an electron microscope to read it. Some things caught my eye. Fludarabine could be mutagenic; it could cause a coma; it leads to neutropenia, thrombocytopenia and anemia in a majority of patients; I had a 16% to 22% chance of coming down with pneumonia. There was more. And even if I wasn’t sure what all those things meant, they sounded serious enough to break through the pleasant fog that had surrounded me since leaving the doctor’s office.
The fog continued to lift as my wife, Marilyn, and I began to poke around the internet, finding further studies that raised more red flags. Indeed, the more we learned, the more we realized that there were serious questions surrounding the side effects of chemotherapy. Hair loss and nausea had nothing to do with it.
Nonetheless, with my kidney ostensibly resting uneasily beneath the Lymph Node of Damocles, I remained focused on treatment. After all, my oncologist said I needed it. And my expectations were at work, too – when you have cancer, you try to kill it. That’s what I’d always been led to believe. It’s natural, when you’re newly-diagnosed and scared, to want to do something to get as much of the CLL out of your body as possible. And this dovetails into the disposition many oncologists have to treat, even when not treating, or treating less, may be a better idea. (The "watch-and-wait" concept of doing nothing was counter-intuitive, at least at that point in my education.)
It wasn’t long before I stumbled across an interesting treatment prospect, outlined in the Spring 2003 Leukemia Insights newsletter from the MD Anderson Cancer Center in Houston. The article, accompanied by a photo of a bearded and beaming Dr. Michael Keating, who also looked full of experience and reassurance, reported that a new combination of rituximab, fludarabine, and cyclophosphamide (RFC) had a 69% “complete response” rate in previously untreated patients. (Eventually, patient reader, I will post in detail about “complete” and other responses in CLL; as usual with this disease, things are never as they seem.)
If I had to do chemo, RFC made better sense than fludarabine alone, which had a much lower response rate. Indeed, the very important fact that there was only a 20 percent chance that fludarabine would provide me with a “complete response” had been ignored by both my doctor and Berlex. When my doctor called to ask me what I had decided, I told her about RFC, which seemed to me to be a promising discovery.
“Oh, that,” she said. “I tried that with someone and he ended up in the hospital on a ventilator.”
“Let me think about this some more,” I said. “I’ll get back to you.”
No easy choices
The more Marilyn learned about the side effects of chemo, the more she threatened to break my kneecaps if I ever decided to leave the house for treatment. Indeed, the evidence began to mount that some side effects could in themselves be life threatening. I realized that there were some unlucky people who were, evidently, done in by their treatment. Remissions were followed by fatal secondary cancers, bone marrow was so compromised that it became “dead” and the patient had no immune system left. Simple infections could then prove fatal.
Some time later we learned that fludarabine has been shown to give a free pass -- at your expense -- to the worst type of CLL cell, the one with the 17p deletion. Bear with me for a minute, if you're interested in further proof of the theory of evolution: CLL cells are wonky little buggers, deformed as a result of chromosomal abnormalities, some of which doctors have recently become familiar with. There is a test called FISH (Flouresence In-Situ Hybridization) that checks for the more common abnormalities. The worst of them is what’s called the 17p deletion, which carries with it a much shorter median survival for the patient than any other prognostic indicator in CLL.
In a normal situation, thanks to a functioning “TP53”gene -- where the 17p is located -- cells have a mechanism by which they can tell themselves to die. This death is called "apoptosis" (or perhaps "Apophis," for confused Stargate SG-1 fans). Every CLL patient most likely has a few B cells with this deletion or that, including 17p. (The FISH test only puts up the red flag when a high percentage of cells tested show a particular deletion, about 20% being the problem point for 17p.) A few out of billions isn't going to matter, usually, since they all compete to survive, often preventing the worst one from predominating. So along comes fludarabine, which relies on the 17p function to do its job, to tell the cell to die. It kills off those CLL clones with functioning 17p. And what doesn’t it kill? The ones where the 17p is deleted, the very worst ones of all. The other clones having been eliminated, the bad boys now have the field – your body – to themselves. Very Darwinian.
This danger is mitigated somewhat by adding other agents that don't rely on 17p, such as rituximab, to fludarabine therapy. Indeed, there is a more-is-better school of thought when it comes to chemo, if you can get past the potentially life-threatening toxicities. But those should not be taken lightly, especially if your back isn't to the wall. It now appears, for example, that the use of fludarabine and immunosuppressive combination therapies such as RFC may be implicated in the overall rise in cases of Richter’s Transformation; this is where the disease takes a nasty turn into large cell lymphoma, and the median survival time is less than a year.
