October 4, 2007 - Go-Slow on the Stem-Cell Transplant

This morning I drive up to Hackensack University Medical Center, for an examination and consultation with one of their lymphoma specialists, Dr. Tatyana Feldman. I hadn't requested this appointment; Dr. Michele Donato (the stem-cell transplant specialist) set it up, after the meeting of the Tumor Board at which the doctors discussed my case.

Between sitting in the waiting room and an intake interview with a nurse practitioner, it's three and a half hours before I finally meet the doctor. (They think nothing of making patients wait for very long periods at Hackensack.) As with my last visit, I'm prepared for this ordeal: both mentally and with a book in hand. I finish the book just before they call my name.

"Oh yes, I remember your case," says Dr. Feldman, as she enters the examining-room and looks at my folder. (She's a member of the Tumor Board.) There's a cursory physical examination, feeling for swollen lymph nodes, but – no surprise – there's nothing remarkable to report (my swollen nodes are pretty deep down).

Dr. Feldman gets right down to business, reading through my file. She's most interested in the report of the Hackensack pathologist, who has taken another look at my biopsy slides. She confirms my indolent-NHL diagnosis, and speculates that, regarding my first biopsy, the Memorial Sloan-Kettering pathologist may have been in error in declaring that my lymphoma had an aggressive component. This sort of pathology is not an exact science, she explains. Different pathologists have different methods of counting cells. Whether I had a truly mixed staging that morphed into indolent-only disease, or whether it was only indolent to begin with, is pretty much academic; there are differences of opinion, among pathologists, about the boundaries of each category. (It wouldn't have affected the treatment I received, either way; R-CHOP is pretty much the universal first-line treatment for a bulky-tumor NHL like I had.)

In any event, we're clearly dealing with indolent lymphoma now, so everyone's still agreed we'll proceed on that basis.

Dr. Feldman tells me she doesn't recommend a stem-cell transplant at the present time. No surprise, there; Dr. Lerner's advice to me all along has been that this is something for the future. The trip to Hackensack is mainly in order to get registered with that hospital, and get my brothers typed as possible allogeneic donors. These transplants – while offering the only real hope for a cure, at a 65% chance of succeeding – also expose patients to a risk of deadly infection. Dr. Feldman points out that 10-15% of transplant patients die of infections, or out-of-control graft-vs.-host disease. So, it's not something we ought to rush into.

Dr. Feldman also tells me my lack of bone-marrow involvement is relatively uncommon. Most indolent-lymphoma patients do have some cancer in their bone marrow. I ask if this makes a difference with respect to the likelihood of a successful transplant – whether there would be any advantage in getting it done sooner rather than later, before it's gotten into the marrow. No, she replies: with an allogeneic transplant (cells from a donor, as opposed to an autologous transplant, with cells coming from me), it makes no difference.

Dr. Feldman is Russian – I can detect an accent – and now she relies on a saying from her culture to explain my situation. It's not exactly like "a bird in the hand is worth two in the bush." She likes the Russian version better, which is something like, "don't gaze up at the crane high in the sky, while there are lots of sparrows on the ground." In other words, as long as my quality of life is good, let's get what advantage we can from the less-dangerous approaches, before undertaking heavy-duty treatment.

When it comes time to treat the cancer again – when the lymph nodes grow to a sufficient size, or when I start having symptoms (pain, sleeplessness, night sweats, sudden weight loss) – there are a number of options available. One of them, she says, is Zevalin (the radioimmunotherapy drug), which she says has an impressive record of success.

However many years down the road we may begin talking seriously about stem-cell transplant, the universe of available treatments will probably have expanded. Some therapies now in clinical trials may then be in common usage, and other, as yet undreamed-of treatments may be in trials (which Hackensack could play a role in getting me into). Time, in other words, is very much on my side.

I leave feeling rather upbeat. The crash-course I’ve had in stem-cell transplants in the past several weeks has caused me to brood about this possibility more than I really needed to. My purpose in going to Hackensack has been both educational for the present, and proactive with respect to the future. I do feel like I know a lot more about the transplant option, and certainly the folks at Hackensack know me, now – which is a very good thing.

Next Wednesday, I'll meet with Dr. Lerner. He'll help me understand more about all this, I know.

Leaving the hospital, I stop for a late lunch at an Asian buffet. Lots of wonderful sushi – a nice way to celebrate the pretty-good news.