Thursday, 11 July 2019

Faithless

I'm nervous. Cos I'm the left eye, you're the right. Would it not be madness to fight?
We Come 1 - Faithless

I do wanna write. And I don't. A lot to say. And nothing. I'll try to avoid a long screed of whateversinmyhead, though it isn’t easy to get it in any better shape, right now.

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Start with the easy bit: the facts. After dropping dramatically in the first month on daratumumab, my light chains then went up, and up again in the second. Just when it seemed clear things weren't working, the count dropped again a couple of weeks ago, which may not be enough to class as good news, but certainly isn’t bad news. Honestly, no-one knows what this means. But alongside a bad bone marrow sample, the doctors tell me they think my 'eloma is "static", which is different from, and not as good as a "plateau" (but better than "progression"). We're awaiting the result of another whole body MRI, which should show up exactly what's there. It’s really going to have to serve as the “definitive” measure of where I am. Prepare for the outcome to be as equivocal as possible. In my experience, it usually is. Meanwhile, I feel really rather good, and my blood counts are almost normal. I'm not getting much fatigue (some acupuncture seems to have really helped). And the pain is OK, though it notably gets worse when my results are worse... and then better again when the results improve.

Depending on the severity uncovered by the MRI, we could be urgently seeking a new treatment... or not. And overall, I could still be heading for stem cell transplant or CAR-T. Indeed, one of the questions right now is whether having one has any bearing on whether I can subsequently have the other! Though unless we can get my disease under control, I may not be fit for any of them. Working my way through the drugs is not a good prognostic, lets be honest. I have never had - and do not want - any numerical estimate of my life expectancy. I always work on the basis that, at any moment, I've about a 50:50 change of still being here 5 years from now. But being in treatment, and the treatment not working well, must heighten the risks.

That’s the status update. One consequence is that, just when we thought we could make plans for the summer, we had to stop. The latest medical advice for travel plans is “wait a couple of weeks”, and “the timing might be better in 2 or 3 months”. I’ve been living with that, pretty much continuously, for years now. We wait a couple of weeks, but a couple of weeks never comes. As for the better times coming… I could be in the midst of a stem cell transplant in 3 months, for all any of us knows. It’s not easy.
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<long>
What follows may or may not be helpful. Feel free to ignore me.

When I relapsed, I imagined a year of treatment, culminating in a transplant, and then a return to (relative) normal. But 18 months on, I'm not sure I'm any nearer to that. It’s forcing me to unpack a lot of my assumptions, which have been all jam-tomorrow, when I need jam-today. A string of failed treatments does a lot to focus the mind (and sap your faith). I’ve lived in this state of perpetual uncertainty for a long time now, and it’s not easy to convey what that’s like, to those who haven’t been there. If you have an hour and a half to spare, I’d recommend watching the BBC documentary “War in the blood”, (on iplayer until end of July - may not be accessible outside the UK). It gives a good introduction to “CAR-T” therapy – which is potentially where I’m headed. But more than that, the experiences of both the patients featured, and their nearests/dearests are much like mine. I found myself reading subtext in pretty much everything they said. Not easy watching though.

I am very grateful to a few people who give me the opportunity to talk while they listen, unencumbered by knowing me socially; notably my nurse, my counsellor and my Alexander teacher. I’m discovering some of my ways of rationalising are a long way from rational, not even healthy. One of my friends in myelomaville, Deb Gasgoyne recently wrote a piece on her feelings of Survivor Guilt. Reading it, I was reassured that I’m not the only one who has some rather perverse responses to my own predicament. What she wrote did a lot to jolt me in to facing up to some of my demons; to explore, explain and sort out some of what goes on in my head. I’m on a bit of a mission now to dump some of the unhealthy things I think. It’s not an easy process, but a constructive one.

I’m going to write some of it down, for the reasons I always do: I find it therapeutic (sunlight as antiseptic); it may help others in similar circumstances; and it might help people who know me understand me better. If you don’t want to read it, don’t!

A lot of it begins with contradictory thoughts: I might still be here in 10 years; but it might all be over by Christmas. Both these things are true, and I’ve struggled to deal with the constant stress. I accuse myself of making up a melodrama. And if I talk about it, I feel like I’m attention-seeking. After all, I might still be talking about it for years to come! I’ve been quite intolerant of myself. It’s become more and more of an issue as I’ve worked my way through treatment after treatment. I project my self-critical thoughts onto other people, which is neither helpful, nor fair. Do I really believe anyone else actually thinks I’m making it all up? Not really. The only real critic is me; beating myself up for being honest.

Plus I have a tendency to denigrate my own experience. My bones get measurably worse after a couple of bad light chain scores, and then I get a better result and the pain fades. I’ve always interpreted that as insincerity: psychosomatic, not real. But this presupposes an underlying objective level of pain, and pain simply isn’t like that. I’m going to write a separate piece specifically addressing pain. In terms of the sorting out of what’s in my head, the point is that I’m endeavouring to stop denying my own experience. Yes, it hurts more when times are tough. Pain is physical and psychological.

