Thursday, December 25, 2008

My Christmas lump of coal

On the eve of Christmas Eve I had a little too much egg nog with brandy. One thing I have learned over time is that alcohol really does thin the blood, so to speak. Indeed, studies show that low hemoglobin can accompany chronic alcoholism. My excuse for low hemoglobin is autoimmmune hemolytic anemia resulting from my CLL (though if life keeps getting more stressful I may decide to add chronic alcoholism to the list).

Hemolysis, in which the body destroys its own red blood cells, is the thing to watch for in AIHA. It can come on suddenly, and over time I have become ade
pt at looking for the signs and signals. Catching hemolysis early on is essential to keeping it in check. The more it begins to snowball, to use a seasonal metaphor, the more it can get out of control, requiring tougher steps to control it. Oh, and there’s that little thing about putting your life in danger as your body runs out of red blood cells. You never want that particular Elvis to leave the building.

If there is a decline in my hemoglobin, the first thing I usually notice is a pounding in my ears. What I’m hearing is my heart pumping away, and when HGB is really low, it’s like a marching band. When HGB is just a bit low, it’s like an occasional lone drummer offstage. When HGB is normal, I don't hear it at all.

Well, the Little Drummer Boy was busy as I tossed and turned in bed a few hours after placing my nog-drenched frame in the prone position. The easiest way for me to tell how my HGB is doing is to drink a lot, then go to bed. That’s ju
st one of the tricks of the AIHA trade that your doctor probably won’t tell you about.

Sure enough, blood tests the next day -- I have that holiday miracle, a doctor who answers her cell phone on Christmas Eve -- confirm that I’m hemolyzing again. On Dec. 2 all my red counts were normal. Twenty-two days later the HGB was down to 11.6 (from 13.5), the MCH and RDW were high, and overall RBC was 3.66, down from 4.47. My LDH, which measures turnover of cellular activity -- as in red cells being chomped by macrophages -- had gone from mid-normal to high-normal, and total bilirubin was now at the very top of normal, meaning debris was moving through the liver.


Results of the Direct Coombs, haptoglobin and reticulocyte tests will have to wait until Friday or Monday. But based on past experience, what we have here is active hemolysis, not quite out of control but definitely past the Miss Manners stage of fine macrophage dining.

So, hello Decadron. Hello, doctor next week. Hello, chemo very soon.

And hello, CLL curveball. As they used to say on Monty Python, “Nobody expects the Spanish Inquisition!” We CLLers with active disease had be
tter learn to expect it at any time, and that includes holidays.

Saturday, December 06, 2008

Ataraxia

I ran across the word “ataraxia” a while back and I liked it. Not only for the way it rolls across the tongue (at-uh-RAK-see-uh), sounding like so many things: an exotic city on a distant continent, a make-believe world conjured by a child, a potent drink that promises to liberate the soul.

No, I also liked it because of its meaning, from the Greek ataraktos, or “not disturbed”: A state of freedom from disturbance of mind. Calmness untroubled by mental or emotional disquiet


Faced with the ever-shifting challenges of the “new normal” that is life with chronic lymphocytic leukemia, ataraxia is something that we patients and caregivers often find lacking in our lives. We crave calmness of mind. Every bad test result or new symptom is a reminder of just how far we can find ourselves from peace and serenity.

It is therefore no surprise that ataraxia is hard to come by in CLL, as the Mayo Clinic has officially found -- I do believe this disease would present something of a challenge to the
coping skills of the Dalai Lama. But nothing is impossible, and I sometimes find vignettes, little triumphs of the spirit that show ataraxia is possible in the face of adversity:

A caregiver, whose husband is in ill health and responding poorly to chemotherapy, wakes up to find that her cow broke through a fence and ate her carefully-tended garden. After she cries her eyes out, she and her daughter go out and buy new plants and, together, start all over again. In replanting, she finds strength.

A patient, who has bad prognostics and is undergoing tough chemotherapy, feels like crap. But he loves to cook, and he cooks a dinner for his wife and their two closest friends. At the end of the night they shoot off fireworks.

A man in his 50s, having fought aggressive CLL with aggressive therapy, including a failed stem cell transplant, rides out into the desert on his motorcycle and plays his guitar, composing songs amid the windswept rocks.

A young mother, whose disease has transform
ed to something worse after chemotherapy, is in hospice care at home. She is in pain, lymph nodes are pressing on her, but her husband buys her a new coat and the two of them and their three-year-old daughter go to the beach and play in the sand and the waves.

There are more stories like these. I like to keep them in mind. Those of us touched by CLL quickly learn that life is fragile, but these stories also tell me that the will to live is strong and that we are resilient. That at times, even i
n the worst of times, we can reach ataraxia.

Sunday, November 16, 2008

My visit to the NCI, Part 2 - The expert consensus on transplants

Readers will recall that in Part 1, I had approached the National Cancer Institute about a transplant clinical trial, a possible donor had been identified, and I was asked to meet with a transplant doctor to determine what to do next. Marilyn and I set out from Arizona on a road trip to Bethesda, MD, where the NCI -- and possible salvation from CLL -- awaited.

Tucked under the passenger seat of our Prius was a black folder stuffed with articles and studies that weighed the risks and rewards of a transplant. Taken together, Marilyn and I hoped they would help provide an answer to the question: When is a transplant a good idea, and am I at that point? At the very least, we hoped to learn enough to be able to walk into the NCI and have an adult conversation.


The day before our meeting in Bethesda, we sequestered ourselves in our hotel room and read. And read. Avoiding temptations like The Simpsons Movie on HBO, we spent the day awash in Post-Its and highlighters, scribbling notes and occasionally announcing epiphanies.

Some of the articles were especially helpful in getting the lay of the land. Among these were a CLL Topics piece
called What Say You Dr. Expert?; an overview by Dr. Andrew Pettitt written for the UK CLL Support Association; and a paper entitled Indications for allogeneic stem cell transplantation in chronic lymphocytic leukemia: the EBMT transplant consensus, which reflects the views of European experts (there is no US equivalent). The latter is hard to get hold of but I can send you a PDF if you write to me.

The bottom lines, as near as we could tell, are these (and I would encourage you to find your own hotel and do your own reading and reach your own conclusions
):
  • Allogeneic transplants are still too risky to undertake without serious thought and thorough investigation. There is a two-thirds or better chance that you’ll get a long term remission or a cure. But it doesn’t take a math genius to realize that there is a fair chance of death or relapse, not to mention the possibility of significantly reduced quality of life due to graft vs. host disease (GVHD).

  • Prognostic tests (aka “biological risk factors” or “biomarkers”) alone (FISH, IgVH, ZAP-70, CD38) are insufficient grounds to undertake a transplant, except perhaps in the case of 17p-deleted patients, whose disease is by its very nature resistant to most chemo and likely to be aggressive and result in early death. As the European paper states, “. . . an adverse prognosis suggested by biological risk factors must be substantiated by an unfavorable clinical course.”

  • The favorability of your clinical course is generally determined by how well you respond to purine-analogue based therapy (i.e., fludarabine or pentostatin). If you don’t respond well, or if you relapse within two years after combination therapy such as FCR or PCR, you are a good candidate for a transplant. (If you respond to FCR for at least two years, you’ll likely be given FCR again.) A short period (less than 12 months) between diagnosis and the need for treatment is another sign of aggressive disease, though I think it can be argued that since we are all diagnosed at different points in our disease progression, this is something of a moving target.

    Dr. Pettitt makes a useful point: “It is very important to remember that the clinical and therapeutic context has a major impact on the prognostic value of some biomarkers. For example the real strength of IgVH gene mutation, CD38 and ZAP70 is in predicting time to progression in newly diagnosed patients with early-stage disease. In patients who have already progressed to the point of requiring treatment, these biomarkers have a relative weak effect on outcome whereas 17p deletion retains its profound adverse prognostic effect. As for patients who are resistant to fludarabine-based regimens, this probably trumps all biomarkers, which therefore become redundant in this setting.”