I had to weigh the choices: If there was a chemo regimen that could guarantee a cure, or at least a very good chance of one, it might be worth taking the risks. But there’s a reason it’s called a chronic disease: chemo can delay it but it cannot stop it. And while there certainly are cases where aggressive chemotherapy is absolutely justified, I had to wonder if mine was one of them. Remember, the main reason for treatment at all was "cutting off a kidney." The only prognostic test I could get at that time -- just two years ago but eons past in terms of available prognostics -- was CD 38, which showed me at 12%, and therefore "negative," and therefore ostensibly with less aggressive CLL.
Still, if I needed treatment, then I had to do something. So we continued our research, trying to absorb as many big words and new concepts as we could while my oncologist fidgeted nervously in the background, visions of exploding kidneys dancing in her head. As it turned out, the more we looked into things, the more we learned that my doctor’s concern about the kidney was highly unusual. We began to suspect that despite charging more than $400 per 10-minute visit, we might not be getting our money’s worth, or our insurance company’s money’s worth, when it came to her CLL expertise.
The worst word in the English language
Meanwhile, we ran across something else to be concerned about, a simple word that Berlex failed to mention anywhere and that my doctor had also avoided: refractory.
"Refractory" is my least favorite word, and that’s quite an accolade, since there are so many to choose from. Removing the side effects issue from the discussion for a moment, if chemotherapy was guaranteed to work every couple of years ad infinitum, then we’d already be at the point where CLL is a controlled disease. But one of the problems is that nothing works forever. Patients can become refractory to a drug, which means the drug won’t work on them anymore. Almost everyone becomes refractory to fludarabine, for example.
This came as a rude shock, something that drug companies and doctors don’t really like to discuss and that patients don’t like to hear. The guy that Dr. Lippencot said had been on fludarabine for “ten years and going strong” was probably skating on very thin ice at this point.
Out of this discovery about “refractory” came some crystal clear logic that began to guide my treatment decision:
Use a drug today when you don’t need to, and that’s one less time you can use it in the future. You only get so many chances with the various drugs that are available, and you’ll likely have no idea how many chances you’ll get with any given one. Don’t burn any bridges before it is wise –- or at least unavoidable -- to do so.
Google does good
One night I decided to investigate this rituximab stuff (trade name Rituxan) that had been so instrumental in the apparent success of the RFC protocol at MD Anderson. I did a Google search and ran across CLL Topics for the first time. Suddenly another side of the story came into view: Rituxan as a single agent, or "monotherapy." Here was this retired chemist named Chaya Venkat, who was reinventing the wheel in an effort to save her husband’s life, saying things like, “Be smart in making your therapy decisions, play for time and stay as healthy as possible in the meanwhile. Live to fight another day when the odds are even more in your favor.”
That made sense.
It was also heartening to see that someone out there with absolutely no vested interest in the cancer business had begun to intelligently deal with all the issues that Marilyn and I had been wondering about: toxicity, effectiveness, what to do and when to start, what tests to have and how to get a handle on where my disease really stood.
Rituxan works well in non-Hodgkin's lymphoma, where CD 20 levels are usually over the top, and I read on Topics that it also seemed to work fairly well on some CLL patients, especially those with highly-expressed CD 20. Excited about the prospect of finding a treatment that would possibly control my CLL with minimal side effects, I went immediately to the file cabinet and pulled out my medical records. I knew I had been tested for CD-this and CD-that. And there it was, CD 20: Moderately bright, expressed on 92 percent of cells.
I was a good candidate for Rituxan monotherapy. There was a way out. (And for those of you who, on the surface, may not be such good candidates, don’t get discouraged. It seems to work pretty well in some people with “dim’ CD 20, too.)
Jumping the SS Lippencot
On my next visit to Dr. Lippencot, I discovered that she was actually afraid of Rituxan. She didn’t want to use it, either alone or in combination with anything else. It might, she asserted, "crum up" my kidneys. Indeed, in the very early days of Rituxan's use in CLL, doctors sometimes did not anticipate the high degree of tumor lysis, or cell die-off, that would result. This did lead to kidney problems in a few patients. But with adequate precautions -- taking allopurinol, drinking a lot of water, slower infusions over more days, even leukepheresis -- this is now a dead issue, and should have been in late 2003, also. I had to wonder, following the ventilator story she had told me, whether another CLL patient was now on dialysis somewhere following her administration of Rituxan.
