Al Gore on the second ballot

Well, a boy can dream. I’ve always liked Al. Behind that stiff exterior lies a man with a good sense of humor and a good head on his shoulders. I’m not going to rehash the travesty that was the election of 2000; suffice it to say that the past eight years would have been infinitely better for our country had Gore been in charge.

Now there is an ever-so-slim hope that he might yet mount a white horse, Nobel Prize medallion around his neck, sun block on his face to filter out the effects of ozone depletion, and ride to the rescue of the Democratic Party.

It looks like we may need it.

Not that we don’t have two good candidates -- it’s just that the longer they stay in the arena, flailing away like punch-drunk prizefighters, the more battered and bloodied and uglier they become.

On the one hand we have Barack Obama, whose ability to inspire is equaled only by what we don’t know about him. The Rev. Jeremiah Wright affair should have been a wake-up call, at 3 a.m. or otherwise. Not the obnoxious things Wright said. Not the fine speech Obama gave on race relations. But the fact that Obama knew it was coming, had known it for a year, and did nothing to nip it in the bud.

"If Barack gets past the primary," Rev. Wright told the New York Times in April 2007, "he might have to publicly distance himself from me. I said it to Barack personally, and he said yeah, that might have to happen."

So my question is, what else does Barack know is coming? What other distancing does he have backup plans for? (I am just a tad uneasy about this Tony Rezko trial, for example.) Obama is an interesting figure. He’s bright, he’s personable, he's full of potential. But I fear he could also be full of surprises. After all, he’s a politician (which will come as a shock to those of you who think he’s the Second Coming of Kennedy). Politicians spin things for the best, and they hide things they think might hurt them.

Speaking as a Democrat, it matters when these things rear their heads and hurt us as a party. (Is there a New York governor in the house?!)

Which brings us to Hillary Clinton, who has been well-vetted, and who we know, warts and all. Obama, who began this year on a pedestal, has nowhere to go but down. Clinton, who has endured often unfair sniping for almost two decades, has nowhere to go but up.

But that doesn’t mean she’s going anywhere, her campaign having blown it in the dozen or so states immediately following Super Tuesday, creating a pledged delegate shortfall that she can’t overcome without a miracle. (As Bill recently said, “It's the caucuses that have been killing us.”)

That won’t keep her from trying, of course. She plans on winning the nomination -- if not this time, then perhaps in 2012. It has been suggested, and not without some plausibility, that Clinton would rather see Obama lose the general election to John McCain than win it. This would, after all, make her the frontrunner for the party’s nomination four years hence, when Americans would be really, really, REALLY tired of Republican rule.

Is she that ambitious? I’d like to think not, but I don’t know. What I do know is that they’ll probably have to carry her out of the Denver convention in a straight jacket to get her to give up the fight. She has been waiting all her life for this, folks, and will not go gently into that good night.

Clinton’s recent approach to winning has been called the “Tonya Harding strategy” -- bash him on the kneecap and hope for the best. And the things that might still make her the nominee -- Obama’s inexperience or skeletons in his closet or a gaffe of some kind -- are the same things that the Republicans are counting on to help them win in November. So her strategy dovetails into their strategy, which is to create the perception that Obama is not ready to be president. This is not helped, of course, by anything that Obama might do to confirm that he is unprepared or too risky to take a chance on.

So we have a situation where two candidates, who are increasingly polarizing supporters on the other side -- witness the Carville/Richardson “Judas” dust-up -- will arrive in Denver without enough pledged delegates to win the nomination.

The superdelegates will have to come up with something, and I am not alone in wondering if Gore might be the answer. Back in the old days, conventions would sometimes select a dark horse on the second, third, fourth, or even later ballots.

Al Gore is hardly a dark horse. He is well known, experienced, a proven popular vote-getter, and more respected today than he was eight years ago. Al could mount that white horse, ride in to unite the party, and gain his rightful place in the Oval Office.

It probably won’t happen, of course, because politics is not like the movies. It is not like fiction. It is stranger.

Life's little annoyances 1

I have decided to embrace my inner curmudgeon and, from time to time, provide a list of some things that are annoying me. If you disagree with my choices, then you are annoying me also. Here, in reverse order of blood boilage, are today's nominees:

5. High fructose corn syrup. Does it have to be put into everything? (Well, apparently, yes.) Is it possible that there are people who might not want the empty calories, or who, if they are willing to risk the calories, might want the taste of real sugar? Here in Arizona you can get Coca-Cola made in Mexico with cane sugar; it tastes like Coke did when I was a kid, before the company switched to corn syrup in the US. . . Try finding a barbeque sauce, or a salad dressing, or even a can of soup or loaf of bread at your average supermarket that does not have corn syrup in it. It will be a miracle, and you should build a shrine.

4. Muzak. The other day I was at the dentist’s office and heard, in treacly, instrumental form, “Give me the beat boys/And free my soul/I wanna get lost in your rock and roll/And drift away.” Could there be a more grotesque irony? Satan himself could not have conjured up anything "better" to play in the waiting room in Hell. This beat didn't get me lost in anything, except laughter and a certain degree of existential despair.

3. Hotels where the windows are sealed shut. God forbid anyone would want some fresh air, especially if the place has been renovated and the carpeting, paint, and luxurious particle board furnishings are outgassing their share of “sick building syndrome” fumes. What does the management think we’re going to do? Jump out the window when we get the bill?

2. Store loyalty cards. So now I have to carry a card for every supermarket I frequent if I want to get the sale price on merchandise at checkout. Ooh, I’m a member of the “Safeway Club.” How nice of Safeway to want to keep track of everything I have purchased, feed it into their computer, and target me with mailings. Why, it even tells the checker my name so they can add that "personal" touch and mispronounce it as they thank me for my purchase. (Sheesh, people, "Arenson" is not rocket science. It's "Air-in-sun," not "Arn-eson" or "Air-EN-son" or that pronunciation of people who just don't try, "Anderson.") Privacy? People have forgotten that one of the treasures of being an American is your ability to be anonymous. Think I'm paranoid? Read this and this and this.

1. Ads for TV programs inserted into other TV programs. Marge Simpson recently asked: “Can’t anyone just watch the show they’re watching?” Well, can’t we? It started with those jarring little logos that networks show on the bottom right of the screen. Now it has gotten way out of hand -- little people walking onto the screen amid flashing graphics to advertise their upcoming shows. Fans of Kids in the Hall will understand when I say "I want to crush their heads." Maybe in this age of multitasking and multimedia people are used to absorbing endless quantities of visual clutter. I want to throw a brick at the television.

