No More Sirolimus

Life is good! Can't forget that.

So yesterday I had one of my current bi-weekly visits to NIH for an anti-fungal infusion, and saw the nurse practicioner and another doctor who have been following me. The rash on my arms is looking a lot better, and my lower legs are looking about a week behind what my arms were. The itching is much improved, and it doesn't really bother me much now. The rest of my skin has cleared up a lot, and overall I'm feeling pretty well.

The GHVD in my mouth is about the same, which is to say its tolerable but doesn't really look good at all. With the mouth not quite looking better and the rash still unexplained, they don't want to rush tapering my prednisone. The problem with that decision is that they don't like how long it looks like I will be on the prednisone. It has plenty of negative side effects including deterioration of the bones and cataracts. So a decision was made to alter my immune-suppressant regimen in order to help improve my GVHD symptoms.

I've been taking sirolimus and tacrolimus throughout the whole transplant process starting in December. My doses for those medications have already been tapered to a minimal amount, and the plan would probably have been to take me off of them if the GVHD symptoms had not shown. Sirolimus is a drug that can cause side effects in the mouth, so they decided to remove that drug from my menu! Thats a relief. Any time I can move away from a drug, especially one that I've been with so long, feels like some sort of success.

The flip side of that is that the amount of tacrolimus I take will be increased in order to put my on a more therapeutic level. That will hopefully suppress the immune system enough to help ease the GVHD symptoms. With the tacrolimus pulling more of its weight with the GVHD, then hopefully the prednisone can be tapered at a quicker pace.

So lets hope the plan helps ease the GVHD and I can return closer to "normal." Its good to note that at this point the doctors aren't concerned about an increased level of immune suppressants hindering the graft versus tumor effect. Before the last two PET scans there was a hesitation to increase my immune suppressants because the main goal was, and still is, to eliminate the cancer. At this point the team doesn't feel that higher immune suppressants will have an effect on the cancer remaining in my body. Lets hope so.

Stopped Counting Days...7+ Months Out

Been a while since I've updated here, and I haven't intended to go so long without an update. I guess watching Isaiah and making hospital visits during the summer has been enough to keep me from updating my blog. The biggest thing going on is that I had another PET scan last Friday and the results were stable to slightly improved again. The cancer remaining is described as minimal by the doctors, but I'm always eager to hear that there is no cancer at all. I'm not there yet, but things continue to go in the right direction.

While the cancer cells are disappearing, the new immune system continues to cause issues with GVHD. Since starting Prednisone at the beginning of the summer, I am doing much better. I have gained back the weight I lost when I couldn't swallow, and my appetite is pretty decent. My throat has slowly improved and doesn't bother me on most days. It isn't normal, but I can finish a meal in a reasonable amount of time and without pain now.

I continue to have ulcers in my mouth, but my sensitivity to different types of foods has improved. I joined a new clinical study for a topical thalidomide gel applied directly to the ulcers in my mouth. A lot of the doctors at NIH were eager to see how I did on the study, but the mouth pain didn't improve and I was taken off of the study after just a week. I had a bit of a flair up with the mouth pain after that week, but things have calmed since then.

I had a follow-up appointment with the opthamologist last week, and he saw no signs of the scar tissue he had seen the previous month. That was great news to hear. My skin rashes had been improving for the most part on the Prednisone, although last week I developed a new rash. On my forearms I started getting very irritated looking bumps. Over a few days the bumps increased in quantity and size. I had a small group of doctors including the dermatologist who has been following me stumped as to what it could be. On Wednesday I had a skin biopsy and a skin exam with the dermatologist, and he shared that it is probably just another presentation of GVHD. He said what it looks like I have now looks like hives, which is more rare for GVHD, but he can't find another way to explain it. Its a crappy experience to leave your doctors clueless, but this doesn't appear to be anything too serious. It itches more than the other rashes I've had, but it seems to be clearing up somewhat in my uninformed view.

So thats where I am medically. The cancer isn't quite gone and the GVHD is better but still bothersome at times. My energy level isn't what it was like before cancer, but its improving. I had a meeting at work today, and it will be exciting to get back to work in less than a month.