  • The 17p deletion indicates non-functionality of the p53 pathway, in which the 11q deletion is also implicated. The less the p53 pathway functions, the more the body is incapable of killing mangled, mutant cells even with chemotherapy, and therefore the more aggressive the disease. Dr. Terry Hamblin makes the point that “TP53 functional assays might be better than FISH.” Such an assay may be very helpful in further determining whether your CLL is reaching the point of getting out of control. Apparently such an assay is not easy to come by -- welcome to CLL.

  • Doctors tend to agree that 17p-deleted patients are better off having a transplant when they achieve their first remission. For the rest of us, they tend to think it should be after the second remission and some might even advise waiting a bit longer, depending upon the patient’s age, general health, prognostics, ability to respond to chemo, duration of remission, and ways in which the disease may be impinging on quality of life.

    To see just how unclear the thinking is on this one, the Europeans note: “Although conclusive evidence for CLL is still lacking, experience from other entities suggests that the success rate of the allo-SCT can decrease as the number of pretreatment cytotoxic lines [English translation: chemo regimens] grows. This implies that it might be advisable to consider allo-SCT in eligible patients as soon as criteria for poor-risk CLL are fulfilled. However, the available body of evidence does not allow sound recommendations on this issue.”

  • So, in the absence of conclusive evidence, what can we infer from the data we have? Does it make sense to transplant sooner rather than later?

    There are two big arguments for not waiting too long. One is that your general health is likely to be better the younger you are, and that means fewer comorbidities and a better chance of successfully undergoing the rigors of transplant. The second argument, and the conventional wisdom, is that CLLers going into transplant with a CR -- which is more likely to be achieved if you have not had too many "pretreatment cytotoxic lines" and become too resistant to drugs -- stand a better chance of success. From what I can tell, this is true. A 2007 study at the Hutch in Seattle showed that none of seven CLLers with a CR relapsed in the first 14 months, while out of 75 CLLers who didn’t have a CR, 31% relapsed.

    But that is not the end of the discussion because the risk of death is high enough -- and the success rate of non-CR patients is good enough -- to make waiting a little longer a reasonable course of action for some. It all depends on how you want to play the risk game: transplant sooner and risk not having time you would have had otherwise; transplant later and, having maximized your time already, assume a somewhat greater risk of not having any more of it. This is the crappy craps game you'll have to play.

    The European paper has a table that covers seven different studies of patients who underwent transplant. For each study, the percentage of fludarabine-refractory patients is given. I was surprised to see that there were not huge differences in overall survival between studies that had high percentages of fludarabine-refractory folks and those that didn’t. In one study of 73 patients, 82% of whom were fludarabine refractory -- which we can take as a rough guide for how many may have entered transplant without a CR -- the relapse rate was 28% after two years. Indeed, the relapse rate after two years seems to be about 30% in many studies.

    Despite the Hutch’s figures on that rather small group of seven patients, there is no guarantee that a CR patient will not relapse. or will not die for some other reason. Having a CR does not protect you from complications and early death (in the first 100 days), which is something around 7%. Nor is it a guarantee against transplant-related mortality, where you might well have a leg up on the non-CR people, but which runs about 15% to 20% in the first two years among all CLLers.

    My conclusion is that while a CR is preferable, the desire to attain it does not necessarily trump everything else in making the transplant decision. Statistics are significant from the angle that you look at them. The Hutch study indicates that 69% of non-CR patients had NOT relapsed. The European study shows that after two years 70% out of a heavily-fludarabine-refractory group had not relapsed. My guesstimate is that going into transplant with a CR might add another 10% or 15% to those numbers in your favor. That should not be dismissed, nor should it be seen as the certain difference between life and death. In the end, luck is going to play a crucial role in your outcome.

  • For those of us playing softball with CLL by using single-agent Rituxan and the like, it may be hard to define “first” and “second” remission. Most of the experts assume you’ll be using purine-analogue-based combination therapy. How many relapses after Rituxan does it take to equal the “first” or “second” relapse that the experts talk about? All I can suggest is that you look at your ongoing responsiveness to Rituxan, and any additional chemo, as a guide. Eventually, because of AIHA, I needed to graduate to something stronger, the R-C(V)P I had at the end of 2007. I am making an educated guess that my relapse from that regimen will constitute the equivalent of “first” relapse.

  • I am making that inference in large part because I seem to respond well to drugs. I always have, be it allergy medication or chemotherapy. The experts agree that disease resistance on the part of CLL will build; the question is at what rate. When there are signs that responsiveness is significantly diminishing, it’s time to think about transplant. Remember Dr. Pettitt’s point about resistance to fludarabine trumping all biomarkers; when the drugs stop working on you, nothing else is going to matter.

  • The art of medicine is definitely in play here, as you can tell by reading “What say you, Dr. Expert?” There are the vagaries of the bell curve, the idiosyncratic individual CLL that may give you a break, or maybe not. Ultimately, as I see it, and as I think a lot of the doctors see it, your responsiveness to therapy, your quality of life, and your clinical course and status (e.g, is your marrow still functioning reasonably well?; can you fight off infections?) are the practical factors that outweigh all others. The path to a transplant does not go like clockwork; there is always the need to finesse.

    To illustrate that point, here are thoughts from two doctors about the dangers of starting too early and starting too late:

    “I had a young patient (50 years old) with unfavorable prognostic factors who was anxious to go to transplant,” Dr. William Wierda of MD Anderson wrote. “He was in CR after his initial treatment. He was transplanted by one of the other transplanters here at MDACC. I was somewhat relieved that he had a sister who was a full match and expected this would reduce his risk for complications. This patient died during transplant, before he had a chance to be discharged from the hospital. I have had many others that have been successfully transplanted, however, this one patient, and the painful conversations I had with his wife after his death, have clearly affected my view of transplant and when to transplant. This is something that I would not like to consider for a 45-year-old with five children.”

    Dr. Hamblin points out the dangers of waiting too long: “The thing that stands out for me is that transplanting too late is a disaster. I have seen patients who remain in hospital for over a year after their transplant before they die. They fluctuate between CMV reactivation and GVHD. The treatment for one makes the other one worse. What is common to these patients is that they were transplanted late in their disease.”

  • So there is definitely a sweet spot, a best window of opportunity for transplant. Not too early (17p excepted, perhaps) and not too late. While you’re still responsive to therapy, but not while you still have a lot of bullets left. While you’re young and fit enough to cope with the rigors of transplant, but, um, not while you’re young and fit enough to enjoy good quality of life while controlling your CLL with chemotherapy.

    To quote Dr. Pettitt again: “At the end of the day, allografting amounts to a big gamble in which short-term risks are traded off against potential long-term gains. The dilemma is not only one of whether or not to have an allograft, but also when to have one. Thus, transplants consistently achieve the best results in patients who have not received too much in the way of previous treatment and are in remission at the time of transplantation. On the other hand, allografting has the potential to shorten as well as prolong life. This is very much an area where there are no clear answers, and under these circumstances patient choice is of paramount importance.”

    Which is why I always say: Go with your intuition.
After mulling over these points, Marilyn and I concluded that I was not yet ready to take the leap. While my 11q deletion is not the best of news -- though even 11q is not monolithic, so to speak, and there are better and worse variations that we are only beginning to understand, some of which Dr. John Byrd is testing for at his lab in Columbus -- my better-than-expected response to what was essentially mild chemotherapy was proof that my clinical course was not sufficiently unfavorable, at least not yet, to justify the risk.

Our feelings were validated when we returned home and a new CBC showed that my lymphocyte count was still stable, my red counts had climbed to mid-normal, and best of all I was finally Coombs negative, meaning the AIHA was now less likely to return.

In Part 3, I’ll report on my interview with Dr. Steven Pavletic, transplant protocol chair at the NCI, and his conclusions about my case and insights into the transplant process.