Here we go again . . .

Flame me all you want but I am here to make the point again: We Americans must do SOMETHING to guarantee access to health care for all, including those with preexisting conditions.

Dr. Terry Hamblin recently posted to his blog about problems with the UK's public health service, the NHS. (Follow this link and search for "Travails of the NHS.") He describes the messes that can be created when bureaucrats, including committees of doctors, attempt to decide on treatment without expert knowledge. If it were not so sad it would be funny: Terry quotes one doctor who read about CLL briefly and said: "I have been reading about this subject for two hours. I am now an expert in the condition."

What is the take-home lesson here? I think it is pretty clear: The best standard of care requires that doctors with (genuine) expertise in a given condition be allowed to make the decisions.

But a couple of those who posted comments about Terry's piece drew another lesson, seen through the filter of their myopic glasses: "Cautionary tales such as this make me oppose national health systems being imposed in the US, " wrote one. "I'm not sure why there is such a hue and cry over the 'failure' of the American health care system when it is in many cases the envy of the world. . . . Changing to a bureaucratic-run system will be made at the peril of the patient."

Hmm. Somehow American veterans have managed to survive the bureaucracy at VA hospitals, and somehow elderly Americans have managed to cope with Medicare without keeling over in large numbers.

But those are asides. The essential point is this: The failures of bureaucracy do not mean that the US should not have a health care system that provides access to all. Access to health care is a moral issue independent of the manner in which it is instituted.

And bureaucracy is not the province of government-run care alone: We have all heard of -- and indeed, many of us have experienced -- cases in which bureaucrats working for health insurance companies in the US make ridiculous calls. They deny treatment, refuse to approve the right treatment, or reject an appropriate test. (Ask the family of Nataline Sarkisyan, or ask Hilary Skvov and then read this.) Indeed, the bozos making these decisions in the US often have no medical training at all; their job is counting beans. They could read about a given condition for two hours and still not know their asses from a hole in the ground, nor would they care. (A committee of doctors -- we should be so lucky!) In America, the fox guards the henhouse. The quality of our care may be excellent but getting access to it is another matter entirely -- even if you have insurance.

Ignorance is ignorance, be it in the public or private sectors. When it comes to patient care, doctors should be calling the shots. Coming up with a fair, workable system may be tricky but it is not impossible. We sent men to the moon, ferchrissakes. Americans want as much freedom of choice as possible, and as light a regulatory touch as possible, but they also want to be able to get the care they need. I have enough faith in my country to believe that we can finesse these matters and devise a system that works reasonably well for all.

None of this takes away from the fact that access to health care is a moral right in a civilized society. I will never forget the post I saw from a CLL patient who lost his job because of his condition and, having also lost his health care, was trying to combat his CLL with herbs. I am almost as sick and tired of those who use "bureaucracy" as an excuse to deny their fellow citizens coverage as I am of CLL.

Transplants and the treatment balancing act

If we’re smart, we CLLers look down the road and think ahead. A question we should be prepared to answer is this: Might I need a stem cell transplant at some point, or is there a reasonable possibility that I can ride this thing out without one?

Chances are, if you are younger than 60 and have unmutated chronic lymphocytic leukemia, you might well need a transplant if you want to become the eccentric old codger you were meant to be. I, for one, look forward to spending my 80s with Marilyn and too many cats while yelling at kids to get off my lawn. I have no intention of letting CLL interfere with those golden years.

Further signs that you might need a transplant -- and, by the way, transplants are now being done on patients well into their 60s if they are in otherwise good health -- are these: Risky abnormalities per FISH test, such as 17p, 11q, and perhaps Trisomy 12; ZAP-70 and/or CD38 positivity; clinical symptoms that show disease progression on many fronts; relapse from treatment, especially after a shorter-than-average remission.

For such young-uns with uncooperative CLL, the stem cell, or bone marrow, transplant is a light at the end of the tunnel. For some, this light may have the characteristics of an oncoming train, but I prefer to look at it as a potential cure.

Harvey ponders the path to success

Anyone looking down this road should keep up with Harvey’s Journal at CLL Topics. Harvey is a somewhat hypothetical fellow who is about to undergo a cord blood transplant. A recent journal entry, Planning for Success, describes the logic of achieving a CR ("complete response") prior to transplant, as well as the ways in which our treatment choices over time can reduce our ability to achieve that CR. The facts presented led to a little surprise and consternation among some readers.

Chaya Venkat, the Topics writer who, like Elwood P. Dowd, enjoys the delusion that there is a Harvey in the house, cites a study from the Fred Hutchinson Cancer Center. It shows that entering a transplant with bulky disease puts you at a disadvantage: after two years, 14% of patients with lymph nodes less than 5 cm at transplant had relapsed, compared to 52% of those with nodes greater than 5 cm. She further cites another study from the Hutch, albeit with a small sample, showing that, in her words, “the risk of relapse in CLL patients going into the transplant with full blown CR was zero, none, nada.” If you think about it, that makes sense: the less CLL the new immune system has to fight, the better the odds of achieving a successful graft vs. leukemia effect.

Chaya also provides data from a 2005 study by MD Anderson, which I have discussed in the past and which can be found in detail here. It shows the CR rates in previously treated patients who are given FCR, which is today’s gold standard of chemotherapy. While 70% of those using FCR as their first treatment get a CR, that number drops in previously treated patients: to 29% in those who have used single-agent Rituxan; to 28% in those who have used an alkalyting agent such as chlorambucil or cyclophosphamide; to 24% among those who have used fludarabine and cyclophosphamide together. Table 3 of the study has details on fludarabine sensitivity: 31% of those considered sensitive achieved CRs, as opposed to just 5% of those who were refractory to the drug. (A note here: Only seven patients in the study had used single-agent Rituxan. That's not a huge sample but it's the only one we've got.)

So what is a patient -- especially one who thinks they might need a transplant one day -- to do?

The treatment conundrum

The question of which treatments to have, and in what order to have them, is much debated among patients -- I have written my share about it in this blog -- as well as their doctors. As Dr. Terry Hamblin has pointed out, the studies are just not there to show us what combination, and in what order, leads to the longest overall survival.

Chaya delineates the problem as it relates to transplant: “Getting that CR ahead of the transplant may prove to be more difficult than you thought. Waiting too long to make the transplant decision may end up costing you. If you become a truly refractory 'salvage' case, it may not be possible for you to get a good remission no matter what you try. Too few bullets left, and too strong an enemy, the window of opportunity to get a successful transplant may not last forever.”

