Biopsy results

We wanted to post a quick update on our news of nearly two weeks ago. Earlier this week, Brad had a liver biopsy, and on Friday afternoon we got the results, which confirmed indeed that he has a new kind of cancer. This time, it’s a diffuse large B-cell lymphoma, which is a fairly common type of lymphoma but in his case is a post-transplant lymphoproliferative disorder, prompted by his Epstein-Barr viral infection. His oncologist is proposing to treat it with rituxan, an antibody therapy that has been very effective against B-cell lymphomas. (In general, there are more effective treatments out there for B-cell lymphomas than for the rarer T-cell types, so that’s a glimmer of good news.) Rituxan is usually better tolerated and less hard on the body than traditional chemo regimens, an important consideration given Brad’s weakened post-transplant state.

Treatment should start next week, and given how fast this new cancer has been growing we are both very glad they have a plan and are moving quickly.

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News

Dear friends and family, we had hoped that we could let “no news is good news,” from the last post, stand as the last-ever update on this blog. We are terribly sorry to say that isn’t the case. There’s news, and it is not good. Yesterday, we learned via a PET scan that Brad has more evidence of cancer. We are awaiting a biopsy to confirm the diagnosis, but his oncologist believes it is almost certainly a new type of cancer, a B-cell lymphoma called post-transplant lymphoproliferative disorder. It is caused by an Epstein-Barr viral infection, which his immune system (suppressed by the post-transplant medications) cannot fight effectively; the B cells proliferate aggressively (hence the name), causing tumors. This is a rare, but known, complication of immune suppression after transplant and is more common in solid-organ transplants.

Needless to say, this was the very last news we wanted to hear or have to share. Brad’s course of treatment is not yet certain, pending the biopsy. It is, however, clear that a very difficult road for our whole family lies ahead. We are grateful for all your good thoughts.

—Brad and Kate

Three months home

It’s been a long time since I updated. In this case, the old cliche has been true: no news indeed has meant good news. Brad has been recovering, slowly in some arenas and more quickly in others. The home rehab company that provided him with intensive physical and occupational therapy pronounced him a star patient, and their services have ended, which means things are much quieter around our house, with far fewer appointments taking place in our living room. Thanks to them and to his own perseverance and hard work, his strength has increased greatly and he’s able to walk much farther, albeit slowly. This morning he walked the girls to their summer day camp. His vision has also, after a long plateau, suddenly seen a rapid improvement, allowing him to walk more independently. (He’s also learned to use a white cane.) Recently he realized he can see just well enough to read extra-large text on the iPad and also to play chess against it. He has to hold the device close to his face and squint a bit, but that’s is a huge advance.

In other news, Brad was recently back in the hospital with a minor infection that proved to have originated in one of his central lines (the chest catheters used for IV nutrition and for the photopheresis—a blood treatment that combats his graft vs. host disease). In the end, his physicians decided to end his IV nutrition (which has made caregiving at home vastly easier) and remove both chest catheters. So, for a few brief days, Brad was completely free of any IV lines for the first time since May 2015. That didn’t last long, however, as he has now had a port (an under-the-skin line) put in to use for photopheresis, which his doctors expect him to continue getting indefinitely. The advantage of the port will be that it is much less susceptible to infection and requires less specialized line care.

There’s not much else to report, medically speaking, but on a personal note Brad is now well able to have visitors at home and has really been enjoying time with friends. If you’re local and would like to come by, please, give him a ring or shoot him a text (he’s now adept with using his phone despite his low vision), or contact me. Recently, his dad Joe was here for a couple of weeks, staying with Brad while the girls and I visited Canada and their grandmother, uncle, aunt, and cousins. We swam and kayaked, played with cousins, and had a great time. I was able to sneak away for a short trip to New York with friends (thanks to the kindness of Brad’s mother Susan, who looked after the girls), where I got the chance to see a couple of Broadway shows, including Hamilton. So, while things are not quite back to normal, and won’t be for a long time, they have certainly been looking up—and all that occurs to me in conclusion is a favorite quote from Hamilton, the musical: How lucky we are to be alive right now.