Wednesday, November 05, 2008

Free at last

I must admit to having cried last night when Barack Obama was elected the 44th president of the United States.

Part of it was jubilation, the sort of feeling prevalent in Eastern Europe back in 1989 when the Berlin Wall came crashing down. As Marilyn said, it feels like we have finally gotten rid of the Ceausescus. That big crowd in front of the White House may as well have been carrying pitchforks.

But the big reason, the one that actually set me to sobbing, was t
he fact that my country has elected a black man, chosen a leader not for the color of his skin but rather for the content of his character. He will be the head of state, but he will be more than that: like all presidents, he is a symbol of the nation he leads. We do not have a royal family here, but we do have a first family, and they are Barack and Michelle, Sasha and Malia, and a puppy as yet to be named.

Oh, how far we've come.


Racism has always been a part of American life. Our very Constitution established that for census purposes “non-free” residents should count as three-fifths of a person. The Civil War may have ended slavery, but for at least a century afterwards we were enslaved by bigotry. Blacks have been lynched, denied the right to vote, denied educational and economic opportunity, denied the right to ride in the front of the bus. I am not all that old, but I am old enough to remember the events of the 1960s -- the fire hoses, the at
tack dogs, the murders of Medgar Evers, Martin Luther King Jr. and others -- black and white -- who laid their lives on the line to put an end to this madness.

And then, last night, Americans did something that signified in a profound way that we have changed, that we have become something different, that we have become something better than we were. There was something almost effortless about it, until we remember all the sacrifices it took to get here.

Those racists who were responsible for the Jim Crow laws, for the
murders in the middle of the night, are no doubt spinning in their graves right now, working their way ever closer to Hell. Those who are still with us, who just can’t stand the idea of a black man as their leader, as their national symbol, have some waking up to do.

I saw a pickup truck recently with a Confederate flag sticker and the words “Kick Ass White Boy” written above it. Next to it was a big American flag. Well, Kick Ass White Boy just got his ass kicked. And I’ll take those Stars and Stripes back, thank you. They belong to a country that is bigger, grander, wiser, and more diverse than it o
nce ever dreamed it could be.

This is the America I love, the one that shows it is, in ways, the Promised Land. It has not been all that many years since Dr. King spoke on the steps of the Lincoln Memorial. I remember hearing his speech as a kid, and his thrilling words have never rung truer than they do right now:

“And when this happens, when we allow freedom to ring, when we let it ring from every village and every hamlet, from every state and every city, we will be able to speed up that day when all of God's children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing in the words of the old Negro spiritual, "Free at last! Free at last! Thank God Almighty, we are free at last!"

Tuesday, October 28, 2008

The joy of Coombs negativity

Been busy here. Kitchen remodel + Ikea = eating too many Swedish meatballs after tramping around a football-field-sized maze of furniture where everything has names like Akurum, Famtid, and Wurm. Me, Marilyn, and half of Phoenix were there on Sunday. Soylent Green is people!

The good news is that I am healthy enough to endure the experience
, which is not unlike a Bataan Death March through a pressboard jungle where gibberish is the lingua franca. My hemoglobin is 14.7, more than double what it was a year ago when I was in the throes of autoimmune hemolytic anemia (AIHA). My RBC is 4.72, hematocrit 41.2. All are well within the normal reference range.

The big cherry on this red blood sundae is that my last two Coombs tests have come up negative, which means the AIHA beast is in its cave, unlikely to show up in the dramatic fashion by which it attacked me last year. Converting to Coombs negativity was my not-so-secret hope when I underwent R+C(V)P therapy for AIHA and CLL, which commenced on October 22, 2007. Conversion took so long to happen that I thought it wasn’t going to. And then on August 19 it did. And on October 7 it did again. (I am a believer in the “make sure you get two tests to confirm a trend” school of blood draw divination.)

According to a study b
y Dr. Kanti Rai, et al of CLLers with AIHA treated with a similar protocol to mine, conversion to Coombs negativity led to a mean response of 23 months, as opposed to 8.8 months for those who remained Coombs positive. “This finding that Coombs conversion portends a longer duration of response suggests treatment goals for AIHA should be a conversion to Coombs negative, and not stopped with recovery of HGB,” the authors wrote.

Well, I’ll be damned, pass the lingonberries and po
ur some Absolut in my Ljuvlig, I am one of the lucky ones. I am also lucky in that I achieved this following just three rounds of chemo (not the five or so that most of Rai’s patients had). And that my absolute lymphocyte count is 8.9 a year later, much lower than I ever thought it would stay.

The imperfect part of the picture is that the lymph nodes began to return, slowly, around June and July. This follows the typical pattern of 11q-deleted disease, where the CLL collects in the nodes. They aren’t as bad as they used to be, but they’re there, a definite reminder that CLL relapse after chemotherapy is, like getting a Florvag for your Tolga, inevitable.

Nonetheless, I am for the moment enjoying a satisfying, quiet victory over the most acute medical crisis I have ever faced. My saga is a reminder of how easy it is to take the fundamentals of health for granted, and what a long and difficult slog it can be to return to a simple, functional state.

There are two lessons I am taking away. One is that things don’t always g
o by the book, that statistics are general but results are individual. By all counts, my response to therapy shouldn’t have been this good. Rai’s patients were Rituxan-naive; I certainly am not, and I had fewer rounds of chemo than they did. Two is that I believe controlling my AIHA is directly proportional to controlling my CLL; when time comes again for treatment I am going to make sure there is at least as much punch to it as there was before. The days of single-agent Rituxan as a means of controlling my CLL are almost assuredly over.

The nice thing about a remission is that I don’t think about these things that much right
now. Instead, I ponder what to do with the three extra inches on the wall over the sink, what color granite goes with Adel medium brown, and whether to put a Luftig over the Mumsig.

Had I tried to make it through Ikea this time last year, when my HGB was 6.8, they would have had to carry me out on an Ektorp.

Tuesday, October 14, 2008

Ibuprofen and AIHA

A few years ago, I read on the ACOR CLL List about a patient who took ibuprofen when his swollen lymph nodes began to bother him. His doctor said it was OK to take 1600 mg daily for a week, which is half the maximum allowable daily dose.

The lure of NSAIDs (non-steroidal-anti-inflammatory drugs) like ibuprofen is their easy availability, low c
ost, and ability to alleviate symptoms. But like all drugs they come with side effects and toxicities, which means that their role in combating CLL is necessarily limited.

When I r
ead about ibuprofen controlling the nodes, I decided to give it a try. I didn't need a lot of convincing, as I had always rather enjoyed the effects of ibuprofen on those rare occasions when I took it for a headache or muscle pain. It would leave me with a pleasant feeling, not exactly tranquilized, but just that more at peace with the world.

I found that it worked on the nodes to a small and very temporary degree, just enough that I began to take it when my ever-growing nodes got painful. Even then, I never went up to the line and used it as much as I could. I am rather conservative about drug use. The most I did was take it once or twice a day for two or three days.

Later, by the way, when I used steroids, the nodes reduced dramatically, so there really is no contest when it comes to NSAIDs vs. SAIDs. But steroids are much w
orse in terms of side effects; being conservative about drugs, I used single-agent Rituxan for as long as I could before circumstances, in the form of my AIHA diagnosis last March, forced me to throw steroids into the mix. AIHA, of course, is short for autoimmune hemolytic anemia, about which I have written a great deal, and which I would not wish on my worst enemy.

After I came down with AIHA, I stumbled across an interesting bit of information in the Merck Manual online. Ibuprofen was listed in a table as one of several drugs "that can cause warm antibody [autoimmune] hemolytic anemia."