Dr. John Byrd has been quoted as saying that your first treatment is the most important because your first remission will be your best. And if transplant success were the foremost goal, then we would all have transplants following our first treatment, and we would all insure that our first treatment is the one that gives us the best chance of a CR.

Indeed, the day may come when 1) we can predict a person's disease accurately enough, and 2) transplants are safe enough, to make that a routine course of action for those with aggressive disease.

But we are not there yet, and transplants are still risky: There is a 20% chance that a transplant will shorten your life and another 20% chance of relapse, those statistics according to UK CLL expert Dr. Andrew Pettitt. (The good news, according to Pettitt, is that 60% are successful.) With the possible exception of 17p-deleted patients, those with the most aggressive CLL, most top doctors hesitate to recommend a transplant at first remission. They are more commonly recommended at second remission in patients with rather aggressive -- perhaps I should say "assertive" -- disease. Still other doctors, those who do not see the transplant glass as half full, recommend transplants only as a last resort, after any number of therapies have been tried. In all these instances, treatment with something as conditioning for the transplant will be required.

And if there is one thing we do know -- just look at that MD Anderson data -- it is that treatment with any drug(s) sets up a disease resistance situation where second treatment is likely to be less effective.

Acceptable (?) risks

So, if we assume that for most of us a transplant at the outset is too risky but may become a desirable risk later, how do we plan? How do we still get treated but avoid becoming salvage patients on whom nothing really works?

There are a couple of points worth noting here:

First, there is no guarantee of getting a CR with your first treatment, even if you use FCR. Thirty percent fail to get a CR in such cases.

Second, according to MDA, 25% of pretreated patients achieve a CR with FCR. Who does the best? Single-agent Rituxan users (29%) and the fludarabine sensitive (31%).

How do you know how you will respond? You don't, but we can hazard a couple of guesses. If you are 17p deleted, you will have a harder time getting a CR. Those with huge lymph nodes may have trouble since it is that much harder to get rid of them. The NCI guidelines say you don't need to treat lymph nodes until they achieve a mass of 10 cm, but as a practical matter many patients report problems reducing nodes that big to an acceptable size. Keep that in mind if you, like me, have a largely node-centered disease (which is, by the way, a trademark of the 11q deletion).

Speaking of nodes, let us recall the data from the Hutch: 14% with nodes of less than 5 cm relapsed. 52% relapsed whose nodes were greater than 5 cm.

Given the risks of a transplant, and the fact that you may be able to keep the disease at bay for many years with treatment, does this data suggest what might be the reasonable standard, the compromise point, which one should aim for? In other words, preserving your ability, to the best of your ability, to reduce your nodes to below 5 cm (and perhaps to get a CR to boot)?

I think "yes" is a reasonable conclusion. I also think the data suggest that two things will be of particular help in preserving this ability: using Rituxan as your treatment of choice and maintaining your sensitivity to fludarabine.

(As always, my opinions are my own: There are wiser people who may well disagree with me. You could be reading the ravings of a madman here; remember that propensity for copious quantities of cats.)

The treatment blue plate special

Harvey the Hypothetical had six years of good quality of life (QOL) with the “soft glove” monoclonal antibodies Rituxan and HuMax-CD20 -- especially helpful as he had no donor match and had to wait until cord blood transplants could be made reasonably safe.

Rituxan and HuMax are not free lunches, as Chaya points out, but I think they at least qualify as the blue plate special. To paraphrase Churchill, they are the worst drugs to use, except for all the others. These monoclonals can plug the holes in the dike without being as immunosuppressive as the alternatives, without being mutagenic, and without building quite so much disease resistance. (Cases of especially aggressive disease, such as the 17p deleted, are the exception here. Studies suggest that 17p-deleted CLL clones are pretty resistant to Rituxan, as well as to fludarabine; in these cases, the start-with-big-guns then straight-to-transplant-at-remission plan makes some sense.)

The MDA data show a CR of only 5% for the fludarabine refractory. It is possible to become fludarabine refractory after your first treatment, although you may luck out and respond two, three, or more times. In the 2004 ASH Education Book, Dr. Byrd noted that "at the time of relapse from initial response to fludarabine, 40% can be retreated and will respond again to the same regimen." He went on to say that "ultimately, virtually all CLL patients who are treated become fludarabine-refractory." (It is generally accepted, by the way, that if you achieve a long remission the first time, your chances of a good response the second time are improved.)

So, are you better off playing for time by using single-agent Rituxan? Or should you start your treatment career with FCR, which obviously carries a greater risk of making you fludarabine refractory? (Of course, even Rituxan can make your disease somewhat resistant to fludarabine; CLL is not black and white. Our stock in trade is shades of gray.)

Let's look a little further at the MDA study: Let's add together the percentage who got either a CR or an NPR (nodular partial remission -- patients with no swollen lymph nodes who would have achieved a CR but for some nodules in the bone marrow). The responses were as follows: 58% in Rituxan users; 40% in those who had alkalyting agents; 39% in the FC group; 48% in the fludarabine-sensitive group; and just 16% among the fludarabine refractory.

The takeaway here is that those who did best -- and now we're talking half of previously-treated patients that managed to get rid of those pesky nodes -- were those who had used single-agent Rituxan and those who were fludarabine sensitive.

So, if I were playing the odds, using Rituxan while trying to preserve fludarabine sensitivity by not using it is the way I would go. In fact, it is the way I had been going, until AIHA intervened and forced me to use cyclophosphamide and a touch of vincristine. (Not everyone should play it this way; Rituxan is still a soft-glove treatment and if you arrive at the treatment door needing something stronger to deal with the problems your disease is handing you, by all means use it.)

It is important to note that your previous treatment is not the only factor that influences your ability to get a CR or NPR with FCR. Do read the MDA article, which I linked to above; it goes into other significant factors, including age, stage, and number of previous treatments. For example, your chance of a CR with FCR is reduced significantly if you have had more than two previous treatments. (Does single-agent Rituxan, with its lighter touch, carry the same weight as other treatments, I wonder?)

Type A personalities, welcome to the seventh circle of hell

We can parse the data all we want, but it's important to remember that what Rowan and Martin of TV's Laugh In called the “fickle finger of fate” is also at play here. Harvey, for example, was not particularly fludarabine-sensitive out of the gate, while many patients are. None of us knows how we are likely to respond to drugs, despite what statistics may tell us.