Meanwhile, back at home…

It is hard to believe that four weeks have gone by since Brad came home from the hospital. In that time I kept meaning to update the blog to say he’s been doing very well, but have never quite found the time. The needs of his care have been fairly overwhelming for me, honestly, despite lots of good help. Brad’s mother was here helping tremendously for the first couple of weeks, and I also hired round-the-clock caregivers. It’s essential that we have someone here, as doctor’s orders (and the assessment of his physical therapist) mandated that Brad never be left alone in the house. I’m so grateful every day that we were able to find home attendants, because without them juggling everything would be impossible and beyond exhausting.

The focus in these weeks has been on rehab to get Brad stronger and more independent. Our insurance company, to my astonishment, went out of its way to find and authorize service from an integrated, in-home rehab company with a team coming to the house to provide intensive physical therapy, occupational therapy (in this case, helping Brad adapt to his impaired vision), counseling, and guidance from a dietitian. They come about 20 hours a week, in total, and in addition to these visits Brad has clinic appointments and a twice-weekly home health nurse, so our household has been a very busy one. The rehab is going really well—over the past weeks Brad has gained some energy and quite a bit of strength, which was sorely lacking after so many months in the hospital. He can now take walks of up to 20 minutes and much better able to climb our house’s many stairs. In the past week, he has even come up to the top floor and helped put Lucy to bed—though thanks to his ongoing vision issues, she read stories to him.

A word about his vision: It’s still very much clouded and he remains functionally blind, though he has regained a little more peripheral vision and some of the corneal scratches and swelling are starting to clear. Progress is, however, very slow, and the ophthalmologist following his case can’t say for sure whether the remaining cloudiness is healing injury, permanent scarring, or some combination of both. If his vision does not clear, the treatment—far, far down the line—would be a corneal transplant. Because it is likely to be many months, he’s trying to learn some technological adaptations (for using his phone and, we hope, a computer) and workarounds for mobility. We’re adding routines and particular spots for items so that Brad can find what he needs easily, and I am pleased to have an excellent reason to make the girls pick up their stuff, since anything left on the floor would be a tripping hazard. All in all, we are slowly adjusting to and settling into this new phase, and while it’s still going to be a long haul, we are all enjoying not being at the hospital so much.

129 days later…

Many of our readers will have heard this news already, but I wanted to add an official announcement. Brad is home! Yesterday we busted him out of the hospital (okay, maybe wheeled him out would be a more accurate characterization) and brought him back to our house where he belongs. (Pictured below: him lying on his rightful couch.)

The days leading up to his discharge were quite a whirlwind, getting a lot of things organized—especially the home nursing help I’ve hired to stay with him overnight, which is making everything vastly easier. His care needs are still profound: he takes more than 30 pills daily, plus eye drops and on-demand medications; he’s on intravenous nutrition (hooked up by yours truly) at night; and he needs a lot of help on the many flights of stairs in our house. But he ate dinner with our family last night, at the dining room table, and the girls were about as happy as I’ve ever seen them.

His doctor, before we left, said he was there for a total of 129 days. Brad immediately snapped back: “Nobody keeps me in the hospital for 130 days.” And then, four months to the day after he received his new stem cells, we left.

 

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Milestones

The last time I updated was a milestone for Brad, day +100 post-transplant. Since then we’ve passed a few more markers and anniversaries, but I will start with the most recent and most important so far. Yesterday, Brad had a PET scan, and it was clear, showing no evidence of cancer.

It’s routine to do a PET at three months or so post-transplant, and nobody was really expecting to see a relapse at this point, but it’s obviously a tremendous relief to have that confirmed. It’s also a reminder of what his ordeal has all been for, to fight the cancer that would certainly have killed him. He will have more PETs in future (next one likely at six months post-transplant), but we can worry about those later. For now we’ll celebrate this one.

This has been a big week in other ways. Yesterday marked four months since his admission for the transplant. And Monday, by chance, marked exactly a year since Brad went into the emergency room with the ruptured lung tumor that signaled to all of us that his cancer was more aggressive, and more dangerous, than anyone had thought. Between his chemo treatments and the stem cell transplant, he has spent almost exactly half of the past year hospitalized. My memories of driving him into the hospital after what had seemed like a perfectly ordinary Saturday (I put in my summer vegetable garden; he took Lucy to the pool) are keen; I ran every red light between here and the hospital, and we were both terrified at his symptoms and had no idea what was happening. Thinking of that day is a reminder, in many ways, of how far he has come. Brad is greatly weakened and still ill, but we have a better sense of what we’re dealing with. He’s on the other side of a debilitating but extremely promising treatment, not facing a completely unexpected and unknown ordeal. For that, and for the clear PET scan, we are deeply thankful.

