Facing Chemotherapy I: This Stuff Could Kill You
When I was diagnosed with acute myeloid leukemia, I received an initial round of “induction” chemotherapy to get my disease into temporary remission and buy time to consider my long-term treatment options.
I had no prior experience with cancer or chemotherapy. My first lesson about this treatment was when my nurse Jane approached me wearing the hospital equivalent of a hazmat suit, face shield, gloves, and mask. She then placed a thick mat over my torso to protect me from any accidental spillage of the drug. All this vividly symbolized the toxicity of the medication I was about to receive. I realized that while it was intended to cure me, this could only happen by first poisoning me.
It was some time later that I came across an arresting footnote in Susan Sontag’s Illness as Metaphor. She describes an incident in World War II when an American ship carrying mustard gas was bombed, releasing the deadly chemical. Some soldiers died from burns and drowning, but most succumbed to bone marrow poisoning from the mustard gas.
When some creative doctors realized that this lethal agent might also kill cancer cells, they fashioned a closely related chemical compound known as nitrogen mustard to treat blood cancers like leukemia and lymphoma. As I proceeded to my stem cell transplant, I received a chemotherapy drug called Cytoxan that is derived from this lineage of chemical weapons. The goal was to kill off both cancer cells and my diseased immune system and it worked. Unlike those unfortunate sailors, however, I received a carefully calibrated dose followed by a cord blood transplant of healthy stem cells that jump started a new immune system.
One of my oncologists captured the role of chemotherapy in transplants succinctly by saying “first we bring you to the brink of death, and then we try to bring you back again.” Needless to say, I’m happy the second part worked as well as the first.
Facing Chemotherapy II: Wait for it
When I received my first round of chemotherapy, I anticipated some nasty side effects. What I didn’t realize, however, is that they take a while to show up. This led to a false sense of confidence about how well I was weathering my treatment.
My stereotype about side effects was evident in a question to my nurse as I was about to receive my first chemo infusion. I asked if I couldn’t get to the bathroom on time, where do I throw up? She smiled and said that was unlikely due to the premeds they used to control nausea. What she didn’t say is that such side effects would take some time to appear. When I still felt fine a week after my treatment concluded, I got a bit cocky and smugly thought “I’ve got this.”
It was another few days before the expected effects appeared: depressed blood cell and platelet counts, nausea, fatigue, hair loss, several unidentified infections, colitis, an E-coli infection, and a full body rash. My smug confidence was replaced by a humbling awareness that I was every bit as vulnerable as I first thought; it just took a little longer than I expected. While the timing surprised me, my doctors just nodded as if to say this is what we expected all along.
A couple months later, I received multiple infusions of high dose, consolidation chemotherapy to keep me in remission until I could have my transplant. Perhaps because of the higher dose, it took only one week for a low-grade fever to appear. More disconcerting was some rectal bleeding that convinced me to head to the emergency room. There, my white blood cell count registered .3 (normal = 3.8-11) and my platelet count was 4 (normal = 140-450). The ER doctor simply said “there’s nothing there” to fight infection or control bleeding. He booked me for a week-long hospital stay and multiple platelet transfusions to control the bleeding.
I consoled myself by thinking that with this response, they must have given me top shelf chemo that would also be effective in bridging me to transplant. But I learned never to be smug about these matters again. When facing chemotherapy’s side-effects, don’t celebrate early. Instead, just wait for it and weather it as best you can.
Facing Chemotherapy III: Your Own Worst Enemy
Chemotherapy kills fast growing cells and hence can be effective against cancer. But it does not discriminate between healthy and malignant cells. Hence, the trade-off for killing cancer cells is killing fast-growing, healthy cells as well.
The most serious side effect may be chemotherapy’s impact on the immune system. It drives down white and red blood cell counts as well as platelets. Low platelets can lead to unusual bleeding and low red blood cell counts can bring fatigue. Perhaps most important, low white blood cell counts leave us vulnerable to infectious agents we might normally resist and never even notice.
To counter this heightened susceptibility to infection, patients receiving chemotherapy must take various precautions to minimize their exposure to infection. Wearing masks, washing hands, limiting contacts, and even isolation rooms are just some of the precautions that patients routinely take.
As important as these practices are, they rest on the premise that infections arise from external sources. This was how I interpreted an E-coli infection I acquired several weeks after receiving induction chemotherapy for my leukemia. I blamed the hospital environment for my misfortune until my doctors offered an even more plausible explanation.
Much to my surprise, most of us have E-coli bacteria peacefully residing in our gut throughout our lifetimes. With a healthy immune system, these bacteria are well controlled and produce no troublesome symptoms. It is only when we are immunosuppressed that these bacteria can morph into major infections requiring aggressive, antibiotic treatment.
The same dynamic played out after my transplant. I was given anti-rejection medication to allow my transplanted stem cells to take root and construct a new immune system. This also caused immunosuppression and opened the door to another critter known as the cytomegalovirus. It is a common virus that resides in many of us but is usually well controlled by a healthy immune system. When that system is compromised by anti-rejection medication, the virus can break out and require proactive treatment with anti-viral medication.
My encounter with E-coli taught me to never scoff at adult diapers again. But more importantly, I learned that for all our well-intentioned efforts to minimize exposure to external agents of infection, sometimes we turn out to be our own worst enemy as “auto-infections” arise from deep within us.