The good news is that Harvey managed to get close to a CR with Revlimid, got those nodes down to well under 5 cm, which is also the cutoff point at which Campath will work on nodes. Since we’re talking hypotheticals here, he perhaps could have followed up with Campath to clear the nodes further, though this sets up a risk of immunosuppression, infection, and viral reactivation. HDMP was another option that he did not use that might have shrunk the nodes significantly. He could have opted for R-CHOP (or H-CHOP) or Hyper-CVAD. (One consideration, of course, is that the more immunosuppressive, toxic drugs you use to nuke the CLL with, the greater the chances of a side effect or complication. And transplants are complicated enough as it is.)

My point is that there are several ways to search for that node reduction and/or CR when the time comes (and, like all CLL treatments, each comes with its risks and rewards). And in the interim I think there is a reasonable middle ground -- exactly the ground Harvey has trod. He got close to a CR after six years of good QOL with monoclonals, and he saved fludarabine for the end. That last gamble didn't work out as well as he hoped, but welcome to CLL.

Hindsight is 20/20: At the beginning of his CLL career, Harvey had only the favorable 13q deletion and was IgVH mutated to boot, so it seemed his disease course would be rather indolent, in which case a transplant seemed unthinkable. It was only as time went on and clonal evolution to 11q occurred and his mutated status proved less significant than problematic clinical symptoms that the transplant option became more attractive. This concept -- “things can change” -- is important to keep in mind. It bolsters Chaya’s argument that one should not wait too long; I can tell you from personal experience, as well as the experience of many patients I know, that once the disease starts to progress, things do not get better. They get worse.

One of the biggest challenges of living with the "new normal" of CLL is that we are forever making decisions without knowing what our disease will do, or what the drugs will do. This is not a disease for Type A personalities. Fortunately, I have always been more of a roll-with-the-punches type of guy. My view is that we patients are dealing in real time, and we make the best choices we can. We should not fault ourselves for making one choice and then finding out that "had I known what I could not possibly have known I might have done things differently."

Chaya's journal entry gives us good food for thought. There is no such thing as a CLL treatment that is risk free or that will not have consequences down the road. No matter what you do, there is no treatment that will not make retreatment more difficult. It is all a matter of balancing the risks and the rewards, playing the odds, and a little luck.

And speaking of which, good luck to Harvey as he heads north to a cure! I confess to having seen him myself a few times. Must be chemo brain . . .

I gob a cobe

Or I should say, I had a cold. In the “life with CLL” category, “new normal” division, file the “common cold.”

What is a common event for most people is always threatening to take an uncommon turn in CLLers. The first symptoms bring a lot of questions to mind: How long will it take to get over it? What if it gets really bad and turns into pneumonia (which, by the way, is the leading cause of death of those with CLL)? Could this possibly be the flu? Will my lymph nodes balloon? Will my lymphocyte count boom?

None of this is paranoia. Any or all of the above can happen. The last time I had a cold, in early 2005, my lymph nodes grew dramatically as the dimwitted B CLL cells went into a reproductive frenzy in an attempt to fight it. My absolute lymphocyte count shot up. After I got over the cold, the nodes reduced to where they had been at the start, as did the count. (This is typical of what can happen to CLLers with infections. Usually the nodes and count reduce to where they had been at the outset, although there is no guarantee of a complete reversal. I must admit that one of my fears as the cold took hold was that it would ruin my so-far good and stable partial remission achieved through R-CVP.)

My first symptom this time was a mild sore throat. I wondered if it would get worse. (Strep throat, anyone?) Then, almost as quickly as it came, it went away. My symptoms turned to a runny nose and sneezing, which later morphed into a cough, which was only occasionally productive. I battled this with Marilyn's tomato-garlic soup, bed rest, zinc lozenges, and augmentin, an antibiotic.

Colds, being caused by a virus, tend to be resistant to antibiotics, but since I wasn’t sure what I was dealing with, throwing the augmentin at it made sense. And the yellow and green, um, expectorations did clear up rather nicely once I started the drug. So it is possible that I had some sort of infection that mimicked a cold. Unlike most colds I have had in the past, this one was not accompanied by a fever or chills. Some CLLers, especially those who are more immunocompromised and in later stages, may not experience common symptoms because the body is unable to mount an immune response. Fortunately, I don’t think I’m at that stage yet.

The good news is that what started on a Tuesday pretty much ended by Saturday morning. And it appears that there was no increase in the size of my lymph nodes. (Unlike two years ago, the neck nodes started out being undetectable thanks to R-CVP, and they remained that way through the cold. Even the abdominal nodes I can palpate did not appear to increase.)

So I am a happy camper, or as happy as I can be with CLL having gone through a cold.

The envelope, please!

I have become friendly with the people who run the blood lab here in town. They are used to my long list of tests, which are kept in a fat plastic sleeve in the “standing order” file. At various times Dr. Belle, who is two hours away in Scottsdale, has faxed them lists of tests. Laid side by side, these faxed papers looks something like a menu out of a Chinese restaurant. When I go in -- which was once a week until recently, now it’s twice a month -- I tell the people in the lab which tests to run. Dr. Belle gives me updated instructions and also doesn’t mind if I add one on my own if it’s something I’m curious about. The tests are all stat, with a copy to patient. I go in the morning, I get the results in the afternoon.

When I went in on Dec. 31, my red counts were noticeably up from the previous time, which was a nice way to ring in the new year. It made sense: I’d had my chemo, it was still working in my system; hemolysis had ended some time ago and continued progress was logical. It fit the picture of how these things are supposed to work.

Then, on January 11, my red counts were noticeably down, virtually identical to where they’d been on Dec. 19. Dr. Terry Hamblin is forever advising us patients that one cannot determine a trend in one blood test; anomalies happen, spikes occur, labs can have a bad day. You need to look at three in a row to see if something is really happening.

All that is nicely rational, but if you have been in the grip of severe hemolysis, your animal brain starts lurking just below the surface, alert to any sign of the return of the AIHA beast. Not that I had been noticing orange urine or pounding in my ears, but in the initial stages hemolysis can be gentle enough to fool you. Having relapsed twice, I am a little paranoid about it happening again.

So when I went into the lab last Wednesday, I knew I was going to learn something important: either things were going up, or they were going down.