Finally, Lippencot resorted to pulling out tricks at random. My insurance, she claimed, might not pay for Rituxan (not that she'd asked them, and she was wrong). Reservations about chemotherapy are the products of "fear-based thinking," so I was a misguided wuss. Fludarabine, in her experience, "works repeatedly." Noticing my lazy right eye, she posited that it could be the result of CLL getting into my central nervous system (highly unusual, by the way). Finally, she exclaimed, "I've been doing this for a lot of years!"
What I learned was that she had her comfort zone, which started with chlorambucil and ended with fludarabine. Her self-limitations were limiting my choices, and compromising my medical care. Ultimately, she could do little for me.
Sensing that my balkiness would not be easily overcome, she had me see her new partner, an oncologist whom, she volunteered, "has had a lot of experience with CLL." It was his first day at work, and he did what any good business partner does: stood by her decision tooth and nail.
Our conversation started badly and then devolved. He spat out various acronyms of older therapies that he was familiar with -- CHOP and COP and so on -- and ended up by insisting that fludarabine was "all you need." Rituxan, comparatively mild and already demonstrated to add enormously to the effectiveness of fludarabine therapy, was out of the question. When I mentioned using Rituxan by itself, I may as well have been yelling "The power of Christ be upon you" at a demon-possessed child. “Rituxan is not standard therapy for CLL!” he repeated at least three times, his voice growing more shrill and his face growing redder. If he could have rotated his head 360 degrees while spewing green slime, he probably would have done so.
Finally, like my Jewish grandmother, he ended up warning: “You could end up in the ER here with kidney failure! Is that what you want to happen?”
Armed with the power of information, Marilyn and I knew that it wasn’t going to happen, and we knew this would be our last visit to this office. On the way out we passed the pleasant infusion room with the spectacular view. It had now taken on an almost sinister aura, and we were glad to be done with the place.
A room without a view
Through patient networking I managed to find an open-minded oncologist a couple of hours away. She was younger, down to earth, pleasant but hardly the touchy-feely type. Lippencot had initially exuded an enveloping sense of calm, until my kidneys got the best of her; my new doctor was pretty much all business. I realized that bedside manner is not the end point of treatment, and I was grateful to have found someone familiar with recent advances in CLL therapy.
The new doctor was open to RFC, and I considered it. It was then, and is now, a new treatment, its track record being written as we speak. There was no way of knowing how long a remission might last, assuming I had no nasty complications. Even a best case scenario -- maybe five years? -- didn't answer that eternally nagging question in CLL therapy: Then what? So I opted for the less dramatic but safer and to me more logical choice: Rituxan alone. RFC, or the next generation of combination chemo, would always be there if I needed it.
We decided to proceed with Rituxan sooner rather than later because my disease had progressed to the point that Rituxan’s effectiveness might be significantly diminished if I waited much longer. The more impacted lymph nodes, and the bigger they are, the harder it is for Rituxan to get into them and do the job.
It was a fine line to walk, of course. I had possibly set the clock ticking on Rituxan’s usefulness in my case, though the jury is still out on if, and to what degree, CLL patients become refractory to it. But I did not want to let my disease get to the point where I would have no choice but to use something more heavy-duty. I was playing for time and it was a calculated risk, which is the name of the game in CLL.
My new doctor’s infusion room was about as inspiring as a bus station, but I didn’t mind. After the first infusion, my absolute lymphocyte count dropped from 157,000 to 9,900. The second week saw my spleen empty out. By the time I was done with eight rounds of Rituxan, my lymphocyte count was down to 2,300. My spleen appeared to be normal, and most lymph nodes were as well. It hadn’t been so effective on a few, and I knew going in that Rituxan doesn’t clean out the marrow like some of the tougher chemo regimens do. But it also doesn’t have the long-term negative effects, and I had not engaged in any significant bridge-burning.
I felt, as I left the office following my last treatment, that I had done the right thing. Everyone in life has their regrets; I am glad that when it came to this life-and-death matter, I had none.
