Thursday, September 03, 2009

My six years of CLL, and six things I’ve learned

September 3 is here, the sixth anniversary of my big doo-doo surprise. It was on this date in 2003 that I awoke from a dream in which the room was spinning. It turns out that the room really was spinning, which meant a visit to the ER, which was followed after a couple of hours by my diagnosis of chronic lymphocytic leukemia. I was told it was a “good cancer” and sent home.

The room, as it were, has not stopped spinning since.

I was going to title this post “Six years of this crap,” but I think it’s best to look back with a more even tem
perament at some of the big screaming bullet points that I have run across. These are things that may be the most help to those of you who are waking up into your own CLL bad dreams.

Since 2003 I have come some distance in my understanding of the disease and what it means to cope with it. Time is a teacher, and I’m sure it has a lot more to throw my way at least I hope it does, if you catch my drift. At six years in, I’m in my CLL middle age, both in terms of disease progression and knowledge. When it comes to the latter, I'm no longer wet behind the ears, yet wise enough to know that the learning curve goes on forever.

Here are some things I’ve learned, sometimes the hard way. They may represent a change or an evolution in thinking over some older posts in the blog. They are the truth as I see it today:

1. CLL is not the same disease for everyone. The “CLL is an indolent disease/good cancer” monster has to be staked through the heart every time it gets out of its coffin to suck your blood. It is the old, cobwebby way of thinking about CLL. Wipe those cobwebs from your eyes, unless you enjoy being mesmerized while your life drains away.

Some of us have relatively mild CLL, some of us don’t. Some of us respond really, really well to easy, breezy treatments, and others of us barely respond to nuclear chemo. This is because, for all practical purposes, we don’t have the same disease. A dog is a dog is a dog, but not all dogs are alike: Paris Hilton would look a lot more chewed up if she were carrying around a pit bull instead of a chihuahua.

Figuring out what kind of CLL you have does no
t involve reading tea leaves, poring over entrails, or consulting the shell of the prescient tortoise. It’s a matter of looking at the results of the tests available IgVH mutational status, ZAP-70, FISH, CD38 and at your clinical history (how fast your nodes are growing, how quickly your lymphocyte count is doubling, how far your hemoglobin and platelets are dropping). When I was diagnosed, the only readily-available test was CD38, so a lot has happened in six years. If you want to know what you’re dealing with, get your tests done.

2. See a a CLL expert (or two) at the very outset. Ol’ Doc Lippencot, highly regarded as she is around these parts for curin’ breast cancer and lice and possum infestations and such, didn’t know much about CLL. This is often the case with the local doctor, whose stock in trade is usually not going to be a disease that affects almost nobody.

And while patient networks and educational websites are excellent for moral support, learning about case histories, and keeping up with the latest research news, they are of limited medical expertise. This is because they are filled with seekers and guessers such as yourself, not to me
ntion the occasional insufferable blowhard. Some of these people are downright brilliant, some of them are extraordinarily helpful. But in the final analysis they are, like yours truly, amateurs what the dictionary defines as “lacking the skill of a professional.”

Which brings us to the professionals. Experts live and breathe CLL and
have seen hundreds of people just like you, with all the variants of your disease. They have a clue. This does not make them infallible. Having consulted a few, I can say that they don’t always agree. Just as painters see the world differently, so do those who practice the art of medicine. So see a couple of the big names — or even a few, the worse your case is just to get a consensus, or maybe that much more confused.

Our CLL experts are a great bunch many of them are approachable by e-mail but they’re not miracle workers and they’re not gods. Sometimes they run out of things they can do to save your life. Dr. Terry Hamblin told me in an e-mail once that, the way things stand today, doctors can only keep me alive for so long. I forgot how long “so” was — it appears to be at least six years — but the point was well taken, which leads me to:

3. The battle has a beginning and an end, and you need to be re
ady to fight. For those of us who don’t have indolent “goody-two-shoes” cancer, the day will come when we beat it or are beaten by it. The opening round came when that first mutant CLL clone got out of your own personal Pandora’s Box. The final round will come when it comes, and for many of us younger patients it will probably end with a transplant, win or lose (or there can even be a draw, of sorts).

Obviously, you need to be as prepared as possible. That is why patient education is important, getting the lay of the land is important, staying up with truly useful news is important, staggering your treatments intelligently is important, doing all the strategy and tactics stuff is important.

And that is also why learning to cope emotionally is important, and why this battle hinges at its heart on more than science and medicine. Healing is a big, mysterious thing. Books have been written. Bullshit has been blathered. But there is a lot about the mind-body connection that we don’t understand. Well-respected, level-headed doctors see “medical miracles” during their years of practice. I believe your chances of healing are better if you put your heart and soul into it, and the evidence seems to back me up.

Emotional preparedness can also help you cope with the inevitable surprises and slip-ups, the disruptions and disappointments (and occasional triumphs) that come with fighting cancer. It is a rough journey, a test of your faith and your stamina, something that demands that you get your inward act together.