The tests were “just” a CBC and LDH, which occasioned much mirth on the part of the techs, who have drawn as many as seven tubes from me on occasion. The CBC, of course, indicates how well the reds are doing, as well as the lymphocytes (we don’t want those to do well) and the platelets. The LDH measures cellular debris, and a high amount means there is hemolysis afoot. (During the height of my hemolytic crisis in October, my LDH was twice normal.)

So they drew the blood and I went about my business, which included any number of errands before returning to the lab that afternoon to get the results. At every stop -- bank, recycling center, post office, thrift store donation center, supermarket -- I was thinking less about the task at hand than I was about the results getting closer. The blood lab was my last stop; it was important to get the other errands done while I could still focus, in my ignorance of the results, on doing them.

When I walked back into the lab to get the envelope containing the single folded sheet with the numbers that might make or break me, I was reminded of the Oscars. “The envelope please . . .” Would I be winner or a loser?

I also thought of Johnny Carson, whose old Carnac routine -- holding an envelope to his head and reading the punch line of a joke, after which he would open the envelope and read the set-up -- appealed to my somewhat black humor about the wiles of the cosmos. Would the joke be on me today?

The envelope with my name on it was pinned to the bulletin board; the tech unpinned it and handed it to me and told me to have a nice day.

Usually I read the results as I walk down the hallway leading to the exit, but today I decided I couldn’t walk and read at the same time. (God knows how I would have made it out of there had I also been chewing gum.) I needed to be seated; I would sit in the car.

And that’s where I got the news: We have a winner!

Not only were my fears unfounded, things looked a lot better than expected: My hemoglobin was 13.2, the highest it has been in more than a year. Hematocrit was 36.9, RBC 3.81, LDH normal, platelets a respectable 168. Even the lymphocytes were still milling around in a stable fashion at 22,000, which for me is low.

So, with the anxiety gone, I felt like dancing. Which is hard to do in a Prius.

It was just another day with CLL, of course. We’ve all been there: sometimes there is bad news and sometimes there is good news. The waiting and the worrying are all part of the “new normal.” As is often the case, my day was a mix of the mundane and the momentous. No wonder it often ends with wine.

I’m doing chemo now, Part 3: The results

Well, the results are in from the R+CVP, which became R+CP after my fingers started to tingle and my vision started to blur . . .

The overriding goal of stopping the severe hemolysis, which in October had taken me on a trip that was a little too close to death’s door for comfort, was accomplished. As readers will recall, this hemolysis, or destruction of red blood cells, was caused by autoimmune hemolytic anemia, or AIHA. That condition is a result of my immune system having deteriorated into some kind of Keystone Cops routine thanks to all those CLL cells sending out silly messages.

My hemoglobin recovered from 6.7 to around 12, where it has stayed for the past six weeks. Hematocrit is in the mid-30s. Overall red blood count is in the 3.5 range. While none of these qualify as a return to normal, they do represent enough of a rebound that I feel pretty energetic. My body seems to have adapted to this “new normal” in my red counts, rendering me as active as I used to be, more or less. (It’s not like I ran marathons.) Now, if I were suddenly to find myself in the normal range, I’d probably feel that much more energy, but at this point it could be said that I don’t know what I’m missing. And given how bad things had gotten -- imagine being unable to bend over to put a dish in the dishwasher -- things are “normal” now by comparison.

The other pretty big success in the treatment was the reduction of lymph nodes. The swelling in my neck and under my arms is, quite simply, gone. My spleen is so petite that, if it were not for something of a pot belly and a little gender issue, I could compete in the Miss America contest. The only holdout nodes I detect are in the abdominal area, which are often the hardest to get rid of, especially in an 11q-deleted patient like me. However, even the mass of nodes on my left side (the “abominable lymph node”) is well reduced, not too noticeable, and no longer painful.

On the downside, two things didn’t work as well as I’d hoped:

One, the absolute lymphocyte count bottomed out in the low 20s, which means that I have a good number of CLL cells resistant to Rituxan and cyclophosphamide. (And god knows what else, but I’d prefer not to think about it.) Fortunately, the count has been stable for the past couple of months.

Two, I never converted to Coombs negativity, which was my not-so-secret desire in all this. Such a conversion would presage a longer remission from the AIHA. However, as Dr. Clive Zent of the Mayo Clinic pointed out to me, the goal of treatment is to control the hemolysis and not subject the patient to any more chemo toxicity than necessary. My hem/onc felt that after three cycles of R+C(V)P, we had accomplished that basic goal and were showing no signs of improving on things any further. I agreed, and that regimen will be held in reserve if I should begin another severe relapse.

It is living with that possibility that qualifies as the newest “new normal” that I have to adapt to. As Dr. Zent also pointed out, patients with AIHA seldom get rid of it. There is nothing I’d rather be rid of more, of course. Wrapping my head around the idea that it could return after such a “big” treatment is taking some doing. But experience teaches, and having a hem/onc who recognizes the severity of the problem also helps. So I am doubly vigilant, and that much more prepared, at any sign of trouble. (The monthly CBC has now become bi-weekly, for example.)

For now, I am continuing on steroids, currently at 12 mg of methylprednisolone daily, with the goal to go even lower. We will add in some periodic low-dose Rituxan, based on my experience with it last spring, in which it was able to control hemolysis when I was off the steroids. IVIg, another anti-hemolysis tool, will also be in the works as my Immunoglobulin G has now fallen below 300 for the first time. I am amazed that I have not come down with an infection, but perhaps I have more reserve immunity than the numbers would indicate. And we have been careful. Marilyn caught a bad cold and wore a surgical mask around the house while she had it, and she washed her hands constantly. Alas, no smooching, and I owe her a big one for taking such pains to keep me from getting sick. (Of course, we patients owe our caregivers not just a kiss but the world.)

As to the tingling fingers (peripheral neuropathy), they are slowly returning to normal. The blurred vision resolved after a few weeks. All this means I can use vincristine again in the future, albeit in very small doses. Had I been able to tolerate it better, it is possible I would have gotten a deeper and better remission, but those are the breaks in chemoland.

In the meantime, since I am in remission, I am trying to enjoy that aspect of it. The “new normal” has its rewards. This is a comparative “rest period” as opposed to the manic “what do we do/time to see another doctor/yes, I have good veins and you can use any one you want” period that accompanied my AIHA backslide in October.

Ultimately, though, my continuing AIHA saga, not to mention the rock-bottom immunoglobulins, illustrates that my immune system is pretty much shot. A stem cell transplant is becoming all the more necessary, and the time frame for it is no longer “some day” but more likely within the next two to three years. Investigating that course is now front and center in my ongoing CLL education.