A year and a half later, when the IgVH mutational status test became widely available through Quest Diagnostics, I found out that my decision to avoid single-agent fludarabine was a good one for another reason: I am unmutated, in that unfortunate group whose CLL tends to reproduce more quickly. But I also have a “normal” FISH result, with no deletions in crucial chromosomes such as 17p and 11q, and this has probably kept the disease reasonably well-behaved up to now. Had I followed Lippencot's advice and used fludarabine alone, there is a decent chance that it might have selected for CLL cells with the worst deletion possible – 17p – leaving me with a recipe for the worst form of CLL: a bad karotype and unmutated. And likely a lot less time on the planet.
I also discovered after the fact that Dr. Lippencot had been pushing fludarabine knowing full well that a blood test had shown that I was "Coombs positive." This means I have developed antibodies to my own red blood cells, not a pleasant thought, and therefore am more prone than average to develop a full-blown case of autoimmune hemolytic anemia, or AIHA, which is no walk in the park. Even the cartoon booklet published by Berlex mentioned this one. The Mayo Clinic, in its latest standards and practices of care, cautions against the use of fludarabine in such patients, as fludarabine can trigger AIHA. Even though I was no longer Lippencot's patient, I dropped a copy of the Mayo article off at her office, hoping against hope that she might, through some miracle that would rival the parting of the Red Sea, absorb the information.
For more about the current state of CLL treatment, and for some very interesting comments on fludarabine refractory patients – and that means you, eventually, if you use it – read this article by the highly-respected Dr. John Byrd and others: http://www.asheducationbook.org/cgi/content/full/2004/1/163
You can read about the Mayo Clinic's "Current Approach to Diagnosis and Management of CLL" at: http://tinyurl.com/dvk23
For more about prognostic testing, such as the IgVH mutational status and FISH tests referenced above, check out this link at CLL Topics, which also contains links to other articles about prognostics: http://tinyurl.com/cog3e
Vis-a-vis the question of immunosuppressive therapy and Richter's Transformation, there is an abstract here: http://tinyurl.com/b9c5x
I will post more about the pluses and minuses of single-therapy Rituxan, as well as combination chemotherapy (there is an interesting and important debate over RFC). Figuring out what kind of CLL you have, and what to do about it, is the main task that patients face.And, yes, Lynn Lippencot is not her real name.
That’s odd, I thought to myself in the dream, I haven’t been drinking. This contradiction brought me to consciousness, and even though my eyes were closed, it felt like the room was spinning, as if I had actually been drinking. It was an odd sensation, and not a pleasant one, and I wasn’t sure if I was still dreaming, or if I was waking up.
I opened my eyes and the room was, indeed, spinning. I felt nauseous. This had never happened to me before, drinking or no. Slowly I managed to sit on the edge of the bed. The chair opposite was moving gently, up and down, as if it were on the deck of a ship. One grows used to the idea that one’s eyes always tell the truth, and that the signals they send accurately help direct the movements of the body. It is scary when, after half a lifetime, things go haywire. When I stood up, I was unable to walk straight, and had to grip the walls to make it to the bathroom.
Just give me a minute, I thought to myself. I can figure out what is going on.
I am not a panicky type, nor am I a hypochondriac. Until that morning, I had seldom visited the doctor. I had graduated with honors from the school of It’s No Big Deal, I Can Get Over It. And indeed, whether I had a cold or hay fever or a bad headache, I had always managed without too much fuss. I could even handle minor dentistry without novocaine.
But I knew, as I looked in the bathroom mirror that morning, that I was not going to feel better from this without some help. I was turning whiter than white and sweating profusely. Am I having a stroke? I wondered. I was almost 47 and out of shape. I puked in the bobbing sink and then sat on the toilet for a few minutes, watching in the mirror opposite as sweat cascaded from my wet hair down my face. It was not getting better.
I gathered my sea legs and made my way back to the bedroom, where I woke Marilyn, and she drove me to the emergency room. I held a wastebasket in my lap, into which I continued to pour whatever I had eaten the night before.
I was immediately admitted to the ER and escorted to a bed, where I was suitably engowned and then hooked up to an IV bag of Phenergan, which for the next hour appeared to me to be the single greatest invention in the whole history of mankind. Slowly, as the drug suffused through my veins, the nausea began to vanish, the walls began to straighten, the ceiling lights assumed a fixed position in the acoustic-paneled firmament.