Returning to school means that summer is on its way out, which brings me to something going on this fall. The Leukemia & Lymphoma Society has an annual event called Light the Night. Its a fundraiser for their organization and I've decided to start a fundraising team that will participate in their walk in downtown DC the night of October 17th. It would be great if anybody would like to join my family for the walk and decided to fundraise on their own. Anybody who doesn't want to fundraise or walk could also make donations through one of my family members or I through the webpage for our team.

http://pages.lightthenight.org/nca/WashDC09/JohnBlattnerHatesCancer

I'll keep people updated with the progress of the team's fundraising, and if there are any opportunities for people to get involved.

Day +197

Having cancer has made it very easy to remember my haircuts. There haven't been many over the last two years, and today Kate gave me a trim with the clippers. My hair has been growing well, just not in all areas. The flaky, dry skin on my head hasn't been conducive to growing hair, and I've looked somewhat crazy lately. I had a balding pattern going on with long hairs that refused to do anything but stand straight up on my head. Now it is shorter, not quite bald, and hopefully it will start coming in a little better.

Over the last week it has felt good knowing the tumor has shrunk. I've been feeling pretty good with the prednisone as well until Tuesday night. My mouth became very sensitive to the texture of food, and I've had a flare up of the GVHD in my mouth. The last two days I've had new sores in my mouth, especially on the tongue. This makes eating and talking uncomfortable, which is especially a nuisance with Kate and I's anniversary today and the 4th of July tommorow. A nice dinner to celebrate four years would have been nice, but I think we will put that off until my mouth is ready to enjoy nice food.

Since the prednisone has been improving my symptoms pretty smoothly, the plan was to taper my dosage again. However, the flare up in the mouth led the doctor I saw today to keep me at the levels I am currently on. Its a little disappointing that I've had a bit of a setback with the symptoms, but this is all just part of what I have to deal with. Mouth pain aside, the rest of my symptoms haven't regressed and I am feeling pretty good overall. I'll make the best of this weekend, and I hope everybody else has a great Independence Day weekend as well!

Day +189

Summer vacation is here for a school employee like me, which meant plenty of time this week to visit NIH. I've put in full days there each of the last three days, and will head over to Bethesda tommorrow for a quicker visit. I've entered a new study at NIH that is not therapeutic, but involves tests in order to collect data on chronic GVHD. I've visited a slew of disciplines for this, including dermatology, dental, opthamology, and more.

I've visited the skin and mouth doctors plenty of times in recent months, and there isn't much going on there. Both of those areas have improved with the introduction of prednisone recently, so that is a positive. The opthamologist was happy with everything he saw until he got to the final part of his GVHD examination. He flipped back the upper eye lid and noticed some scar tissue on the inside of the lid. He felt that this could have explained the runny eyes and crustiness that I had recently. While the prednisone has cleaned up those eye issues, he was still concerned that the scar tissue there could have a negative effect on the eyeball. He prescribed me some eye drops as well as a steroid ointment for the eyes. I'm not happy about having to medicate my eyes, but at least this might prevent a more serious future problem. This makes me thankful that I chose to participate in this study.

So the prednisone is slowly easing the discomfort and pain of the GVHD, and this study is helpful because there are a lot of talented doctors weighing in on how to best treat this issue. Meanwhile the cancer is still there and my family is praying and hoping for that to improve. Today was another PET scan and like always its a big deal to hear what the results are. The meeting to discuss my situation was scheduled for 3:00, but it was closer to 4:00 by the time it got started. We have learned that waiting for the results hasn't been a good sign, so that raises the anxiety. My dad was the only person with me at the meeting, which was probably a good thing. Kate and my mom would have been stressing having to wait that long to hear the results.

The lead transplant doctor and several other familiar medical faces were there for the meeting. He looked exhausted and stated in a beat-up voice, "The scan showed significant improvement." It was great news to hear but the voice he said it in was somewhat depressing. One of the nurses and another doctor kind of gave each other an odd look when they heard him give such positive news in that type of voice. My Dad appeared to match the doctor's emotions and seemed ready to take in some more worrisome news. However, hearing "significant improvement," no matter what the delivery was like, was an immediate great feeling. The doctor explained that the previous spots near the tumor had all disappeared on this scan! Great news. He also stated that the size and the intensity of the tumor had significantly decreased as well. EVEN BETTER NEWS! There was a spot on the sternum that lit up on the PET, although it was barely measurable. He had no explanation for that, but was unconcerned about it considering how much the tumor mass had responded.