As Roseanne Rosannadanna said, “It’s always something.”

Doctor shopping in the 21st century

How do you find a good doctor? A good dentist?

You can look in the phone book. You can sign on to one of those bogus websites where doctors pay to have themselves recommended, or where you pay to be provided with information that you can find by yourself for free. You can look in a magazine where local doctors vote each other “top doctor.” All of these choices are inherently unreliable, of course, and provide little or no meaningful system for filtering the wheat from the chaff.

States do have medical boards of examiners that keep track of complaints and malpractice judgments against doctors. This tells you when a doctor screws up in a big way but it tells you little else.

What about a doctor’s bedside manner? Punctuality? Ability to communicate? General quality of care?

For answers to those questions, patients have long relied on word of mouth. This is subjective, of course. My neighbor, who has battled and defeated breast cancer, is a patient of Dr. Lippencot, and likes her. Lippencot was my first CLL doctor, and I fired her. So depending on which door you knock on, you’ll get two different views of the same doctor. Perhaps you would benefit from both, depending on the cancer you need treated.

Word of mouth works on the internet, too. CLL Forum has a section called “Doctors and Centers” in which people ask questions about, and describe their experiences with, doctors who treat CLL. (By and large the comments are complimentary, by the way.) On the ACOR CLL List, someone will occasionally ask “Can anyone recommend a doctor in Gotham?” and several people will reply, both on the list and privately off the list.

This works, sort of, for CLL, because there are specific discussion groups for the disease. But what if you are looking for a local urologist, or gastroenterologist, or orthodontist?

All that patient word of mouth has joined the internet age in a useful website called RateMDs, which contains more than 400,000 patient reviews of doctors and dentists.

Words to the wise, sort of

Personally, I think it’s about time something like this was created. Not that there aren’t pitfalls -- some patients simply aren’t going to be fair in their assessments and some doctors are going to try to game the system by encouraging patients to comment favorably -- but we’re all adults here, and we can more or less separate the reasonable reviews from the BS.

Any system of evaluating doctors is going to be subjective, based upon user impression and experience. To make it work, it needs to be designed intelligently, with some safeguards to insure a reasonable degree of fairness. RateMDs, located in Sunnyvale, CA, lets physicians post rebuttals and removes comments that are libelous. It is, for example, OK to say the doctor “has the bedside manner of an orangutan” but you can’t say “the doctor killed a patient.”

Of course, some doctors are not happy about this regardless. For a long time doctors have existed “above the law,” seldom held responsible in the court of public opinion. But that great equalizer, the internet, is changing things.

The creators of RateMDs offer this simple statement in their FAQ:

“We're just average patients who happen to know how to make websites; we are not doctors and are not affiliated with any medical organizations so we don't have any conflicts of interest. Having visited several doctors in the past few years, we became frustrated with the treatment we received, and the lack of comparative information available for choosing a good doctor, so we decided to create this web site to help people who have had similar experiences.”

Or as RateMDs co-founder John Swapceinski told Forbes, "Patients are ultimately the customer, and they're paying for a service, and they can decide whether or not they're satisfied."

RateMDs covers doctors in the US, the UK, Canada, and Australia. American doctors can be sorted by state and profession. Patients are encouraged to rate them on a system of one to five points, five being the highest, in four categories: staff, punctuality, helpfulness, and knowledge. The scores assigned by all patients are then averaged in each category; an “overall quality” rating is assigned based upon the helpfulness and knowledge ratings. Patients are also given space to describe their experiences, and these narratives form the heart of the evaluation.

Before commenting, patients are told: “Please make your comments detailed, helpful and polite and tell us WHY you rated as you did. Libelous or very short comments will be deleted. Further, this is not the right forum for reporting illegal activity, unless you include a link to a site with supporting evidence. And remember, you are legally responsible for what you write here.”

Spend some time surfing around the site and you will see a reasonably high level of satisfaction, with most of the negative comments concerning the doctor being rude or hurried and paying little attention to detail.

There are some amusing stories. One man visited a dentist and ran into a little problem when he called the dentist “dude.”

“I was scheduled for a root canal after suffering for almost 2 months,” the patient wrote. “I asked a question, using the word 'dude' at the end of the sentence. He refused to work on me because he said, 'no one calls me dude.' I apologized and explained that I didn't mean anything by it. I left his office in pain and disbelief. I guess when he is charging over $800 for approximately one hour of work, he can afford to be a prima donna. I need a dentist who is more compassionate and can understand that after two months of pain, antibiotics, and pain medication, perhaps a patient could be off their game a little. So, be on your toes, only speak when you are spoken to, and for goodness sake don't call him 'dude.' He has absolutely no sense of humor.”

Avoiding the urologist from hell

Of course, there are more serious issues at stake. I used the site to find a urologist, for example, and ran across some interesting information.

In my town and on my health plan, there is one urologist. My primary care doctor gave me a referral to this guy for a routine prostate exam and I decided to check him out at RateMds.

Based on three reviews, he had a low “overall quality” score of 2.3. One reviewer said this:

“This doctor was hired to repair a recurring hernia and testicle pain. Not only he did not repair the hernia (open surgery without any mash reinforcement) he did cut the blood flow to my testicle which within six months slowly died of starvation. He ignored my complaints for those six months and then he said: "Oh well, it is not a big deal, testicles are like kidneys -- you have another one." The dead testicle was removed last month. I am facing a lifetime of expensive HRT [hormone replacement therapy] and of course the damage done to me and my family life is obvious, and this man will keep doing this until who knows when.”

Hmm. Nothing like the prospect of a dying testicle to get the average man's attention. So then I went to the other place where I check on every new doctor I make an appointment with, the state medical board. (Conveniently, RateMDs provides a link to each state’s board.) The board website provides information about the doctor’s education, residency, area of medical interest, whether they are board certified in a specialty, and license. It also lists any medical “board investigations and actions” and whether there is any “malpractice/criminal information.”

Sure enough, this doctor had one “board action” in which he received a letter of reprimand in 2004 for “failure to timely repair a damaged ureter that contributed to the death of the patient.” Clicking on a link took me to a 5-page PDF describing the incident in detail.

After reading the RateMDs review and the PDF, I decided to take my prostate elsewhere. Back I went to RateMDs. I expanded my search geographically and matched the names on my health plan against the doctors who had reviews and found one with four reviews and an overall quality rating of 5.0.

