Susan's Recovery Chronicle: DAY +3: Dullsville (a great place to live)

Friday, June 5, 2009

DAY +3: Dullsville (a great place to live)

Top Line: Susan's the same, feeling mostly OK, but extremely fatigued with nausea that comes and goes.

Bob left this morning, stealing out while Susan was still sleeping. He claimed it was because he needed to take care of some things back in the City. I think the real reason is profound embarrassment over the Great Boston Scorched Frozen Pizza Fiasco (GBSFPF). Maybe I shouldn't have outed him in the blog. Bob will likely return sometime Saturday afternoon to early evening. For the interim, I'm sole cook, housekeeper, chauffeur, and first-line medical alert worker, in addition to my duties as blogster.

Susan has spent the afternoon, from noon on, at DFCI. The dripping should have dripped its last drop fairly soon now and we should be out by 6PM. Today it was Methatrexate, a preventative for Graft Vs Host, followed by Vancomyicin, an antibiotic, and an injection of Neupogen. Of more interest, we also had a consult with Amy of the Many Initials. Everything seems to be on track, but here are some highlights of what we learned (you always get more out of a good nurse practitioner or physician's assistant than you do out of the doctor):

Somewheres around the point where Susan's white cell count reaches its nadir (Day +6, or Monday, give or take), Susan may well need an infusion of platelets. Depending on her numbers, she may also need whole blood.
The main risk during the first month or so is infection, which is serious business when you don't have an immune system worth mentioning. It is signalled by fever. Of course we're on watch. The most dangerous week will be next week; then the graft starts to take.
The risk of infection subsides with the strenthening of the immune system, thanks to the donor stem cells successfully engrafting. By Day +30 or so, corresponding to the point when Susan is cleared to leave Boston and close proximity to DFCI, the concern over infection subsides, to be replaced by fear of GVHD.
The risk of Graft Versus Host Disease begins to increase around this time and is actually at its greatest in the 3-6 month period following the transplant, so September through November will be a period to be especially alert to any symptoms that might develop. Beyond the first 6 months, there is still the risk for chronic GVHD, which continues through the first year plus.
With the "mini" allogeneic (or non-myeloablative) transplant that Susan had, the risk of Host vs. Graft (where Susan's body rejects the donor stem cells) is small.

Tomorrow, it's back to DFCI for another round of I&I, aka infusion and injection. The appointment is for 10AM. That's going to be a challenge for Susan.

More tomorrow.

6 comments:

AnonymousJune 5, 2009 at 9:46 PM
Hi Susan and Jerry,
Can you help me post a comment without being anonymous. I don't know what the other profiles mean. Jerry, after all the experience you are obtaining from Susan's experience, you may want to go to med school. You are doing a great job. Winding down here in WH. Condo is officially on the market. Most of the work cleaning it out is done. Leaving Monday for Napa. Hope to speak with Susan upon my return. Glad everything is on track and always thinking of you and love to all, Gig
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Jane PollakJune 6, 2009 at 7:28 AM
Love hearing how boring it is! Thanks for the update, Jerry, and for doing the hard work of enduring this all, Susan.
Love,
Jane
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Susan DalsimerJune 6, 2009 at 10:31 AM
Love and best wishes from Susan and Andrew Dalsimer(Sam's parents). Sam shared a cab from JFK to Manhattan with Siegel cousin purely by chance and learned of this blog.
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HarrietJune 6, 2009 at 6:46 PM
Susan,
So glad all is going according to plan with no glitches. I'm thinking of you all the time. Big news here is I've found a great place to live in Chicago right between Rachel and Gail. I should be settled in well before the wedding! When this is all in the past, you have to come visit!