It was hard to find any more information on the subject, but I immedia
tely quit using it, even on the rarest of occasions. I am convinced, based on my reading and the conventional wisdom of doctors, that my AIHA came about as a result of the CLL having gotten out of control and gumming up the immunity works. But the thought that ibuprofen might have had even a tiny role in helping me reach the tipping point into hemolysis -- the vicious cycle in which the body destroys its own red blood cells -- was enough to make me quit using it.
Some time later, after my R-C(V)P therapy at the end of last year, I wrote to Dr. Clive Zent of the Mayo Clinic. Dr. Zent is a CLL and autoimmune disease expert who has generously allowed me to share his thoughts with you. I asked, quite simply, whether it w as safe to use ibuprofen, or whether it could contribute to a possible relapse of AIHA. Here's his reply:
Ibuprofen -- this is certainly a drug that has been associated with autoimmune complications including AIHA. It (and all the other drugs in its class -- NSAID) have many other potential toxicities which are generally rare. We rarely determine the triggers (if any) of AIHA in an individual. This is all a prelude to saying that unless ibuprofen was the cause of your AIHA, I don't believe that you are at high risk of causing a relapse of your AIHA if you use the drug, but it (and all other drugs) should be used only when indicated. If acetaminophen is effective for your pain, it could be a safer option. 
The bottom line is "better safe than sorry." How to handle CLL and its myriad effects is something that keeps even the experts guessing. Those of you out there who are Coombs positive, or have been diagnosed with AIHA, and who are also scarfing down the ibuprofen, may want to think twice about it.

Sunday, September 28, 2008

The sea otter with CLL

Chronic lymphocytic leukemia is not the province of people alone. If you've been around Google a few times you've run into references of CLL in dogs and cats. Indeed, they're pretty much subject to the whole range of leukemias and lymphomas that we humans are. When it comes to CLL, our pets get some of the same treatments that we do. CLL kitties can live a year or two if given chlorambucil. French researchers found that dogs responded to a combination of prednisolone and melphalan (the latter being an older drug that is rarely used in human CLL today).

The animal world has lost its first CLL celebrity, a sea otter named Nyac. She was a 20-year-old survivor of the Exxon Valdez oil spill and a popular resident of the Vancouver Aquarium.
Whether or not the oil spill had anything to do with her CLL is unknown, but it didn't seem to interfere with her longevity. Sea otters usually live 10 or 15 years and some have reached 20 in captivity, so she died at a ripe old age.

A statement by the Vancouver Aquarium on Tuesday read in part:

"Nyac was at the upper limit of a female sea otter life span. Over the last 2-3 years Nyac has been showing signs of her advanced age most obviously a gradual slowing down in her general behaviours. In July, Nyac suddenly showed limited energy and mobility. The Aquarium’s veterinary team immediately began their work in an attempt to determine a reason for the sudden deterioration of Nyac’s health. An MRI revealed a serious inner ear infection however blood test results showed a more serious underlying disorder.

"With treatment, Nyac’s behaviour improved and since that time she had been under close observation by the marine mammal and veterinary care teams. Last Friday her condition worsened and she was diagnosed with chronic lymphocytic leukemia.

"Nyac was placed under 24-hour care with key staff in attendance. Her condition continued to worsen until Nyac passed away early this morning.

“Nyac was a very special animal and had been placed under palliative care. Our entire veterinary and marine mammal care team is, of course, devastated this morning. Lymphocytic leukemia has not been previously reported in sea otters and because there is some association with contact with petroleum in other species, she is an important animal. From a medical perspective, Nyac is also very important because of her long life. Even as we’ll miss her we know she’ll continue to provide vital information on the long-term effects of oil exposure.” said Dr. Martin Haulena, Staff Veterinarian, Vancouver Aquarium."

Below is the YouTube video that made her famous. Get out your hankies.



Thursday, September 25, 2008

A house of cards

What a mess we’re in. As Chris Dodd put it, we’ve entered an era of privatized profit and socialized debt.

Greed is at the center of it all, greed and lack of meaningful oversight, not just on the part of government regulators but also on the part of corporate elders who should have known better, or should have cared more.

Back in 1984, Marilyn and I bought out first house at a cost of $87,500. It was a definite fixer, an older home with an in-law apartment that had been added downstairs. The couple who owned it were divorcing. She lived upstairs, he was consigned to the dungeon, which he trashed. Termites had built themselves a magical kingdom in the walls. The fireplace was leaning away from the house. Roots from a giant willow tree routinely plugged up the sewer lines. It wasn’t i
n the best neighborhood. But it was just about the last house in Berkeley, CA for under $100,000 and we were lucky to get it, with 20% down and a 13.25%, 30-year fixed loan.

Jumping through hoops to get financing
was expected, and made some sense. The lender needed to know that we could afford to pay the mortgage.

That was back in the good old days, when homes almost everywhere in the country were in reach of people with average incomes. I took a look at zillow.com, just to see how our first home has fared. Riding a real estate boomlet, we sold it in 1989 for $200,000, a record for the block. The boom steadied and the people who bought it from us sold it in 1994 for $235,000.

They’re probably kicking themselves. By 2003, it was worth around $580,000. In mid-05 the old dump reached its peak value, $818,000. Today, it’s $661,500 and heading south.

How can people pay for such huge mortgages? Smoke, mirrors, and lemming-like behavior. Things like 100% financing, or 80/20 financing, interest-only loans, ARMs fr
om Hell, HELOCs, refinancing, issuing loans to the insolvent, paying routine bills with credit cards, which were passed out like candy.

As Suze Orman has repeatedly pointed out, financial management skills should be a required course in high school. Just because someone offers you something you can't afford doesn't mean you have to take it.

This madness started in California, then spread to Nevada, Arizona, Florida and a lot of other places that were considered desirable. I have been to all these places, have lived in two of them, and let me say here that none of them are THAT nice.

Anyone with common sense could see that this could not continue. Our Berkeley hovel more than tripled in value from 1994 to 2005. Were they thinking it would more than triple again, be worth $2.5 million in another ten or eleven years? And who did they thi
nk (in their right mind anyway) would buy it at that price?

That we are now in a financial crisis, built on bad mortages, should rea
lly come as a surprise to no one. It was almost like everyone, from Wall Street to Main Street, was doing financial crack. Everyone ran on overdrive, pocketing money that wasn’t there.

Now this binge has to be paid for, and we’re all going to suffer. Like most Americans, my visceral reaction to the idea of a $700 billion bailout involves a fair amount of disgust. I don’t like rewarding the avaricious. Especially when this money could be better spent on things like health care, cancer research, and so on.

But I am told that we have no choice. That’s probably the case. We have built ourselves an enormous house of cards, not just in real estate but in credit and investm
ents, things that drive our economy and provide financial security and opportunity. It's a monument to folly that we will be paying for, one way or the other, for a long time to come.

Tuesday, September 16, 2008

My visit to the NCI, Part 1

Marilyn and I like road trips. We’ve taken them for as long as we’ve had something with four wheels and an engine.

In the old days we went car camping out of ou
r Toyota Celica, pitching a backpacking tent in Death Valley, which threatened to blow away during a dust storm -- with us in it. Then we upgraded to a Volkswagen Westfalia van with a pop-up roof, in which we went over the Rockies in first gear. Our cat, Tut, used to nap on a picnic basket wedged between the two front seats. This was followed by the RV era, which involved towing a house (aka fifth-wheel trailer) behind us. Now we’re back to square one -- just a car -- though we prefer motels to tents these days.

And now that I have chronic lymphocytic leukemia, we’ve combined ro
ad tripping with doctor visiting. In 2006, we set out for Columbus, OH, home of Dr. John Byrd. And in July of this year we took off for Bethesda, MD, home of the National Cancer Institute and National Institutes of Health.

We were going because I was looking into a clinical trial that offers free reduced-intensity- conditioning stem cell transplants using matched unrelated donors -- the popular mini-MUD. I need an unrelated donor because I have n
o sibling donors; my two brothers and one sister are all half-siblings. Since my health insurance won’t cover transplants, participating would be like winning a million-dollar lottery of sorts. Of course, I’d rather win a million dollars and not have CLL, but that’s another story.

