Thursday, January 26, 2012

When medicine fails

I've been a mess lately....emotionally speaking mostly. Since I first was treated for thyroid cancer back in 2005 until now, I've had 2 friends with whom I've been close or connected with basically the same age as me, go through their own experiences with cancer treatment. Now they're both gone...both in their twenties or early-thirties and both after having gone through 'cures'.

The first died of a relapse of his cancer in 2008, 3 or 4 years after he was first diagnosed. I think he was 25 or 26.

The second is gone because of a complication associated with the treatment of his leukemia, a process that began soon after he was in remission and continued and worsened for years. And over those years, this friend and I have both gotten married, moved on with our lives in many ways, and essentially both of us stopped climbing, so we didn't have that common shared activity any longer which originally brought us together. I had no idea what was going on and how bad his condition had become. After talking to his wife yesterday, it sounds like hardly anyone knew how much pain he has been in (lesson-stoicism can be extremely stupid). I'm not sure how appropriate it is too tell the story of this friend here. But, his death, like my other friend in 2008, hits incredibly close to home.

Leukemia is a cancer of white blood cells. When someone has leukemia, there are multiple cellular and genetic events which define the precise type of leukemia, but in almost all cases, treatment involves ensuring that the source of white blood cells, which is the bone marrow in adults, stops producing the cells which constitute the cellular component of our blood and most of the cells of the immune system. Of course the mutation or abnormal cellular event is only in one particular type of cell, and that cell basically makes clones of itself over and over again until the person's bone marrow, blood, etc are filled with a clone of that original cell. Without addressing the bone marrow, there's no way to ensure that the original cell (or at least the most stem-like cell of the cancer) is killed. So, patients get chemotherapy and radiation to kill of the rapidly dividing cells, then their bone marrow is ablated and they're given a transplant of stem cells that should go to the bone marrow, re-populate it, and rejuvenate the production of new platelets, red blood cells, and white blood cells. Sometimes the stem cells that are given come from another person, other times they are one's own stem cells.

A potential consequence of receiving white blood cells from another person is that some of these cells may have the potential to recognize the patient or recipients body as foreign, and begin an immune response against it. This process is the outline (although many details are left out for the purpose of simplicity) of a disease process called Graft vs host disease, or GVHD.

My friend that just passed away died from complications associated with GVHD. He died in the hospital after having been there for a month completely sedated and on a ventilator because he could no longer breath under his own power. The disease process of GVHD was causing an immune response that incited a genetic program associated with wound healing, where fibrotic tissue was being rampantly deposited all over his body. For him, the space surrounding his lungs were incased in this restrictive, fibrous mass and essentially this tissue inhibited him from breathing. He was slowly suffocating to death and as far as I can understand, that was part of the reason why he needed to be on a ventilator. The other reason for the ventilator was that in order to treat his GVHD, he had his bone marrow ablated again and received another stem cell transplant, essentially hoping that they could treat the GVHD like a cancer. The process where the transplant engrafts back into the marrow is incredibly painful, so the sedation and ventilator were also meant to help with that.

After a few weeks on the ventilator, it became pretty clear that he would not be able to breath on his own again. I don't know how the decision took place, but when I spoke with his wife on the phone yesterday, the decision had been made to take him off the ventilator and to let him pass.

If you want to read about his experience, he and his wife kept a blog here. The first time I read through the blog, I was crying and literally shaking, so be warned. The mix of anger that this happens, with guilt for not being able to do anything, and an incredible amount of sorrow for his wife is all culminating into this incapacitating dark place or uncertainty and fear.

Climbing was our original shared interest and allowed us to make our acquaintance. But when he was treated originally for his leukemia back in 2006-2007, I was working in a lab at Wash U, the year prior to going to medical school. My lab was pretty close to his hospital room and I went and visited quite often. I recently received my 2nd neck surgery and at that point had 4 radiation treatments, so even though his leukemia was considerably more severe than my cancer, we were brothers of sorts. He was one of the only people in my life besides my wife who I really talked to about having cancer.

Now I'm in this state of shock and hurt and anger. My mind can be so self-centered and of course, always wants to use fear to project a similar situation for me and Maggie one day. Fear, projection, hatred, anger...these are what currently summarize my feelings that summarize the devastation associated with this story.

To this day after my first friend died back in 2008, I talk to him, usually when I'm on my bike. Maybe this would all be easier if I had a clear ethos about what the hell happens when we die. But even if I did, I'm haunted by the thought that both of these two friends were relieved when it finally came. Of course we can never really know, but from some of the writings on the blog, it was clear that sometimes a desire for the release of death is the plan B for when medicine fails.

1 comment:

Renewed Fuelling said...
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