Marilyn sat to my right, holding my hand. The doctor would have to run some routine tests, but it wasn’t a stroke. I would be home by noon. They marched me through some X-rays. I was hooked up to an EKG. Some blood was drawn. The curtain to our cubicle was pulled and we waited, secure in the knowledge that the emergency was growing less acute as the minutes went by.
It gets worse
After a short while, there was a rattle as the curtains were drawn back. A thin, gray-haired nurse walked in, a little too rushed and businesslike.
“Have you ever been diagnosed with leukemia?” she asked.
“No,” I responded, as a knot began to grow in my already overworked stomach. The nurse turned and left us, abruptly, on her way to something important.
Marilyn squeezed my hand. We looked at each other.
Neither of us knew much about it, except that we knew it was something that affected children, and we assumed it was usually fatal.
I fought off a tendency to think that it can’t be true. Laying in a hospital bed, exhausted from my vertigo and vomiting, was proof enough that something was wrong with my body. My survival instinct kicked in, and I somehow found the strength to hold it together and deal with the news. There would be no rest, no welcome dozing, no letting go.
Tears began to creep down Marilyn’s face. Abruptly awakened from very little sleep, she had been coping with the unknown all day; now circumstances had forced a new role upon her, one of a helper who often feels helpless, a watcher of fate. There would be no going back to that morning before my dream, or to last night, or to last year, or to any time when health could be taken for granted and life could be lived as if there would always be another tomorrow.
A young orderly came in, fresh-faced and well-scrubbed, as if minted from some technical school for medical assistants that is advertised on afternoon TV. He proceeded to tell me, in almost breathless and excited tones – as if this were making his day – that my white blood count was 144,000, and that normal was somewhere between 4, 500 and 11,000. He said something about lymphocytes, which in my case accounted for 129,600 of the total, and then prattled on about other types of blood cells that I had barely heard of. I had not had a CBC -– complete blood count -- in seven years, thanks in part to changes in health insurance that tended to obstruct, rather than enhance, medical care. I’d had my cholesterol checked a couple of times at health fairs, and I’d even donated blood the previous year, for which they perform a rudimentary screening, but not for leukemia. Being middle aged, I had assumed heart issues were my primary concern, and that there was little value in a full blood panel.
In retrospect, as I will explain more fully in another post, my ignorance was probably a blessing.
The longest ten minutes, ever
The doctor came in and the orderly left, wheeling the EKG machine away, undoubtedly off to phone his friends with the news that, dude, this guy is full of like, lymphocytes.
The doctor was about my age, white-coated, with reddish hair and a pleasant manner that did not diminish with the news. Yes, she said, it appeared that I did have leukemia, and they needed to find out what kind I had. If it was an acute case, I would need to go to a hospital immediately (I was at our small town’s medical center, which is affiliated with larger hospitals in the area). If I had a chronic case, I could just go home.
My vertigo, she said, was probably “just” labrynthitis, an inner ear infection of unknown origin and for which there is no particular treatment.
“Is it caused by the leukemia?” I asked.
“Probably not,” she replied. And then she paused. “Well, I suppose it could be caused by one of the acute forms.”
Something spiked in me. Blood pressure? Stomach acid? Adrenalin?
My blood had been sent down the hall to the office of Dr. Lynn Lippencot, a hematologist/oncologist, which means a blood doctor/cancer doctor. She would look at it under a microscope and let us know what kind of leukemia I had. If the blood was full of tiny blast cells, it would mean acute. If it was full of larger but immature lymphocytes, it would mean chronic. It would take ten minutes or so to find out. The ER doctor went back to her other duties, leaving the curtains open.
Marilyn and I tried to hold a conversation about the merits of, worst case scenario, having to go to Hospital A or Hospital B. Tears ran down her cheeks. The real conversation, the one we didn’t need words for, went like this:
I love you and I am so sorry.
I love you, too.
We held hands in silence, and we waited. And waited.
The "good news"
We could see the doctor from our cubicle, sitting at the nurses’ station when the call came in. “Excellent!” she yelled, punching the air with her pen. She came back into the room.
“You appear to have chronic” -- she stumbled over the next word – “lymphat – lympha -- lymph-o-cytic leukemia
“This is good news, in a way,” she went on. “It’s the best leukemia to have. It’s very slow-moving, and most people die with it, not because of it. In fact,” she added a little sheepishly, “some people call it a good cancer.”