CLL Topics published an article about the trial in January, one mont
h after I completed my R-C(V)P therapy for CLL and autoimmune hemolytic anemia (AIHA). The year 2007 had not been kind to me: AIHA was diagnosed in March, treated, and followed by relapses in July and October, each worse than the one before. Not only was my quality of life going down the tubes, it appeared the AIHA might be uncontrollable. The idea of a transplant, which had once been fuzzy and distant, was now taking on some immediacy. It was prudent to look into it seriously, especially as I had no idea in January how long my remission might last.

One in seven million

So I called the transplant coordinator and explained my situation. He said I was, on the face of it, worthy of consideration.


The first step would be to see whether there was a 10/10 HLA match, which is required for participation. (A less-than-optimal match equals less-than-optimal results, both for me and the trial.) A blood kit with two tubes was sent from Bethesda. I had the blood drawn at a local lab and then Fed-Exed the package back to the NCI, along with copies of my medical records.

It took several months to get any answers, partly because the trial was stopped at one point to allow for a routi
ne review of how the protocol was working. It turned out that the six people who had undergone transplants were doing well, and so accrual of patients resumed. A total of 20 people will eventually be enrolled.

The NCI first looked at my blood on low resolution for 6/6 matches, and when a number of those were confirmed by searching worldwide donor databases, moved onto the next step: testing at low resolution for 10/10 matches. Twelve were found, and this was followed by the final search at high resolution, after which the tr
ansplant coordinator called with the news: Of the twelve 10/10 low-res matches, only one donor, out of seven million in the databases, appeared to be a 10/10 match at high res.

But one, as he pointed out, is all it takes.

He added that the ne
xt step in testing, should I be provisionally accepted into the trial, would be to contact the donor and make sure he or she had no infectious diseases and was physically able to undergo the donation procedure.

The testing and donor searching that had already been done -- which would have cost me $15,000 or more had I been paying for it myself -- thus answered a very important question: Are there donors for me and is an adult stem cell transplant therefore going to be an option now or in the future?

The answer is -- and it’s fortunate that I am not a Type A personality -- “maybe.” It is worth noting here that the 5-million-strong U.S. National Marrow Donor Program database returned 22 low-res 6/6 matches when I used their website's HL
A matching gizmo last year. In retrospect, those results are pretty much meaningless. When the rubber meets the road in the form of further testing, 22 6/6 matches can mean bupkus, or close to bupkus. (For those unfamiliar with road trips, Bupkus is just east of WaKeeney, in central Kansas.)

Having completed the HLA preliminaries, the transplant coordinator wanted to move ahead to the next step, an “informational meeting” with one of the doctors involved in the trial. I could have done this by phone, but I hate talking on the phone. You can’t see who you’re dealing with, you don’t have the presence of mind that you do when you’re there with all five senses, and you can’t grok the facility,
get an impression of what actually taking such a big step would be like. So off we went.

Did I mention that this was also a good excuse for a road trip?

Meanwhile, back at CBC ranch

In the months following my three rounds of R-C(V)P, my CBC continued to look better and better. Not only had the hemolysis stopped, but my red counts were making a slow climb toward normal. My lymphocyte count was c
ontinuing to drift downward. My lymph nodes, which were knocked back to the point of being less swollen than they were at diagnosis in 2003, were stable. By the time we went to Bethesda, my red counts had crossed the line into the low-normal range and my Coombs test, though still positive, was now only “microscopically” so. The nodes had come back a little, but not much. My spleen and liver were behaving themselves. The lymphocyte count had dropped to its lowest level since I had the chemo eight months before.

In other words, I was doing better than I could have hoped when I finished the R-C(V)P in December and approached the NCI in January.
And so the transplant immediacy factor was beginning to diminish. When your back is against the wall, you do what you have to do, regardless of the risk. When the pressure is off, you look at things from a different perspective, especially when you are considering taking a step that has a 15% to 20% chance of killing you.

But the prospect of having just one donor added a little drama to my decision as we traveled east. Do I seize the moment before there is no donor at all? Or would it be reasonable to expect that more donors might come along in the future
?

And are those even the right issues to be focusing on?

For as a learned friend once told me when I was young and we were all sitting around a campfire drinking a lot of beer, “The thing in life is not to know all the answers but rather to ask the right questions."

In Part 2, I will discuss the questions I asked, the answers I found, and the general consensus to date when experts grapple with the question, "Who should have a transplant when?"


We stopped to see the giant Van Gogh sunflower canvas in Greatland, KS. Apparently Van Gogh was taller than we thought and traveled further afield than is commonly known. The middle photo is of our cat Pyewacket in the driver's seat on our (doctor-visitless) road trip to Nova Scotia in 2004. Both of our cats have enjoyed traveling; we adopted Pye at an RV park. The top photo shows Tut enjoying a claw-scratch at a campground, circa 1987. That's a 1971 VW.

Saturday, September 06, 2008

Then and now, Part 2 -- Five years later

Wednesday marked the fifth anniversary of my CLL diagnosis. I am now entering year six of a journey that, according to survival statistics, should last another two to nine years. At which point I will become permanently out of print. Crossed out by the Big Blue Pencil. Remaindered at the bookstore in the sky.

Unless, of course, I get lucky. Which, the statistics show, can also happen.

My feelings about chronic lymphocytic leukemia are a lot different today than they were five years ago. Then, it was a challenge that demanded my full attention: How can I get a grip on the unfathom
able to outwit the unthinkable? Now, the adrenaline response to diagnosis is gone. The war of attrition has set in. CLL is less of an imminent threat and more of a lethal annoyance.

This has led me
to conclude that, as much as I can, it’s time to get on with my life. In the words of that sage philosopher Doris Day, “Que sera, sera. Whatever will be, will be.”

Over the years I have learned what to expect. I know how the disease progresses, how drug resistance develops, how I respond to therapy, how clinical symptoms have impacted my life. I have seen the pace at which new therapies come along and I know that at the end of my CLL journey, barring something fairly miraculous, there will be a transplant of some kind. And that it will probably either cure me or kill me, and that nothing I do can control the outcome with certainty.

I am along for the ride. Over time I have come to accept my situation, and very little good can be said about it. CLL is a bitch. But I am getting used to it. As the
days go by and the crises come and go, it feels less like a roller coaster and more like a bumpy road. And so the experience has taken on a more even feel. It’s not new anymore. It’s just that thing you do, that thing that happens to you.

I used to look for silver linings, and I suppose there have been some. For example, getting to know other people affected by CLL has brought out my empathetic side, made me more comfortable speaking the language of emotion and acknowledging pain and loss. I learned through this blog and online forums that I could turn my experiences into something that might be of help to others. When things have gotten bad for me personally, I have found an inner strength I didn’t know was there, an ability to hold things together and st
ay focused and not freak out. You could say that I have grown as a person. The shorter my life threatens to become, the fuller it is.

But this is a war of attrition, and that takes something out of you. The silver linings usually pale in comparison to the clouds. There is a slow drain of resources:
emotional, financial, and in the form of dreams deferred and plans altered. Five years ago, CLL had an air of unreality about it; now it has been around long enough to have impacted almost everything in my life. It is impossible to deny.

After five years, I have also learned that knowledge is imperfect. For example, in the time since my diagnosis, FISH testing has become part of the diagnostic and prognostic workup.
But the test looks for just a few things, and many lay hidden, unseen players in the game. There is a lot that the experts still don’t know about CLL, and the learning curve requires patience; the first chromosomal abnormality (Trisomy 12) was discovered the year I graduated from college, 1979. And in the words of Dr. Terry Hamblin, “We still do not know what it means.”

On a more practical level, I have learned that knowledge can only take you so far. Understanding the tests and treatments and all that is essential. But how your disease progresses, how it reacts to therapy, these do not always follow the rat
her incomplete book. CLL is notoriously idiosyncratic, and there’s a lot of trial and error when it comes to managing it. There is no way to know for whom the bell curve tolls. And so I have learned to expect the unexpected.