In the meantime, I'll be in NY last part of June and first half of July. PLEASE let me know if there is ANYTHING I can do to help out. I'll stay in touch with Callie also to find out what I can do.
Lots of love,
Harriet
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AnonymousJune 6, 2009 at 8:15 PM
Hi Susan-have been thinking about you a lot and reading the very helpful information about you and what’s going on. However I am so technologically challenged that I had to ask Phillip HOW to respond on this blog(who knew)
Natalie has her graduation on Wed.
She had her prom last Tuesday. I thought about Callie’s prom-you described her prom dress and sent me a photo of her in it. Wow-how time flies!!!!!That’s what I wish for you -for time to go quickly by so you can eat all the pommes frites you want.
We will all keep our fingers crossed for you to feel good as quickly as possible!!!
Lots of love-Marjorie, Aron, Claire, Natalie, and Phillip
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AnonymousJune 6, 2009 at 10:53 PM
Hi,
Just got back from Mimi's. Everyone sends there love and prayers. We had our 15th anniversary party there. Leslie is going to try and send you pictures. I hope she can. We all missed you very much. Just remember that next year on the roof with Rick and I. Hope you are doing okay today. Much love, gig
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Susan's disease

Chronic Lymphocytic Leukemia (CLL) is a slowly progressive form of lymphocytic leukemia, characterized by an increased number of B lymphocytes, one of 5 types of white cells in the marrow and blood (hence the concern when white cell counts are elevated). The role of B lymphocytes is to produce antibodies to help combat infectious agents such as bacteria and viruses. With CLL, B lymphocytes multiply unchecked and, in the absence of threats to combat, will attack healthy cells and tissue. It is common to experience enlargement of the lymph nodes and spleen as the disease progresses. CLL is the most prevalent form of leukemia and occurs predominantly after age 55, although Susan, ever the precocious one, was 50 when she was diagnosed.

Susan's diagnosis came in December, 1999, when routine bloodwork revealed an abnormally high white count. After evaluating the several world class cancer centers in the US, she settled on Boston's Dana Farber Cancer Institute (DFCI), affiliated with Harvard Medical School.

Susan was fortunate to be introduced by mutual friends to Dr. Lee Nadler, a Senior Vice President at DFCI and Professor of Medicine at Harvard Medical School. Dr. Nadler, who does not normally take on a patient load, agreed to become Susan's primary oncologist and has, over the years, arranged for her to see the appropriate specialists as needed, whether at DFCI or other institutions.

Susan underwent a regimen of chemotherapy from May through September of 2001 which provided her a strong remission lasting until the Spring of 2005, when elevated bloodcounts indicated that additional treatment was required. Tests revealed that the locus of the disease at that point was in her spleen, and she underwent a successful splenectomy operation in August 2005, enabling her to reestablish her remission.

Of course, there's a wrinkle. Over the past couple of years blood sample analyses have shown the presence of both Hodgkins Lymphoma and non-Hodgkins Lymphoma cells, suggesting that the disease has been morphing, muddying the waters as far as a clearcut diagnosis is concerned. There is no label for what Susan has (we are calling it a variant of CLL, for simplicity's sake). However, it doesn't really matter. The course of treatment at this point is the same: a stem cell transplant.

Although Susan has been fortunate enough to be essentially asymptomatic all these years, her white cell counts have gone up as high as 320,000, only to be brought back down to a reasonable level through chemotherapy. To put that number in perspective, a healthy individual's count usually ranges between 4,000-10,000. The fact that she doesn't look sick and generally feels fine does not mean that she doesn't have a serious and progressive illness.

From the beginning, Dr. Nadler had indicated that at some point the disease would advance to where the best course of action would be a transplant procedure, which is dangerous but potentially curative. That point is now.

Susan's Transplant Procedure

RATIONALE for the TRANSPLANT

While the right protocol of chemotherapy can produce a remission in patients with blood cancers, these remissions are almost always temporary, not curative. The number of remissions a particular patient's disease may enable him or her to realize is very limited - sometimes only one, sometimes several - but in general any successive remission(s) is less robust and of shorter duration. The time comes when the best approach is to go for a cure, which is what a successful blood and marrow stem cell transplant can offer. The transplant entails significant risks (as outlined below), but Susan is at the point where the benefits of another remission (if successfully achieved) might be fleeting and leave her less able to tolerate the transplant at some future date.