Marilyn and I squeezed hands again. I would be going home. And it looked like I might not be dead next week.
The doctor went on to tell me that CLL was something I could live with without much trouble, and that they even had a doctor on the staff who had it.
She felt the lymph nodes in my neck -- “yes, I can see they’re enlarged” -- and reported that the X-rays done earlier showed that my spleen was a little swollen.
“Don’t worry,” she said cheerily. “You can always have your spleen or your lymph nodes taken out.”
The doctor breezed off to process my discharge papers as I got dressed. On my way out she handed me a prescription for more Phenergan and relayed the message that Dr. Lippencot wanted me to set up an appointment.
But there was one thing I couldn’t get out of my head:
The best leukemia? A good cancer?
I remember thinking, as I left the ER with my wastebasket in tow, that the day had become every bit as surreal as my dream.
Friday, November 18, 2005
I am a writer, partially by trade and always by inclination. It comes as naturally to me as any obsessive habit comes to anyone. If I have a talent, this is it. They say to write what you know, and I have chronic lymphocytic leukemia, so I have shelved my plans to pen a mystery novel about a man who inherits a seedy motel, and I am writing about this instead.
I have thought about doing some sort of CLL website for a long time. At first I was going to do something just for newbies, to help them get past the shock and awe stage, give them some gentle guidance, some tools to hold up the sky that seems to be falling. You will indeed find some of that here. But I have now entered my CLL adulthood, as it were. I am in the learning-to-live-with-it-and-get-on-with-life stage. New challenges, a slightly different reality. That, too, will be part of this story.
I have never deluded myself into thinking that there needs to be another site trying to keep up on the science of it all; CLL Topics (see "Links") does that better than anyone. Blindfolded and dancing backwards in high heels, Topics science writer Chaya Venkat can still run circles around most people, including some of our fabled Consortium doctors, and that is the site you should visit if you want the facts, ma’am or man.
What there is not, in our little CLL community, is a site with a more reflective bent, a place where someone offers freewheeling commentary on the whole scope of what it means to have leukemia: the choices one faces, the foibles of the medical establishment, the pain in the ass it all is, and the cosmic messages that might occasionally be found in it. This is where I might have something to say. Think of me as a cross between Mark Twain and Michael Moore and the crazy cat lady on The Simpsons.
There are things I will say here that I cannot say in places such as the ACOR list, which is the internet community meeting room for some 2000 CLL patients and their families. ACOR contains a broad swath of people, including myself, each of whom is dealing with an emotionally difficult issue. Our common disease masks our many social, cultural, and political differences. So, in order to function best, ACOR is bound by a set of rules: No politics, no religion, no getting too far off the subject, no gratuitous humor, and no cursing. One must also sometimes tread very lightly when posting there, since cancer and death and its prospect are understandably sensitive subjects (see “Another Disclaimer,” below).
ACOR's restrictions allow people to share their CLL experiences in a generally supportive environment geared largely to medical issues. But the rules also tend to discourage a broader, more unbuttoned commentary, and life is not always best described in polite or politically correct terms. ACOR is good at what it does, but it does not pretend to do everything, nor can it. I will continue to post there, but there are times when I just want to shout from the comfort of my padded cell, or mumble and throw cats. So I will do that here.
One of the silver linings in being diagnosed with a potentially fatal disease is that one feels a little freer to call it as one sees it. If you can get something out of this blog, if it shines a little light on your experience, maybe gives you something to laugh about once in a while, or something to think about, then good. I may not always agree with your outlook, and you may not always agree with mine, but I know that we are brothers and sisters in the struggle.
I am not a doctor and I do not play one on the internet. If you feel compelled to take something I say as medical advice, that is your business. If you end up dying as a result, then perhaps in your next life you will be careful not to believe everything you read on the internet.
I know what this disease is like. It can be frightening at times, disappointing, depressing, terrifying. The comments in this blog are sometimes lighthearted compared to the situation, they find humor, sometimes black humor, where one sometimes does not feel like laughing. I understand what you may be going through, I respect where you may be at the moment. What you read here are my thoughts on any given day, at any given time. They do not take away from, or denigrate, or otherwise deny what the disease means to you. It is serious shit. I know that, always.