Over time, I have also come to see that knowledge only takes you so far, for reasons that have nothing to do with medicine. The quality of the CLL experience is something that evolves in part from your reaction to it. I am talking about the emotional and spiritual component, what the clouds and their silver linings, the thunder and lightning, does inside of you. There’s who you are going into this and who you become.

In my case, I was afraid of death and am now less afraid. I’m not happy about it, mind you. But I’ve gotten used to the prospect.

I have also found some balance. A CLL diagnosis comes as a shock, and the ongoing experiences of getting test results, visiting doctors, being treated an
d then relapsing, all these things can create a life lived on a medical treadmill. This was the case with me, and then I realized that when the treadmill slowed, the sun was still rising and shining on a planet that contains more than B lymphocytes. The beauty in life began to reassert itself.

For a time the world is CLL, and then it becomes the world again.

Knowledge only takes you so far. The whispering in your soul takes you the
rest of the way. This is where CLL meets the cosmos. Where a terrible burden meets its context. Where the stars float and you do, too, set loose by the unbearable lightness of being.

CLL is nothing more than one possible end to your story.


So keep writing.

Saturday, August 30, 2008

The deadliest catch

I was brushing my teeth Friday when I heard that my neighbor John McCain had chosen Sarah Palin of Alaska to be his running mate. My first reaction was “Has he lost it?” My second reaction was a mirror-smudging spit-take upon hearing a TV reporter say, “Her favorite food is moose stew.”

In a single stroke, McCai
n gave up his best issue against Barack Obama -- experience -- and showed that he is just another cynical politician whose slogan, “Country First,” is meaningful only when it is convenient for him. In the process, he has insulted the intelligence of the American people and cast his own judgment in doubt, looking more like a desperate opportunist than the statesman he purports to be. In contrast, Obama’s pick of a solid and experienced running mate in Joe Biden makes him look like Lincoln, Washington, and Jefferson rolled into one.

Readers of this blog know that I have had reservations about Obama and his lack of experience. I ended up voting for Hillary Clinton in the primary. I have always liked McCain, more or less, though I disagree with him on a
great many important issues. For the first time in my life, I have been questioning whether to vote Democratic. (Marilyn, furious about the sexism she saw during the campaign, plans on writing in “Hillary Clinton” this fall.)

Now, thanks to the Palin pick, John McCain has pretty much convinced me that voting for him would be an unacceptable risk. For there is no way on God’s green earth that someone who has served 20 months as governor of a state with fewer people than Austin, TX, and whose prior experience was as mayor of a town of 5,469, is ready to assume the presidency of the United States and the leadership of the free
world. As today's editorial in the Fairbanks News-Miner puts it, "Most people would acknowledge that, regardless of her charm and good intentions, Palin is not ready for the top job. McCain seems to have put his political interests ahead of the nation’s when he created the possibility that she might fill it."

If something happens to the 72-year-old, melanoma-prone McCain, I shudder to think of Sarah Palin negotiating with Vladimir Putin, or finessing Kim Jong Il, or dealing with a sudden nuclear crisis in Iran. And I have to wonder, too, whether a President McCain might not do something as rash and impulsive and nonsensical as he did in picking Palin. John McCain has thus cast doubt on his own fitness to serve.

I really do have to wonder about his tempera
ment -- which Obama mentioned in his speech Thursday night -- and which has been the subject of some not-so-quiet concern by McCain’s own GOP colleagues. "The thought of his being president sends a cold chill down my spine," Sen. Thad Cochran (R-Miss.), told the Boston Globe. "He is erratic. He is hotheaded. He loses his temper and he worries me."

Consider me worried, too.

And we may be hearing the word "Eagleton" pretty soon if this "Troopergate" investigation shows Palin to have been playing petty politics in the governor's office.

The Palin pick has been just another episode in what has been a bizarre political year. As Marilyn said the other day, “Doesn’t this whole campaign have an air of unreality about it?”

There is something about the GOP ticket that smacks of a bad sitcom (I nominate Tim Conway and Tina Fay for the leading roles) -- the story of a crusty, doddering war hero married to a beer
heiress who runs for office with a gun-toting, moose-eating, hockey mom who also happens to be governor of the 49th state, where she and her snowmobiling-champion husband are raising their kids Track, Trig, and Willow (Paper, Scissors and Rock evidently having been taken, as someone pointed out). Oh, and between the McCains and the Palins, they have ten homes, so there’s always another venue for a hilarious misadventure.

Except, let's hope, the White House
.

Your president after next, possibly as soon as January, seen here with what appears to be a group of neoconservatives.

Sunday, August 17, 2008

Blind trust

A CLL patient with an allergy to Tylenol, which is clearly noted in his chart, is treated at MD Anderson. Before his Rituxan infusion the nurses try to give him -- what else? -- Tylenol.

Another CLL patient -- me -- arrives for his first day of R-CVP therapy. “So, what are we doing today?” I ask the chemo nurse. “FCR,” he says.

A patient with a
high lymphocyte count goes to a leading cancer center, Dana Farber, to find out what’s wrong. He is diagnosed with CLL by one of the "names" in the business. Chemo nets the patient a CR; it is only when he is coming out of remission two years later that he discovers, at the Mayo Clinic, that he has Mantle Cell Lymphoma (a much more aggressive disease) and was misdiagnosed in the first place.

These stories hav
e one thing in common: No matter where you go for diagnosis, care, or treatment, people are fallible. A chart is not read. Chemo orders are misread. Assumptions are made at diagnosis when every last “t” should be crossed and “i” dotted. People get busy, sloppy, or inattentive. It happens in all walks of life, and one should not assume that the gravity of the situation -- your health, your life and death -- inevitably provides an extra measure of competence.

I will never forget the e-mail I received from the woman with stable CLL who went to see a world-famous expert and was told that her platelets had crashed. Whic
h had her in quite a panic until the doctor realized he was reading someone else's CBC.

The purpose of this post is not to slam health care professionals, most of whom do a good job in a busy and stressful environment. It is to remind you, dear patient, to stay on top of all the little things so that they don’t become big ones. As a managing editor told me when I was a cub reporter: “When you assume something you make an "ass" ou
t of ‘u’ and ‘me.’" Corny as hell, but prophetic.

Or as Ronald Reagan said about treaties with the Soviets, “Trust but v
erify.”

Or as the woman I know who went in for a mastectomy and had the wrong breast removed said, “How was I supposed to know that I had to remind them which breast to remove?”

Read here about a man who went to the Mayo Clinic and lost an eye because he assumed he was being seen by a doctor but was instead being seen by a man who look
ed like a doctor and acted like a doctor but was in fact a convicted criminal with no medical training. How was he to know the man was not a doctor?

How was our patient at Dana Farber to know that he had been misdiagnosed? Sadly, this error was to cost him his life, for at relapse he had to proceed immediately
to a risky stem cell transplant and was unable to get anything close to the CR that was required for it to have a real chance of success. All too late he learned about a certain chromosomal translocation, t(11.14), that his first doctor should have been on top of.

That is the most extrem
e and tragic example of what can go wrong, for the patient tried to do everything right and the system failed him. Try as hard as we might, we cannot always navigate safely through a world of strange words, concepts, procedures, and tests.

But we have
to try. Our only recourse is to follow my managing editor’s advice and assume nothing, not even the most simple or obvious thing.

For example, Marilyn or I check every chemo bag that is attached to my IV pole.
Does it say "David Arenson" on the bag? Is the name of the drug correct? Is the dosage as planned?

Caretakers are extremely helpful for patients who are feeling sick, or worried and anxious, or who have been turned into zombies by medications. Benadryl lowers my IQ by about 50 points. Me . . . wa
nt . . . sleep.

In the case of the Tylenol at MD Anderson, the patient noticed the error. Later, as he snoozed away thanks to premeds with Rituxan dripping into his veins, his wif
e noticed that his blood pressure was not being taken, which is supposed to be standard procedure at MDA. That was error #2 of the day.