BLOOD and MARROW STEM CELL TRANSPLANTS: the SHORT COURSE

Blood, despite its homogenous appearance as a red fluid, is actually a very complex medium that contains many different factors, all of which are generated by a person's bone marrow. In a blood cancer like Chronic Lymphocytic Leukemia (CLL) these components of the blood become unbalanced. A person with CLL produces an ever increasing quantity of white cells in the blood over time, particularly B lymphocytes.

White blood cells , including lymphoctyes (B lymphocytes, T lymphocytes, et al.) act as the body's defense against infection and other foreign bodies, and so they naturally increase to combat such threats, but when the threat has been eliminated, the white cell count returns to its normal level. To oversimplify, elevated levels of white cells, pumped out by malfunctioning bone marrow, with no disease or infection to neutralize, begin attacking healthy tissues and systems. This is the case when a person has CLL.

If the bone marrow which produces the white cells can be restored to its proper functioning, then the white cell count will return to normal. A blood and marrow stem cell transplant can achieve this by largely destroying the sick person's marrow through chemotherapy and/or radiation and then replacing it with healthy marrow. To be more accurate, it is not the physical marrow which is destroyed and replaced but rather stem cells within the marrow responsible for the production of red cells, platelets, and the various kinds of white cells, including the lymphocytes. Therefore, the procedure is most accurately called "Blood and Marrow Stem Cell Transplantation" or Stem Cell Transplantation, although it is often referred to loosely as a Bone Marrow Transplant since the diseased marrow is being regenerated via the healthy stem cells of the donor.

There are two basic kinds of Transplants: autologous and allogeneic. In the autologous version, the patient's own stem cells are harvested during a period of strong remission when healthy stem cells predominate. The blood or marrow with the healthy stem cells is then frozen for later use when the disease has returned in force. In the allogeneic version, the healthy stem cells are provided by a donor whose tissue type closely matches that of the recipient. Susan will be having an allogeneic transplant.

In fact, there are two types of allogeneic transplants - the full or standard transplant (myeloablative transplant) and the so-called "mini-transplant" or "reduced intensity transplant" (non-myeloablative transplant). The standard transplant involves very high doses of chemotherapy and/or radiation in the conditioning phase (the week prior to the transplant), which is very hard on the recipient's system. The mini-transplant involves less intensive conditioning and is better tolerated by older patients (roughly 55 years old and up; Susan, like Jack Benny, is 39 . . . for the 22nd time). The standard transplant works by destroying the diseased bone marrow nearly completely, but with very significant stress on the recipient's system. The mini-transplant works by relying on the donor's immune cells, whose efficacy is bolstered by a drug protocol, to destroy the remaining cancer cells. Susan's medical team has determined that the mini-transplant is the most appropriate procedure for her.

The week or so prior to the actual transplant is referred to as the "conditioning phase" and is used to destroy as many of the cancer cells as possible as well as to suppress the patient's immune system to minimize rejection of the donor's cells. This is done via chemotherapy and/or full body irradiation, and can be very taxing. The actual transplant procedure is similar to a blood transfusion but takes several hours to accomplish.

In the immediate post-transplant period, the patient's immune system is severely compromised and he/she needs to be kept in a protected environment (first the hospital and then a kind of half-way house) and closely monitored. Within a month or so of the procedure, normal blood function is re-established to a degree sufficient to allow the patient to return home, but the environment needs to be very carefully managed to minimize infectious agents. Chronic Graft Versus Host Disease (GVHD - see below for "Risks") can be a significant risk for a year or more after the procedure.