So while the phrase "No Evidence of Disease" has not been mentioned, this is still a great result. My new immune system is doing its job quite well! Since the transplant I have had a PET scan every month in order to closely monitor the tumor site. PET scans this frequently definitely aren't commonplace, but this was the doctor's decision considering how quickly I relapsed last year after experiencing a full remission. It was a positive sign today that he felt it wasn't necessary to have a PET scan next month. He was willing to wait a longer period of time before the next scan, which is always a milestone for a cancer survivor. I decided to go ahead and have a scan in a month anyways just to be on the safe side in monitoring the cancer. However, its an amazing feeling to know that enough progress has been made that the doctor is willing to increase the amount of time between scans.

So I remain on the prednisone and I am taking other topical steroids in order to control the GVHD. Its not a pleasant deal at all, but there is some sort of satisfaction in worrying more about this than the cancer. I'll continue to visit NIH a couple of times a week most likely through the summer. However, I am hoping that when work resumes in the middle of August that I'll be healthy enough to put a lot of my current struggles behind me.

Day +181

Today is June 17th, which means I am six months out from the bone marrow transplant. I try to take things one day at a time in life, especially when thinking of the cancer. Therefore I didn't really have many expectations for what it would be like at this point when I was back in the hospital receiving the new cells. However, there were some things that I was hoping for. I haven't gotten the news that I'm free of the cancer yet, which is a bit disappointing, but I haven't received any negative news about the cancer either. I don't think I fully appreciated at the time how long this process would be. I was obviously hoping that I wouldn't have a big problem with GVHD, and I felt I was doing great for a few months. While I missed the acute GVHD right after the transplant, the chronic GVHD has been a recent pain in the butt. I don't know if I had any other goals, but one things I really wanted to do was to get back to work before the end of the school year. Today was the last day of work for the summer, and I thankfully put in about a month of work before the year ended.

So while I didn't quite know what this time would bring me, I have to say that things are pretty positive right now. Bad health is something that I feared before my cancer diagnosis, but I've realized that I can handle the physical problems pretty well. There were some times that I was truly exhausted, sick, or in pain, but these are things that I've been able to handle...especially with Isaiah and Kate helping me along the way. Missing so much work wasn't fun, but the biggest positive taken away from that was a lot of time spent with Isaiah and Kate. Family time, even under less than ideal circumstances, can be as good as it gets.

Moving on from the reminiscing, I celebrated six months with nothing less than a trip to NIH. I saw the dermatologist, who was happy with the progress since the prednisone began. I am also starting a new protocol that will involve some tests to help document what my GHVD symptoms are. For this study they took a couple of skin biopsies today. It was a pretty easy visit overall.

Tommorrow I will head back to NIH for a busy day. I'll meet with the transplant team in the morning for them to check on my progress. They will decide then how I will continue with the prednisone dosing. With the progress I am making they might decide to taper the dosage to every other day. After meeting with them I'll have a dental visit for another study that I'll be starting. This one involves a thalidomide gel to help with ulcers in my mouth. The prednisone has helped my mouth since I started it, but there is still room to improve. This might help out as well, or I could end up on a placebo. Either way it shouldn't hurt.

In the afternoon I will take part in a swallowing test which will give the doctors an idea about how my throat is affecting my ability to swallow. Supposedly this involved some eggs with some traceable isotope in it. Sounds delicious. Following that I'll have to inhale pentamidime, which is the prophylactic for preventing pneumonia. So tommorow will be another busy day, but it feels like business as usual. I'm still a regular around NIH at six months, but that was to be expected. Hopefully it is just the beginning of another successful six months on the long road of life.

Day +178

After my appointment last Tuesday, I returned to NIH on Friday for the doctors to check on my GVHD symptoms and discuss the next step in treatment. My Dad was able to come to the meeting as well, with some questions he had for the doctors. The meeting was in the afternoon and I was pretty exhausted at that point. My fatigue seemed to be getting worse the previous few days, and my mouth was irritating me as much as ever. Not only was I still having trouble swallowing, but I was developing sores on the top of my tongue that made putting anything in my mouth, even room temperature water, uncomfortable.

So the nurse practicioner I saw on Tuesday initially thought I looked worse when she saw me Friday. She had me weighed and I had lost two and a half pounds in the three days since my last visit. This is my lowest weight since I was first diagnosed back in September 2007. In the last three weeks I lost thirteen pounds, which is more than a pound every two days. I think its safe to say I wasn't heading down a healthy path.

