Thursday, 1 March 2018

Thal

Here he comes, he's all dressed in black. PR shoes [*] and a big straw hat. He's never early, he's always late. First thing you learn is that you always gotta wait. I'm waiting for my man
Waiting for my man - Lou Reed

End of Cycle 1 ... Neutros = 1.4 ... Hb = 9.8 ... (KFLC tbc)

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Those who've seen me around - probably walking a bit unsteadily, certainly wincing - will know my last couple of weeks have not been good. This is in part due to back pain and bone pain. I'm not certain what has caused it all to get worse: whether it is my myeloma progressing; or whether I've aggravated it; or whether it is my body becoming resistant to the painkillers; or whether it is the adjustment/accommodation into the start of treatment. Whatever the cause, it hasn't been much fun. On top of this, I'm feeling even more out of breath than before.

(Plus, I have the ups and downs of steroids to contend with. But more on that another time.)

In summary, not great. I have been reminded - as if I needed it - quite how grim myeloma can be. Though it could, of course, all be a lot worse. And I'm optimistic that the worst of the bone pain is coming back under control. Hopefully the next few weeks will be less arduous than the last.

When I arrive to get my new prescription, the doctors take it all quite seriously. My anaemia is becoming a real concern, but there's nothing to suggest the drugs are making it dramatically worse, so no reason not to continue the treatment. We won't have any meaningful feedback on whether the drugs are working, for another month (they took a blood sample today, but it takes a week to get the result, and anyway, one result on its own won't tell us much). So, we continue on the current course.

They suggest to substantially increase the doses of my painkillers. Hopefully I can return to some quality of life that is a little more bearable. Living "in" it, one sometimes lacks the perspective to see what's going on. It is only when the docs ask me the clinical questions - what is the pain like, how has it changed over time - that I appreciate that living as I have done of late is not OK. It's not just part of the process. It's not my lot in life. It's not just something I have to put up with. It's not just something I have to keep quiet about. Actually, I have a right to expect better, to demand better. Better, in the immediate sense, meaning stronger drugs!

One cycle down, 3 or 5 to go.

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A little about the second drug in my treatment triad: thalidomide, of which I currently take 100mg each day. I'm intrigued to be taking thalidomide, because its name is so arresting, so shocking. There isn't a medicine on the planet with a worse reputation. Originally marketed as an anti- morning sickness medication in the late 1950s, thalidomide did appalling damage to the unborn children of unsuspecting mothers-to-be, before being taken off the market again in 1961. Having failed patients so badly in the past, the medical profession is understandably making a significant effort to avoid any more unborn children being exposed to thalidomide. This basically means ensuring those of us taking it don't procreate. I'm not aware of any evidence that thalidomide can affect a baby from its father, but no-one should even want to let that risk exist.

My supply comes in rather glamorous packaging - practically gift wrapped - and with extensive instructions and warnings. The hospital checks up on me too, by asking all sorts of very personal questions. If I were female, they would insist on regular pregnancy tests. I can be grateful of being spared that intrusive indignity. Frankly, it is all a little unnecessary: having managed to have only the children I wanted to, these last 30 years, I have no intention of letting my guard down now.

The thalidomide crisis/scandal served to demonstrate the necessity for proper clinical trials, and to show the need for proper processes to manage and monitor drugs. It is also a striking example of the pharmaceutical industry failing to live up to its responsibilities. It is an important story, but it is not my story.

The reason thalidomide proved so devastatingly dangerous was, ultimately, the reason it was considered as a possible cancer treatment. The deformities in unborn children were caused, we know now, by Thalidomide impeding blood vessel formation. But it wasn't until the mid 90s that this property (called "antiangiogenesis"), was recognised and considered as a possible cancer treatment. Surprisingly, it turned out to be most effective in blood cancer - a cancer where one would intuitively imagine blood vessel formation is not a factor. (Do myeloma tumours have blood vessels?) The pharmacology is complex, and the effects of thalidomide are still not entirely explained. It does a number of things, but we don't really know which of them gives it the anti-myeloma properties. As well as stopping new blood vessels from developing, it is known to inhibit the development of the cells in the body tasked with breaking down old bone ("antiosteoclastogenesis" - just rolls off the tongue!). One of the symptoms of myeloma - the biggest single problem, for me - is that it alters the balance between bone destroying and bone building cells, so that bone is destroyed more quickly than it is replaced. Thalidomide appears to act in the opposite way, but it is not clear whether this helps to explain why thalidomide kills myeloma cells. Maybe it is just a bi-product of interfering in the same processes.

Thalidomide and the other drugs that have more recently been developed in the same family (lenalidomide and pomalidomide, which are presumably working on the same pathways), are not completely understood. We know they work, but not exactly how. You'd be surprised how common that is in medicine. This group of drugs are classed as "immunomodulatory", but given that they are used to treat myeloma, a disease of the immune system, the classification really doesn't tell you much!

Thalidomide is often part of people's very first ("front line") treatment. When myeloma relapses, it is normal to move on to different drugs; the general premise being that the disease is likely to become resistant to drugs it has been exposed to before. As it happens, I didn't take it last time round (because it wasn't part of the trial protocol I participated in). If it weren't taking it now (this time round it is part of my trial protocol), then I think it is quite likely I would have ended off missing it out altogether. That it could easily not have featured in my treatment at all, I find remarkable, considering that less than 20 years ago it was the very first available alternative to old school chemo. That shows how quickly the treatment options have changed and are changing. It is quite likely that I will take its siblings - particularly lenalidomide which seems to have the best combination of effectiveness and fewer side effects - at some point later in my journey.

The side effects of thalidomide are basically that it can suppress bone marrow function. So it can cause or exacerbate neutropenia (weakened immune system) and anaemia. Given that these are problems I already have, there's a risk that things get worse before they get better. That's how it feels right now, with me puffing at even the slightest exertion. Still, I haven't been struck down with any infection (yet) and for that I must be grateful.

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(* PR shoes = Puerto Rican, i.e. "Fence Climbers". Not, as those of us in the trade might incorrectly surmise, Public Relations shoes. Though in spivviness at least, if not in practical law evasion features, the difference isn't necessarily great.)

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