Last week we had a large family conference with Brad’s entire medical team to discuss his prospects for coming home. It was very productive, and we all concurred that discharge needed to be slowed down until he has a little more independent mobility and slightly less overwhelming care needs. In fact, our caseworker from his health insurance company called me to say she felt he still had too many complications and would be safer, for now, in the hospital. When the insurance company says, “no, no, we think we’d rather pay for more hospital time,” well, you pay attention. So now the entire team’s focus is on giving Brad the skills and retraining he needs to operate safely at home with his compromised vision.

The tarsorrhaphy (suturing shut of the eyelids) presented particular difficulty for his home care, as the care for it is very time-consuming and tricky. Happily, the corneal team concluded that it has done its work in helping heal the corneas and removed it two days ago, to our surprise. In its place they inserted something called “bandage lenses,” clear protective contacts. Brad’s vision has improved somewhat, particularly the peripheral vision, which is encouraging, but it’s still not nearly good enough to help much with independent function. A rehab team is coming to assess and work with him tomorrow, and I’ve also been in contact with some vision-rehab specialists who are going to give him some retraining.

Meanwhile, at home, I’ve been cleaning and reorganizing, starting to get things ready and set up the rooms he’ll primarily be using to be more functional for him. I’m also, with help, looking for caregivers, as we’ll be hiring in-home help, especially at first. It’s starting to seem more real that he can come home—and also more exciting. Last week, going into the family conference, I felt very apprehensive. His care seemed so overwhelming that it would be unmanageable at home. But now that we are addressing his barriers to functioning (such as his lack of confidence with reduced vision), the prospect of him coming home feels like great news—but even that is not as great as that clear PET scan.

Day +100

So. Today is the hundredth day post-transplant. We haven’t been paying much attention to the calendar and counting of days that used to govern everything, but this one I noticed. It seemed like a good day for a status report.

Day 100 is traditionally seen as the cutoff between a diagnosis of acute graft-vs-host disease (GVHD) and the chronic variety, or ongoing issues with GVHD that are usually less severe. Brad’s GVHD is greatly improved from its harshest manifestations of a couple of months ago, but he does have some ongoing issues, including stomach pain when he eats. The good news there is that he’s eating, and even having some solid food—the other day I arrived at lunchtime to find that he’d had half a grilled ham and cheese sandwich. That represents a big advance. He remains on IV nutrition, but the doctors have adjusted it so that he only receives it at night—and thus he is able to be disconnected from the IV completely during the day. They’ve also shifted all his (considerable number of!) medications to oral versions. That has been great, and enables us to take him out for walks untethered—a huge sense of freedom after three months tied to a an IV pole. It’s turned warm here, and he likes to go over to the shady and relatively quiet breezeway in between the buildings of the Cancer Center, across the street from the hospital.

His vision continues to be a problem and the tarsorrhaphy (in which his eyes were sutured shut) is still in place, and likely to remain so for some time. The next-step treatment, autologous serum tears made from his own blood (so they mimic his natural tears precisely) is now underway—it’s a lengthy process to make the tears and then quarantine them, however. We expect to get them in 3-4 weeks and are hopeful they will speed healing of the corneas along. For now, however, he functionally has no vision, though when the eye doctors open the tarsorrhaphy he is noticing slightly improved peripheral vision.

Speaking of a timeline of 3-4 weeks, we are also getting some indications that the medical team may be ready to send him home within that timeframe. That, of course, depends on continued improvement. But, with a view to him eventually being at home, the medical team is getting him some more physical therapy to increase his strength and ability to handle the challenges of being home, as well as occupational therapy and other services to help him cope with his functional blindness. With the help of some friends, I’m working on lining up reliable in-home care. While it all seems a bit daunting, we are very much looking forward to him being home at some point.