August 7, 2007 - The Whites of Their Eyes

“Don’t fire until you see the whites of their eyes.” The saying is traditionally attributed to American General William Prescott, at the Battle of Bunker Hill in 1775.

Much as I resist military metaphors when it comes to cancer treatment, that phrase seems apt to me today, after this morning’s second-opinion consultation with Dr. Carol Portlock at Memorial Sloan-Kettering Cancer Center in New York City.

Dr. Portlock says the Memorial Sloan-Kettering pathologist who examined my biopsy slides confirmed that what I’m dealing with is indolent lymphoma – small cells, with the CD-10 protein marker on their outer surface (there’s no sign of the large, CD-20 cells I had previously). My swollen lymph nodes are few in number, and they’re quite small. For that reason, Dr. Portlock is going to recommend to Dr. Lerner a strategy of watchful waiting.

What I’ve experienced, she tells me, is something called “retrograde transformation.” While the larger, aggressive cells were indeed there previously – primarily in the large mass in my abdomen – they seem to have disappeared after treatment, leaving me with indolent (follicular) lymphoma.

There’s a part of me that distrusts the watchful waiting strategy – that wants to just get on with it, and push back against the cancer, hard and fast. Yet, just as there was a certain strategic wisdom in the Continental Army marksmen holding their musket fire until they couldn't miss, so there’s wisdom in waiting to recommence treatment of my lymphoma. Not every cancer treatment is repeatable. It’s best to save the ones we have for when they’re truly needed.

With lymphoma, the doctors have a certain number of arrows in their quiver – more than with many cancers – but, that number is still limited. We can’t just fire them off wildly. We’ve got to make them count.

“Is there any downside to watchful waiting?” I ask.

“Well, sometimes the patient disappears,” Dr. Portlock admits. When I ask what she means by that, she explains that some watchful-waiting patients get overconfident, and – in the absence of obvious symptoms – stop going to the doctor. Then, the silently-advancing recurrence sneaks up on them. By the time they do get back to the doctor, it’s advanced far enough to be truly dangerous. The “watchful” adjective is a crucial part of the formula, in other words. Vigilance is the key.

“You won’t have that problem with me,” I assure her. I have every intention of continuing to go back for scans, at whatever intervals Dr. Lerner recommends.

I ask her how long I can reasonably expect it to take, before my cancer has advanced far enough to require treatment.

Maybe a year or two, she replies. Maybe longer. Dr. Portlock makes a circle with her thumb and forefinger, that looks to me to be about the size of a small grape. This is about how big the malignant lymph nodes should be before we start treatment, she says. We should keep monitoring them using CT scans, at whatever interval Dr. Lerner recommends. (CT scans, she explains, are better than PET scans in this instance. We already know what the enlarged lymph nodes are. We’ve just got to keep measuring how big they are. CT scans are better suited to this purpose.)

When the lymph nodes do get large enough to treat, I ask, what treatment is most likely? Dr. Portlock says treatment with Rituxan only (not chemo, this time) is a possibility. This drug is often effective against follicular lymphoma, and has few side effects.

She also talks about an allogeneic stem cell transplant (that’s the variety in which the stem cells are donated by another person, ideally a sibling). Such a treatment is “potentially curative,” she says, but with the swollen lymph nodes still so small, it’s too early to move in that direction.

I leave feeling upbeat. This does seem to be pretty good news (although, as I’ve said, there’s an impatient part of me that just wants to get on with it).

After a quick lunch in the hospital cafeteria, and after calling Claire to fill her in on the news, I decide to take advantage of having a free afternoon in Manhattan. I walk the five or six blocks over to the nearby Frick Collection, and spend a couple of hours looking at Old Masters paintings. I’ve never been to that museum before, and am impressed by it: it’s smaller and more manageable than the Metropolitan Museum, and contains a collection of very famous artworks indeed: displayed in the home of the collector himself, much as he would have wanted them to be viewed.

A subway ride and a train ride later, it’s back home again.