Here was a typical comment:

“Superb surgeon and doctor. Treated me for testicular cancer, removed the testicle and did follow-up prosthetic surgery. All healed well and quickly. Very knowledgeable, and extremely empathetic and supportive. I would not hesitate to recommend him. Great bedside manner. A very genuine nice guy, who is extremely highly skilled.”

So I went to see him and found him to be as advertised: professional, knowledgeable, and friendly.

And all this thanks to RateMds, with an assist from the Arizona Medical Board.

I did the same thing when looking for a gastroenterologist and was similarly happy with my choice.

Without RateMDs, I would have been wandering around in the dark, hoping for the best, and not necessarily getting it.

There is a lot riding on the doctors we choose -- our health, our time, our money. “Luck of the draw” and blind referrals are not reliable methods of finding a doctor. As countless CLL patients have discovered, having a medical degree does not always mean a doctor can provide an adequate standard of care. Sites such as RateMDs provide a worthy and valuable service. The ass you save -- or the testicle -- my be your own.

Uh-oh, Obama

I was going to stay clear of politics for a while, but as some of you may have figured out I am a bit of a political junkie and I can’t really help myself.

As we all know, Barack Obama scored an impressive win in Iowa and now stands to reap the rewards with a probable victory in New Hampshire on Tuesday, where he is starting to lead in the polls. Could it be that the presumed Democratic nominee and next president, Hillary Clinton, is watching her dreams evaporate as Obama’s sunny message gets hotter and hotter and threatens to go supernova?

I saw Obama’s victory speech on Thursday and it was, indeed, a fine oration. Obama can effectively weave together our national story and his personal story and what it means to believe in ideals larger than ourselves. He is not quite so good at debating, or at one-on-one interviews, but give him a platform and a microphone and a prepared speech and he is right up there with Bill Clinton and Ronald Reagan.

Hope is always a powerful force in politics. And I think that one of the reasons it resounds so much now in the Democratic primaries is that for the past seven years most Democrats and many independents have felt profoundly hopeless and powerless. We have watched the country go downhill in almost every respect, often betraying those ideals we were raised to believe in, which has made it all the more painful. And until the Democratic victory in 2006, we were shut out of the process of governance by a take-no-prisoners approach exemplified by the leadership of Tom Delay in Congress and Bush, Cheney, and Karl Rove in the White House. All this happy talk from Republicans about “reaching across the aisle” didn’t start until after they became the minority party on Capitol Hill.

Barack Obama is a thoughtful man who offers an idealized version of how things ought to work, but I fear that is not the way they do, in fact, work. Almost every significant reform that has been accomplished in this country has come through, as Winston Churchill once said, “blood, toil, tears, and sweat.” The civil and voting rights acts of the 1960s passed not because everybody suddenly realized that it was criminal to deny people equal rights based upon race but rather because Lyndon Johnson twisted arms and busted heads to get the legislation through Congress. How did FDR get a conservative US Supreme Court to stop blocking some important aspects of the New Deal? By threatening to increase the number of justices and pack it with his own people. How did labor unions become established? Not by asking politely, but by workers striking and being beaten and dying in the streets. (The same is true, of course, of those who fought the long struggle for civil rights, without which the stage for Johnson's legislation could not have been set.)

Not everything has to be confrontational -- and I think most Americans are tired of the hyper sense of divisiveness that has characterized the Bush era -- but history is written by those who stand their ground and fight. For good or ill, Dubya has done just that on Iraq: he won’t take “no” for an answer, he insists on the rightness of his policy, and he has indeed kept us in there long after most Americans thought it wise.

And elections are won by negative things as much as positive ones. Attack ads work. Swiftboating works. Wedge issues work. And sad to say, as much as most Americans say they don’t like these things, they are indeed swayed by them.

Now, has something finally happened to change all that? Has there been come cosmic shift in the political landscape? Maybe I’m just getting to be an old fuddy-duddy, but I am skeptical.

That is the reality of politics, and that is why I prefer the John Edwards “fighting” approach when it comes to getting things done. My fear about the rather inexperienced (and possibly naive) Obama is that he could suddenly find himself facing bare-knuckled politics and not be capable of coping with it effectively. When was the last time, if ever, that we had a “gentlemanly” general election in this country? 1792?

It’s an exaggerated example, but Marilyn put her finger on it the other day when she said that what we Democrats need is not a Neville Chamberlain but a Winston Churchill. Chamberlain compromised with a man who had absolutely no interest in compromise and he accomplished nothing. I fear that there can be no real compromising with the GOP leadership, or with the entrenched corporate interests that try to run the show in Washington. Like Churchill, we need to recognize the opposition for what it is and we need to fight like hell.

In other words, blood, toil, tears, and sweat.

Is Barack Obama the man to lead that fight? Or would I rather have John Edwards or even Hillary Clinton at my back in a brawl?

Maybe I am wrong about Obama, maybe something has indeed changed in this country -- Mike Huckabee's "positive message" campaign is a breath of fresh air on the GOP side (good luck getting past the GOP establishment, Mike) -- but I have seen too much in history to believe that we will get, say, universal health care, without kicking some major ass.

John Edwards for president

It’s the new year, and it’s time to pick a new president. In just three days Iowans will caucus, and five days later the people of New Hampshire will vote, and then it’s off to the races, with Feb. 5 being Super Tuesday, when some 20 states vote, including mine.

I have been watching the debates, enduring extended interviews with the candidates on C-SPAN and Charlie Rose, and generally investing far too much energy in trying to make the right choice. If you haven’t figured out who you’re voting for, the time to do so is fast approaching. Maybe I can help.

Of course, if you’re planning on voting Republican, there is little I can do except to suggest that you take two aspirin, go to bed, and see if it passes. For everyone else, I offer the following analysis:

In a field of good Democratic candidates, John Edwards has the edge. He has the edge because of his health care reform plan and his dedication to putting it front and center if and when he becomes president. I saw his wife Elizabeth on C-SPAN the other day and she pointed out that John will make it his number one priority, with the intention of signing universal health care into law by July 2009.

Even if it takes a few months longer to achieve, no other candidate has brought the passion to this issue that Edwards has, and no one has as good a plan. As I have written in the blog before, Edwards would give Americans the choice of staying with private insurance or signing on with an expanded Medicare program. You will be able to vote with your feet as to which type of coverage you prefer. You will not be forced to choose 'socialized medicine," nor will you any longer be at the mercy of capricious market forces that leave many with no insurance, or with inadequate insurance.