You can walk out into the ring with all the technical skills, having read hundreds of papers and abstracts, having consulted every expert doctor within a ten thousand mile radius — but if you don’t learn to float like a butterfly and sting like a bee, if you can’t get in your groove, make knowledge and soul work together, you are fighting with one hand tied behind your back.

4. Be a pain in the ass. No, I don’t mean be a cry-baby or a whiner or a ninny (take that blood draw like an adult!). I mean learn to stand up for yourself in medical settings, learn to question things if you are uncomfortable, learn to say “No” and “Are you sure?” Do not be railroaded by doctors, office staff, or well-meaning family or friends. Be as diplomatic as the situation allows, but keep in mind the words of Teddy Roosevelt: “Speak softly and carry a big stick.”

This is where those emotional/intuitive clues come in handy. If someone says, “This is right,” but it doesn’t feel right, honor that thought. Float like a butterfly, and whack! with that stick. And the bigger the thing, the bigger the pain you must be. Do not stand on ceremony or save face; it will be at your own peril. The face you save could be
you own.

5. You cannot predict the future with certainty. So far, CLL has humbled the great minds of medicine, so get your humble on. Nobody can predict the future. Nobody can know an outcome for certain. Sure, a lot of cases follow the conventional wisdom;
things often, unfortunately, go by the book.

But there are exceptions. Let me tell you a story:

A patient has a sudden relapse, finds herself refractory to every therapy, has to live on transfusions. Like a Greek chorus, there is whispering offstage: “She should go into hospice.”

And now, two years later, like some mighty Greek goddess who has triumphed in an epic battle, she has survived a sudden transplant and is doing pretty well, thank you.

Bad things often happen in CLL, but good things can, too. This is not an article of
faith, it is a matter of medical fact. There really IS hope, tempered as it is by this thought:

6. In the end, it often comes down to luck. Dr. Allan Hamilton is a respected neurosurgeon, and the author of a book called The Scalpel and The Soul, and his number one piece of advice after decades of practice is this: “Never underestimate luck good or bad.”

The more I see of CLL, the more I believe t
his to be true.

Why do some people live and some die? My ever-practical younger brother puts it this way: “When your number’s up, your number’s up.”

It’s called Fate. This is why the best-prepared sometimes fail, why the least-prepared sometimes live. That’s no reason not to
care, no reason not to make the odds as much in your favor as you think you can make them.

But nobody gets off this planet alive. Dr. Hamilton has a blog, and he talks rather poignantly (tearjerker alert) about a couple who drive up a mountain to share a glass of wine in the twilight of life.

So enjoy wine and a sunset, whatever day it is for you. Life is not all about the battles we wage to stay here. It is about how we live it while we are blessed to be here.

That can be easy to forget when you’re in the trenches battling cancer. But with time and wisdom, we can learn to savor what life is about de
spite the challenge it has thrown at us. And life can become all the more sweet in the face of the dangers ahead.

Nobody said beating CLL was going to be easy, but n
obody who knows what they’re talking about says it can’t be done.

So here’s to six more years (come to think of it, I think the number “12" was in Dr. H’s e-mail somewhere).

With this post, I am stepping back from the blog for awhile. I have some fighting trim to get into. There are other things in life I must attend to. Over the years I have said a lot, but sometimes there is wisdom in being quiet and listening. I promise to post every few months, and I will let you know if I encounter any big health emergencies or breakthroughs. In the meantime, no news is good news. Take care, and stay as healthy as you can.


Julie said...

Another great post. As I get ready to start my transplant process, I will truly miss your posts. All the best to you and thank you for everything you have done for the CLL community.
Thank you!

Anonymous said...

great post, so much wisdom. I love you.

Anonymous said...

David, you are a good man, my friend. If I had to bet money, it would be that you will come down on the good side of the bell curve.

I look forward to your future posts.


Anonymous said...

Dear David:

I just read your blog for the first time today. I am also writing a blog, but waiting for the courage to make it public. I was just recently diagnosed. We have both an Arizona connection and a journalism connection. I have a feeling we will someday meet.

You and Marilyn are in my prayers.


Grateful said...

Thank for another great blog! I will miss your writing, but as you say, I will remember that no news is good news.

Anonymous said...

First off, David buys into the myth that pit bulls are savage attack dogs. Nothing could be further from the truth. They are bred to be fighting dogs. They are powerful, so they are selectively bred to be very people-friendly. I've rescued two of them. One of them is a bit too interested in other dogs, but both are very loving and very friendly towards humans.

As far as tests go, get them done at a research facility, especially for the ZAP-70 test, which can give a good clue as to your prognosis. Probably the most important test, though, is the mutated/unmutated status. Unmutated CLL generally has a more aggressive course. CD38 and other markers can give you more insight into your CLL. Remember, though, that no marker is infallible; your course will vary from every other CLL patient.