This sort of thing happens all the time. I know of one CLL patient who was given massive amounts of Decadron because the nurses did not understand the conversion between dosages of different steroids.
40 mg of prednisone does not equal 40 mg of dexamethasone (Decadron). Somebody assumed something and made an ass of themselves. Fortunately, no real harm was done.

Many patients live to tell the tale of a symptom that is ignored or dismissed but that turns out to mean something. My initial drop in hemoglobin last year, which
my doctor and the head nurse assumed was due to marrow impaction, seemed a little too suspiciously rapid to me for comfort. I knew it was AIHA before they did, and it was only my insistence on tests being done that confirmed the diagnosis before I collapsed in the street.

Of course, like everyone else, I am not always so lucky at second-guessing and fielding curveballs. In March I made an appointment to see a dermatologist. When I got there I was seen by the physician's assistant, who used liquid nitrogen to burn off a few suspicious keratoses on my head. Later I asked why the doctor did not see me and was told that upon arrival I should "ask for the doctor specifically," otherwise he would probably delegate to the PA if he thought the issue at hand wasn't significant.

Well, it's all significant to me, and I had assumed -- oops, there's that word again -- that if I made an appointment to see a doctor, that's who I would see. I had better luck than the Mayo eye patient but still was blindsided by this wrinkle in the process. On m
y next visit, three months later, I asked for the doctor, who saw a suspicious growth that was biopsied and which turned out to be a squamous cell carcinoma. The PA had tackled it with liquid nitrogen during my previous visit to little avail; would a better-trained eye have noticed something "significant" at that time and handled it better?

Live and learn.

Treatment, obviously, is one area where getting it right is essential, especially when it comes to chemotherapy. Here are some common sense precautions you can take:

Arrive on chemo day knowing what is supposed to happen. Bring a complete list of drugs and dosages, including premedications. Try to bring a caregiver with you, especially if this is your first chemo experience, who can stay on top of things, including your reactions when the drugs are infused. More than once Marilyn noticed that my face would get flush during Rituxan therapy. You cannot see your own face, and if the premeds have z
onked you out, you may not be aware as other symptoms come on. Nurses can get busy and step away; caregivers can watch things like a hawk.

Verify with the chemo nurse what is to be done, in what order, and at what dose and rate of administration. Let the nurse know if you have any allergies, or suspected allergies, to any of the drugs. Do not hesitate to ask to speak to your doctor, or the doctor on duty, if you have any concerns.

All this comes under the heading of "why you should become an educated patient," or at least an organized and thorough and vigilant one. Do not hesitate to be a pain, or to ask "stupid questions." Many health care workers appreciate patients who try to make sure things are going right. That benefits everyone.

Where does blind trust lead you? Perhaps to where you want to go. Or perhaps to life without an eye. As Louis Pasteur once said, "Do you ever observe to whom the accidents happen? Chance favors only the prepared mind."

Saturday, July 12, 2008

O blessed iPhone

My grandfather was impressed by airplanes. Of course, he was born in 1895 and grew up in Tomsk, Siberia. Freedom and electricity were pretty big deals, too. But whenever I arrived by jet at JFK airport in New York in the 1960s, it was an occasion. Sure, his grandson was arriving from Arizona for a summer at Seagate. But, ox carts be damned, look how he came!

Well, you know you're feeling older when technology surprises you, when it outpaces your wildest imagination. Take cell phones, for example. During my lifetime they have gone from science fiction (a la the communicators on the original Star Trek) to clunky imitations of real phones (remember the big box mobile phones of th
e George Herbert Walker Bush era?) to the iPhone 3G, which Apple's Steve Jobs calls "the internet in your pocket." (Speaking of wild imaginings, the -- um -- internet?)

Back in 2001, Marilyn and I bought our first cell phone. It was a Motorola Timeport. The name was absolute Sta
r Trek. It flipped open like Kirk's communicator. It had a screen with bright green display, which was forward-thinking back at the turn of the century, when most cell phones had dull black-on-gray LCDs. And it did a whole lot of stuff, things that would have dazzled Lt. Uhuru, the communications officer of the Enterprise.

That's another way you know you're getting older: When things like phones have functions you didn't know existed, and when they tend to baffle you, and when they require glasses to attempt. (There are ads here for a cell phone called "Jitterbug" which is intended for old people, has big numbers, and doesn't do a lot besides make ca
lls. Not wanting to cross entirely into codgerdom, I have refused to even consider the thought of getting such a, er, simple and functional device.)

For seven long years we used our trusty Timeport, which continued to function even though the "4" key began to fall into the body of the phone. Then, early in June, we went to the Verizon store and looked at the phones. Each one was smaller, thinner, and more complex than the next. If you have fingers the size of pencil lead and the eyesight of a spy satellite, you can work them. Other than that, they were unremarkable. The display screens were tiny and hard to read, web pages that loaded looked disjointed, not unlike they do when they load at home and there are several errors on the page.

Then we went to the Apple store. Now, I am not an Apple groupie. I prefer PC to Mac (sorry, but no delete
key?). The employees at the Apple store tend to look a bit like members of a cult, outfitted in light blue T-shirts emblazoned with the words "I could talk about this stuff all day." At any moment I expected to be asked, "Have you heard about the Rev. Steve Jobs?"

So it was with a ce
rtain amount of skepticism that we both approached the iPhone display. "Twaddle!" I muttered. "Hype!"

But within about five minutes we were in love. It was sensible. It was intuitive. It had a big screen, for a cell phone, and you could "dial" the numbers without pressing all the numbers around it. The web interface looked like the web. It had Google. You could search for "pho Phoenix," have 20 Vietnamese restaurants show up on a map, then touch one
, which would bring up a display showing the phone number as well as the website of the restaurant. You could touch the phone number to dial the restaurant, then ask the map to show you how to get there from the Apple store. It did everything but cook dinner.

Lest you think locating food is all it's good for, this "internet in your pocket" is a godsend for eBay sellers. Countless have been the times that we have run across a pile of something and said to ourselves "I wonder if this will sell on eBay." Now, envisioning God's gift to communication in our paws, we realized we could easily go to eBay and find out. It would pay for itself in a month.

Rev. Jobs, take my money! I'll sign over anyth
ing to have one of these magical devices!

But they were out of them. They had been out for a month. "Steve has
a big announcement next Monday," a starry-eyed young man confided. "We think it's the new iPhone 3G."

And so it was. And Steve described the improvements and new features. And
they were good. And it was half the price of the old iPhone. And we fell upon our knees and gave thanks.

And this is why we arrived at 7:15 a.m. on F
riday at the AT&T store in Flagstaff, Arizona. Now, Flagstaff is not a big city. It has less than 100,000 people. But it's the biggest thing for hundreds of miles in any direction, so it gets an AT&T store. And they get iPhones. There were a grand total of 15 people in line when we got there, 35 by the time the doors opened. As they say in questionable massage parlors, everyone had a "happy ending."

And so the little darling is at home now, wanting to connect to our in-home network but willing to bring us the net via AT&T (whic
h means we also have a backup way to get online the next time our $%@#! internet provider crashes). We have set up voice mail, which could not have been easier and which also is visual as well as aural. We went to eBay and saved it as an icon on the home screen of the phone. We have located pho in Denver.

It also takes pictures and plays music and synchronizes with your e-mail account and seems to burble when you call it (which I think is actually the vibrate function).

Like my grandpa, I have reached the age when I am, quite simply, blown away.

Monday, June 30, 2008

Farewell to a dear friend

P.C. and Chaya Venkat were pestering me to wear a hat. I had made the mistake of admitting that, despite a history of skin cancer, I did not always wear one.

We were meeting the Venkats at an Italian restaurant in Sedona early in 2004. Marilyn and I were taking them out as a “thank you” for their website, CLL Topics, and for being there while I stru
ggled with my diagnosis and early treatment decisions.