Even if health care were not such an important issue, I would still be supporting Edwards. Like many Americans, I think things in Washington are dysfunctional. Big problems face us and no big solutions are offered. I also agree with him that part of the problem is that lobbyists, particularly those for corporate interests such as oil, drug, and pharmaceutical companies, call the shots too often. Why, for example, do you think Medicare is forbidden to negotiate with drug companies for lower rates for prescription drugs?

Politics is the art of compromise and the American political system is designed to balance competing interests, but there are times when the system itself becomes unbalanced and lopsided; in these times a leader is needed to put powerful interests in their place. Teddy Roosevelt busted the trusts. We need someone now to stand up for American families and American workers, not to compromise their opportunities away. This view is shared not only by some liberal Democrats like myself but also by libertarians like Ron Paul and conservative populists like Pat Buchanan.

So, for those who say Edwards is too confrontational, I’ll let the candidate himself reply. This is what he said when the New York Times asked him about Barack Obama’s nice guy approach and how it would play with insurance and drug companies:

"You can’t nice these people to death. You’d better send somebody into that arena who’s ready."

Can anyone seriously doubt the truth of that statement?

I appreciate that fight and that spirit, though I have not always been an Edwards fan. But something has changed in the man since 2004. I think his natural populist tendencies have come out now that he no longer has to hedge his bets representing North Carolina, a rather conservative state. And I think Elizabeth’s experience with cancer has helped the Edwardses focus more on what is truly important to them, which is something they have talked about. This happens with us CLL patients and it is natural that it would happen with them, too.

John Edwards has two other things going for him: He can reach across party lines and bring independents and some Republicans on board to win the election. And he can be a moving and impassioned speaker. I glued myself to C-SPAN and listened to his Jefferson-Jackson Day speech in Iowa, as well as the speeches of all the other candidates. His was the only one to bring a tear to my eye, and I felt he was more effective than the reasoned but reserved Obama and the somewhat robotic Clinton. In John Edwards we Democrats have a candidate who represents real change and an excellent chance of success in November.

The also-rans

As I said at the outset, there are a number of good Democratic candidates.

I have grown to respect Chris Dodd, whose impassioned defense of the Constitution and its protections for civil liberties, which the Bushies seem to regard as some sort of inconvenience, is appealing. His decision to return to Washington to fight the FISA bill, which would give a pass to telecom companies that handed your private information over to the feds without a warrant, is a definite plus. Dodd is clearly intelligent and experienced, though with a somewhat senatorial speaking style overlypunctuated by the word “here.”

Joe Biden also impresses. He has the right foreign policy experience and instincts to deal with thorny issues such as Pakistan, Iran, and Iraq. He has shown an ability to speak in short, pithy bursts that combine humor and common sense, and thus comes across as an appealing figure as long as he doesn’t start rambling. In his personal life, he is a man of quiet faith, of modest means, and one who has overcome the tragic loss of his first wife and infant daughter to a drunken driver.

In a country hungry for change, no one represents "new" quite so much as Barack Obama. The Illinois senator is just different enough -- young, African-American, not in Washington long enough to be a creature of the place -- that he appeals to the emotional need for, as Monty Python says, Something Completely Different. He is a good speaker and his argument that we need to rise above the sort of politics we have been experiencing has appeal. But I am forever reminded that, in the street thug world of elections, nice guys usually don’t finish first. I also think he is a little shy on experience. Three years in the US Senate, much of which has been spent campaigning for the White House, is a paltry amount of time to learn the ropes of governance. Serving in the Illinois state legislature may have been adequate experience in the days of Lincoln, but those were simpler times. I can accept the argument that judgment trumps experience, and while I appreciate Obama’s opposition to the Iraq war, one good call does not make for a record of good judgment. With Obama we are clearly taking a big chance: he may work out, he may not.

In contrast to Obama’s freshness, Hillary Clinton is the familiar choice, the establishment candidate. After all, she and her husband are the Democratic establishment, such as there is one. If “establishment” means stability and experience, it also means, for many, a failure to get things done. Voters think the Democratic Congress they elected in 2006 has largely failed them by playing the same old games. They are reminded of the Clinton era, and of concepts like “triangulation” and the definition of “is” and they are a little worried that another Clinton presidency will not bring the real change they hunger for. Perhaps this is a bit unfair to the senator from New York, but her campaign’s wanton attacks on Obama -- everything from kindergarten to cocaine -- have not helped overcome this concern. Hillary Clinton would probably be a good president, and I will happily vote for her if she is the nominee, but I do not think she is the strongest choice in the primaries.

I have a soft spot for Dennis Kucinich, who calls it as he sees it, who has been right on the Iraq war since the start, and who has challenged the other candidates to find principle and consistency in their actions. I am not sure the country is ready for him, but I appreciate the fact that he gives the left a sincere voice in party affairs.

Bill Richardson seems like a nice guy but somehow I do not get the impression, despite his long resume, that he is quite ready for the presidency, or that he has the debating and speaking skills to inspire and persuade.

Fortunately for us Democrats, the GOP field is about as weak as any ever was. Mike Huckabee has an easy manner and a good sense of humor but his ineptitude on foreign policy and his tendency to wear his religion on his sleeve will mean trouble in the general election. Mitt Romney flip flops more than a fish out of water and has a patrician, Kerryesque quality that is not appealing. He looks like a mannequin that has come to life, and he has all the personality of one. Fred Thompson is a decent enough fellow but dull and uninspiring, all the more surprising since he has made a career as an actor. Rudy Guiliani has no foreign policy experience, parrots the neocons who got us into this Iraq mess, and has made just enough bad judgment calls in his career to sink him in November.

Ron Paul has developed a following among libertarians and some traditional conservatives, who rightly think the Republican party has left its roots, sold its soul to corporate interests, and ended up in the land of fiscal irresponsibility, unnecessary foreign intervention, and disrespect for Constitutional rights. I would argue that not a few Paulites -- Paulies? -- might consider a vote for Edwards over someone like Romney.

And finally, there’s John McCain, the exception to the rule. I disagree with him half the time but I respect his independence of mind and his experience. He is the best-qualified Republican running and would do best in the general election. Here’s hoping he continues to grate on enough purist GOP voters that he is denied the nomination, just as he was in 2000.

Regardless of who the Republicans select, it promises to be a Democratic year. But we should not be overconfident; in my view our best bet to win and our best bet to bring about reform in Washington is John Edwards.