When the doctor saw that I wasn't rebounding in the last few days he decided it was trime to start the systemic treatment with Prednisone. I was prepared for this and it was a relief to know that I would be getting some relief. My father asked about losing the graft versus tumor effect when starting the Prednisone, which was a concern of mine as well. The doctor explained that statistics show an improvement in graft versus tumor effect with mild GVHD, but that there is no correlation between greater graft versus tumor effect and more severe GVHD. Since I have already had the minor GVHD symptoms, his thought was that I likely already received as much of the graft versus tumor help as I can get. This was a relief to my father and I to hear, and made it clear that there really would be no reason to not start the Prednisone treatment at this time.

My father brought up his thought that more tumor-fighting techniques could be used to help eliminate the tumor because of its tough nature and the aggressiveness with which it came back last year. He brought up the idea of radiation with the doctor, who did not rule that out as a possibility in the future. Most patients who have a mediastinal lymphoma receive radiation after their initial chemotherapy. I did not receive this after chemotherapy because the original study I was in was testing if the therapy I was given would eliminate the need for radiation. The idea of radiation certainly isn't pleasing, but there are plenty of people who have been through it and are doing well. If that is something I need to have done in order to improve my chances of living cancer free, then it would be worthwhile. For now the doctor wants to focus on improving my GVHD symptoms, and possibly thinking about radiation further down the line after some more scans.

So in addition to the Prednisone the doctors gave me some morphine to help with the pain of swallowing and some encouragement to keep nourishing myself despite the discomfort. I started the Prednisone Friday evening, so while I write this I have only taken three doses of it. Its pretty encouraging though that Kate has already noticed an improvement in how I appear to feel. I feel its made a big difference already as well. The most obvious sign that I've noticed is that my skin rash looks better. I had a rash on the back of my hands that were raised purplish/reddish bumps, and those are barely noticeable now. My throat feels better although it is still uncomfortable and occasionally painful to swallow. Taking the morphine before meals seems to help a little bit. My fatigue has also seemed to improve, although some of that might be explained by the energy boost that Prednisone tends to give you.

So I will be interested to see how I feel as I continue to take the Prednisone. Returning to a more normal state would be great, and keeping the GVHD from giving me further problems is the most important issue right now.

Day +173

I continue to work and this past Friday was the first payday since I've been back. The check came in the mail with a whopping $13.73 made out in my name! Well...it was only two days worth of work, so it wasn't quite a full paycheck. However, even when I am receiving my full pay checks, they will not be their usual amounts for a while. When I took medical leave in December, I elected to continue with our health insurance through work so Isaiah and Kate would still be covered. The options we were given were to either pay as we go or to incur a debt. Since we would be short on money for other bills anyways, we decided to incur the debt, which would then be deducted when I started receiving pay again. About six months of health insurance premiums is a good amount of money, so the debt won't be paid off right away. I was expecting the full amount of my pay check to go towards the debt, but I guess somebody felt I needed that thirteen dollars for something. I'll have to check with payroll about how long it will take to pay off the health insurance debt, but finances are still an issue despite being back to work. At least I can take solace in knowing that avoiding the insurance system and getting my care at NIH has helped our family immensely when it comes to money.

On to the health stuff, I was given an antibiotic last week for a bacterial infection, and it seemed to clear up my congestion pretty well. The members of the team I met with last week were hopeful that when that cleared up that my swallowing might improve, but that wasn't to be. My throat feels a little better, but it is still painful to swallow. I lost another four pounds this week, so I'm still having a hard time with eating. The GVHD on my skin and in my mouth has been pretty stable though. Any changes with those have been pretty minor. However, the GVHD has been getting worse below the belt. I met with a couple of infectious disease doctors today who shared that the problems there aren't the results of any infections. One of the doctors from the transplant team took a look at what is going on and stated that it looked like GVHD. Dermatology has been trying to help me out with that, but nothing seems to be solving the issue.

This doctor from the transplant team seems to feel pretty strongly that its time to put me on prednisone. This would be the systemic steroid that would clear up the GVHD symptoms relatively quickly. He explained that my GVHD isn't serious at this point, but that he doesn't like where its heading. I'd be relieved to start the prednisone and to have these symptoms improve. However, the prednisone would decrease the potential graft versus tumor effect, and there is a small fear in the back of my head that it might be best to hold off on it longer. However, I also might be fine and no growth would occur if I started prednisone now. Its impossible to know what will happen with cancer. Right now though the improvement in quality of living would definitely be welcomed.