On transplants: Transplants are not in everyone's future. Patients with very enlarged lymph nodes will not be given a transplant, since it is unlikely to work. And transplants are no walk in the park. I've personally known of one CLLer who had a transplant. She had a very rough time and lived only a couple of years, dealing with a variety of complex problems. In the end, cancer took her life.

I do recommend a consult with a CLL expert. They have seen hundreds and hundreds of CLL patients, they are up on the latest research, they often run clinical trials, and they are your best bet for a longer, better quality of life.

Even if the expert is outside of insurance, a consult needn't be expensive. Call around and see what an appointment with the best will cost. (MD Anderson, however, is very expensive for those without insurance.)

Anonymous said...

I understand, David. Although I will miss your timely updates and thoughts on everything that life has thrown in your direction, I know that there are times to write and then there are times to kick it back and live.

One thing that I have learned about CLL is that it is a relentless fighter. It is a sniper, dressed in the appropiate camo gear, waiting for the weakest link of the chain to show it's entry point. It is a quick learner on the ways to fool all treatments when presented too many times, it is the cancer roach......adaptable, hard shelled, survivable, mutatable. But, like the roach, a few get lazy and enter the wrong house. I've noticed that a hard shoe works better on killing a roach than a newer spray of pesticide. I am now wearing army boots and I have my war paint on.....I have learned to sneak attack does have an achilles heel. I want to find that weak spot. That's what all the researcher's are trying to find also. I think we are on the right path.

Love you David. Take special care and don't put down the big stick.


Soapy said...

I understand too David, following the same path as you with the AIHA. I have learned a lot from reading your blog. I have had 10 years since diagnosis, so that means you have at least 4 more years and I hope they'll be good ones. I raise a glass to you and hope you will be back blogging soon. I am floating like a butterfly, but you should see the size of the stick I carry.

Cyberhugs, Soapy

Anonymous said...

My hopes and wishes are with you, David. I will raise a glass of Irish Whisky to you and send positive thoughts.

Anonymous said...

By the way, (imho) pit bulls are a lot like the rest of us: products of our genetic predispositions, our environments, and our own thoughts & actions. I've known a couple of sweet, lovable pit bulls - but I'd never cross one or underestimate one.

Yes, I think "pit bull" is a pretty good description of David. He won't give up the fight prematurely; we can count on that.

Chonette said...

Dear David,
All the best getting on with life and enjoying other things, I have lived with CLL one year more than yourself and fully understand and agree with your writings over the years.
I never wrote a Blog as I did not think I had the discipline to keep it up, you have my whole admiration for your continuing writing and I have enjoy your writing over the years.
I myself never felt having CLL was a terrible thing, I have made wonderful friends I would have not made otherways, the pain of loosing some has been hard and always felt dying must be a much simple thing than loosing a dear friend.
You are still young and I wish you many years to enjoy life, since my SCT I do not feel very communicative, but I hope you will not abandone us all together and I look forwards to keeping in touch and reading what you have to say every few months.
With very best wishes

David Arenson said...

Thanks for all your kind comments -- yes, like Chonette says, we make friends in this crazy thing, and I am proud to have you among mine, even old Scott there who gets pissed off with my every liberal breath. (And yes, it's pit bull fresh!)

I just had to send that last comment through Babelfish -- this is what I got:

"Breathes heavily the tone, reads an article, thanks your check"

Chonette said...

Happy to hear you are well, I had forgotten today is my 10th month aniversary, only now reading your comment realised it is the 25th.
I was talking to another CLL transplanted person at a transplanted patient meeting in London and we both experienced similar feelings, some sort of guilt at how easy we had it compared with some other transplanted people, of course in my case the worst might still come, but she was already 2 and half years after SCT and she looked so young and well.
Although some people think science moves slow, I amaze myself looking at how much things have improved over the last 7 years.
I am moving on in life but the CLL family will always be part of my life and the closeness one feels makes one realise how many good friends and wonderful people are out there.
Thanks for keeping in touch
best regards

Anonymous said...

ok all you cll people out there
lets get to the point. when did your doctor say you need a transplant,,and who are the people with cll that do not qulify for a transplant? i have cll i found out during a blood test 15 months i ended up being alergic to rituxin my first treatment of that went bad,,i had all the side affects plus broke out on my face with sucked but i got through it 1/2 a bag....since that day my cll blood counts came back to normal and the doc said that 1/2 bag killed off alot of cancer and my platlits came back strong...right now i feel and look great,,so tell me what type of problems did you all experience with cll and then what type of treatments did your doctor do to help you,,and how offten?? this is the type of info i need to know and can't seem to find..
and how long before i start to feel really sick? i have no night sweats,,i have energy,,i feel myself,,but i do have cll
i have had heart surgury in the past at age 44 i'm now 55 with cll
so with the heart thing going on does that make me unable to get a transplant if that time comes?
help me out here
joey in montana
drop me a line about your personnel
experience with this cll cancer