I had run across Topics one night in October 2003, some five weeks after I got the news that I had a virtually unpronounceable as well as incurable disease that could only be treated by dangerous drugs I had never heard of. Topics was a fairly new website then, not quite as encyclopedic or well-known as it is today. But it was still a welcome voice in the wilderness for those seeking to understand chronic lymphocytic leukemia. I found the feedback form and wrote the following:

“Hi, Chaya, et
al.: [I didn’t realize the “et al.” was P.C., who acted as webmaster and editor.] I just want to let you know how much I appreciate this website! I have recently been diagnosed with CLL, and your site is a comprehensive, intelligent forum for the latest information. I'm 47 and I feel fine, but have swelling of the spleen and lymph nodes; my oncologist recommends I start chemotherapy within the next couple of weeks. I found your site quite by accident, on page five of a Google search on 'fludarabine.' I'm amazed I had not run across it before. At any rate, thank you so much. I'll be spending a lot of time here in the coming days as I learn everything there is to know about CLL and my treatment options. I see you are in Arizona -- my wife and I live in Sedona. Thanks again for all your hard work. Believe me, it is very much appreciated! Cordially, David”

And I received this reply
from a Mr. P.C. Venkat:

“Hi David:

Thanks for your email. Delighted that you find our website a useful resource.

I knew we were going to run into a CLL Topics visitor from Sedona sooner o
r later. The amazing thing is that until we got your message, it hadn't happened yet. Well, congratulations, you are #1 from Sedona, which is where Chaya and I just happen to live. Welcome, neighbor.

Chaya and I would be happy to hear from you if you would like to talk to us. You may reach us at XXX-XXXX. What the heck, we can even meet if that works better.

Best regards,

P. C. Venkat”

That is how our fri
endship began, and it was the start of our shared struggle against CLL. I say shared, for we were comrades in battle, even though the Venkats had a somewhat better understanding of what we were fighting. Chaya and P.C. quickly became mentors, examples of how to research the facts and put all the information together in a strategic vision.

The struggles of ensuing years were yet to come. That night at the restaurant, over pasta and with our faces framed by candlelight, we were in a sense starting out, optimistic and hopeful.

When Marilyn and I arrived, the Venkats were already there.
P.C. looked rather dashing, a thin and wiry man with a salt-and-pepper goatee. Chaya had a friendly face and radiant eyes, and salt-and-pepper hair that complemented his. Before dinner began, P.C. briefly donned a brown Aussie hat to demonstrate how such amazing contraptions are worn.

One thing the Venkats had been learning about was the tendency of CLL patients to develop squamous cell and
other skin cancers, of which I had a history. (This is the sort of dinner conversation we often enjoyed with the Venkats: chemotherapy, complications, the latest buzz about promising treatments, as well as the unending kerfluffles in the world of CLL.) Here I was, pink-complexioned, a product of the Russian steppes and the British Isles. And stubborn as hell, having ignored Marilyn’s admonitions for years to wear sunscreen (“too yucky”) and a hat (“too hot,” “too inconvenient”).

Chaya and P.C. put the fear of god in me, with plenty of abstracts sent
my way and other incontrovertible evidence that proved that when it came to sun precautions, I was being a dumbass. I will never forget the e-mail P.C. sent me, following on a discussion of skin tone and sun damage:

“Hi David:


Just so that you don't feel singled out on the strength of your undeniable pinkness, consider this. I have cafe-au-lait or perhaps cafe-mocha skin color, I was born in Malaysia (2 degrees north of the Equator), and have not always been afflicted with CLL or knowledge of it. Nevertheless, ever since we moved to Arizona, I have worn a broad-brimmed hat, even before I was diagnosed, and wore it on ten yard trips to the mailbox, excursions into the back yard, to the post office, fancy restaurants, doctor's offices, not to mention hikes and long drives. And, I might add, took a lot of ribbing for it from parties I will not mention. With some determination and in spite of an early tendency to lose track of the much maligned object, it has become a trademark. People are surprised now when they see me without the darn thing. See, cussedness does pay off. You can take comfort from this too: if it gets ratty enough, nobody will be tempted to make off with it.

Best,

PC (Mr. Bronze to you.)”


I still smile when I read this even though P.C. is gone, for it sums up his sense of h
umor, his no-nonsense approach to things, and his willingness to be of help. This was something that ran in both Venkats. A short time later, Chaya published Dying to Get a Tan on CLL Topics. She wrote it with me in mind, she said. In other words, I was the idiot who helped inspire her cautionary warning to patients everywhere. But it was done out of love, and with good humor.

And that is what CLL Topics was and is, a labor of love. It was a labor for the larger patient community, an effort by two people uniquely suited to making sense of insensible papers, a couple with bullshit detectors the size of the Hubble telescope, a talented pair who could separate the wheat from the chaff and distill a muddle of information down to the essential. I was honored to serve on the Topics Board of Directors for a few years and was able to observe close-up the quality of attention that the Venkats put into patient education and advocacy. They lived it and breathed it 24/7.

But Topics was also something more personal, a way for Chaya to help her husband and for both Venkats to put their heads together in search of a way out of this CLL mess. We used to joke about the fact that many of the articles seemed to be about medical issues P.C. was currently experiencing or treatment options that he was considering.

And we also used to joke about the fact that I seemed to be following in P.C.’s footsteps when it came to treatment. We both started out with single-agent Rituxan, for example, and once sat side by side in the infusion room. By last year, when it was clear that P.C. was going to undergo a double cord blood transplant, a transplant looked to be in my future, too. Dr. John By
rd and the inevitable progress of the disease had told me it was.

When we ate dinner last summer at a Thai
restaurnt, P.C. explained in detail why the time for his transplant had come. There was no sibling or unrelated donor for an adult stem cell transplant. His remissions from HuMax-CD20 were getting shorter. He was in the peak of health, with no comorbidities, and he wasn’t getting any younger. It was clearly a decision that he felt comfortable with, one that made sense.

I am reminded here of a quote from the Czech playwright and president Vaclav Havel:

"Hope is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."

And so P.C. began his preparations and earlier this year traveled with Chaya to th
e University of Minnesota to undergo the procedure. I last spoke to him around the end of May. He was feeling good, happy that the engraftment was going well. It all looked promising. And then, as Chaya has so eloquently explained in Harvey’s Journal, the unexpected happened, and it was followed by the unthinkable: P.C.’s death.

As I write this I still cannot fully believe that he is gone. The story was supposed to end differently, with P.C. finding his cure and me somehow lumbering along after and with the four of us raising glasses of red wine in 20 years and saying, “Remember that time we had CLL?”

Oh, how I wish stories had happy endings. I wish
it for Chaya, who wrote article after article with love and affection for the Round-Headed Kid. The EGCG-based recipe for Harvey’s Chocolates symbolized her devotion -– a homemade treat, a way to knock back CLL in the dark chocolate that P.C. enjoyed.

And, of course, I wish it for P.C., who was as good a man as any I have ever known. Many tears have been shed this past week, and not just in Sedona. P.C. had friends everywhere that people struggle with leukemia.

But he would not want us to spend too much time crying; he would call upon us to be brave and continue on. P.C. approached things with logic, focus, and determination. He did not spend his time shaking his fist at the stars or bemoaning his fate. He was not a prisoner of fear. He did not ask anyone else to do the heavy lifting when it came to learning what CLL was and how to cope with it.

P.C. was a superb strategist who did everything right. It was one of those curveballs that Chaya has written about so often that got him. There was
no way to see it coming.

It strikes close to home, of course. One of those curveballs may yet get me. Or perhaps I will survive. The one thing I know is that if I do somehow beat CLL, it is because I learned how to fight from P.C. Venkat.

I tip my hat, which I wear all the time now, to you, P.C. You will be missed more than you could ever know.


Three of my favorite people: Terry Hamblin, left, with P.C. Venkat and Chaya Venkat. The photo was taken when the Venkats went to England in 2006. The landscape photos accompanying this post are of Sedona, the sort of scenes P.C. saw every day from the trails he loved to hike with his dog, Jasper.