RISKS

The conditioning procedure for an allogeneic stem cell transplant may produce a variety of unpleasant side effects, from mild to quite severe, but these are generally manageable and not considered life threatening. Because it involves a less rigorous conditioning, the "mini" version of the allogeneic transplant (the kind Susan is having) generally causes fewer and less difficult complications. However, there are still three major risks to consider with an allogeneic transplant :

1. Disease or infection.
The conditioning process essentially destroys the patient's immune system, leaving him or her virtually defenseless against disease or infection in the pre- and immediate post-transplant period. Therefore, it is extremely important that the patient's environment be carefully controlled to minimize contact with infectious agents. Measures include filtering the air in the room, requiring visitors to wear masks, ensuring frequent and thorough handwashing, eliminating raw foods (e.g., fruits and salads) from the diet, not allowing flowers or plants (which well-wishers might send) into the environment, and so forth. The medical team will also provide the patient with antibiotics and antimicrobial drugs as a preventive measure. It generally takes a month or so for the donor's stem cells to promote formation of enough blood and immune cells in the recipient for him or her to leave the protected environment.

2. Graft Versus Host Disease (GVHD)
The allogeneic transplant works largely through an effect called "graft versus tumor" (GVT), where the donor's lymphocytes identify the patient's cancer cells and destroy them. However, the donor's lymphocytes may also attack the patient's normal cells, which they might recognize as a foreign body and so a threat to be neutralized. When this happens, it is called Graft Versus Host Disease (GVHD), a complication that carries a definite mortality risk. The careful tissue matching that is done to ensure donor and recipient compatibility reduces the likelihood and potential severity of GVHD, but it cannot eliminate the risk.

The more complete the tissue matching (it is never 100%, except with identical twins), the healthier the recipient is going in, and the younger the recipient, the milder the case of GVHD is likely to be. Nevertheless, the majority of recipients will experience some degree of GVHD, despite the prophylactic drugs that the medical team administers.

GVHD occurs in two forms -- "acute" and/or "chronic." The terminology has nothing to do with the degree of severity, but rather refers to the timing. Acute GVHD occurs within the first three months, but its likelihood of occurrence diminishes somewhat with time. Chronic GVHD is what develops at some point after the period for the acute phase has passed. The risk for chronic continues for a year or more after the transplant procedure. A person who has developed and been cured of acute GVHD is still at risk for chronic, as is someone who has been symptom free even a year out.

3. Host Versus Graft Effect
Since the patient's immune system is not entirely destroyed by the conditioning regimen, it's possible for the remaining cells to reject the transplanted donor stem cells, in which case the transplant is unable to gain traction and do its work. Again, careful tissue matching between donor and recipient will reduce the likelihood of this effect to any worrisome degree, but some level of risk remains.

SUSAN'S MEDICAL TEAM

Dr. Lee Nadler - Lead oncologist and case manager - DFCI
Linda Drury - Physician's Assistant to Dr. Nadler - DFCI
Dr. Robert Soiffer - Lead transplant specialist - DFCI
Amy Joyce, Nurse Practitioner for Dr. Soiffer
Dr. Michael Grossbard - Local (NYC) oncologist and case manager - Roosevelt Hospital

Blood and Marrow Stem Cell Transplantation - a pamphlet

In the top right corner of the pamphlet's control bar is an icon that will toggle the document to full screen. Then use the +/- buttons to control the size of the viewed page. Toggle back to return to the top of the blog window.

Transplant Pamphlet

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http://www.scribd.com/doc/15894155/Transplant-Pamphlet?secret_password=14dot1c2s1fyv9g8j4k2

Susan's Recovery Chronicle

Friday, June 5, 2009

DAY +3: Dullsville (a great place to live)

6 comments:

Background Information

Leukemia and Lymphoma Society-Home

Dana Farber Cancer Institute - Home

Blood and Marrow Stem Cell Transplantation - a pamphlet

National Bone Marrow Transplant Link

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Susan's disease

Susan's Transplant Procedure

Blood and Marrow Stem Cell Transplantation - a pamphlet