I hurt a rib a couple of weeks ago, playing football with the boys. I mentioned it to my Alexander teacher, adding some qualification the gist of which was that I wasn't doing anything too dramatic when it happened. Her reaction made me question what I had said. Just what, exactly, in a bit of gentle father-son football would make me responsible for hurting my ribs? I know full well that if I threw myself heedlessly across the pitch, that'd be asking for trouble. I know I have limits. When we took the boys indoor skydiving, and indoor surfing, last weekend, I did not participate. But having limits isn’t the same as knowing where they are. I could try to steer well clear of my limits, but that would basically mean spending the rest of my life in an armchair. If I attempt to live any more than that I’m inevitably going to overshoot sometimes, and suffer for it in pain or fatigue. What I don’t need to be doing, when that happens, is carrying blame. I suspect the only person who really blames me, is me. But that's enough. It needs to stop.

Another area where I need to cease blaming myself, is the impact that my illness has on anyone else. I’m not responsible for it. I can be sad, but I’m not sorry. It’s not my fault. Why does this matter? Well because it's a short distance from being sorry to thinking people would be better off without me, or if I'd never been here. There have certainly been times, this last year, when I have felt like that. Those are the darkest thoughts of all.

The other day I told my counsellor something to the effect that I've always felt like myeloma was sort of appropriate to me - complicated, a bit cryptic, heavy on the numbers. She gave me a very odd look. So much so that I’m already finding it hard to think I even believed what I said – but I know I did. I’ve always thought of my myeloma in those terms. As long ago as 2013 I wrote in dialm: “It is very in character, for me, to get a rare, complicated disease”. Of course, that’s nonsense. My experience of myeloma is filtered through the fact that it is happening to me. It is as it is because it is my experience (and other people experience their disease their own way). One quizzical look burst the bubble in my head. This “myeloma” thing is no more meaningful than random chance. It doesn’t have a personality. It is nothing more than a profoundly shitty software bug. I don’t think I’ve been mythologizing it, but any residual interest I had in it, beyond the practicalities for me, disappeared on the spot.

I don’t know how helpful any of that is for you as reader - its been difficult for me to articulate as writer. My physical condition is like the proverbial swimming duck: it might look calm on the surface, but it’s more turbulent underneath. My mental condition is similar. I’m grateful for feeling good and looking well, really I am, but I’m not deceived by it.
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Wednesday, 8 May 2019

Dara

When I fall from the wagon, hiding from the businessmen, won't you find a way for me somehow?
Syrups - Foals

... KFLC (29/4) = 272 ... That's a 1/3 drop, after 3 weeks of daratumumab ... Currently on week 5 ...

It’s been a while. Much has changed. (Though the underlying predicament, has not.) I guess I’m bringing dialm back out of cold storage.

Having completed 4 cycles of RCD (lenalidomide based regimen), I had to stop treatment due to a collapse in my platelet counts. We’re still not 100% clear why this happened - could be treatment toxicity, could be autoimmune (chronic ITP)... who knows. Whatever the cause, for more than a month I needed platelet transfusions several times a week. We attempted to treat the problem with pulses of high dose steroids, and by putting me on a drug called eltrombopag that should stimulate platelet production/retention. Eltrombopag is a bit hard on the liver, so I’m not allowed to consume dairy products (or anything containing calcium) for large parts of the day. As a cheese lover, that’s a bit of an issue. My calcium levels are often low and I’m always being instructed to take calcium supplements. But since the calcium seems to collect as stones in my kidneys, I’m a bit reluctant. Finally, three weeks ago, my platelet levels began to recover. A relief - it’s unnerving to know one is being kept functional/ alive by blood donations. And it’s very restrictive having to spend so much time in hospital. I’m fed up of looking like a junky with track marks and bruises everywhere. To top it all, we were supposed to be going away for the weekend, and were forced to cancel the trip at the very last minute, as I was advised it wasn’t safe for me to fly. Instead, a weekend in Sussex, with regular messages on our phones prompting us to check in for abandoned flights and hotels... We do our best to keep cheery and positive, despite events, but it’s not always easy. Having a platelets crisis has been yet another crappy unpleasant disruption I could have done without. Add it to the long list of challenges I have had to overcome, this last year.

I had an inconclusive bone marrow biopsy two months ago, which didn’t explain my platelet problem or my apparently recurring disease. We decided we’d have to do it again to see if we could get a better sample. Every biopsy is an ordeal; it always takes repeated attempts to get a solid sample out - inject, stab, dig, hammer, pull, wince, repeat. In total, we have dug our 5 solid samples - of various qualities - in the last few weeks. My pelvis must resemble Emmenthal. Submitting to it repeatedly, in the knowledge that it may well be futile (there may not be enough good marrow to get a decent sample) requires a certain kind of resignation and acceptance. The doctor was as troubled by the process as I was, by the time we were repeating it for the 5th and final time: the first occasion I’ve observed my predicament cause visible distress in the person treating me. I’m deeply grateful to the professionalism, and the dignity, of my medical team. Perseverance paid off. The 5th sample was “good”, though the payoff was bad news. My marrow  was 80% plasma, when it should be <5%. Most of my marrow is myeloma - and the good marrow is squeezed into just a fifth of the space. This result would count, on its own, as active/progressive disease. And in the time off treatment, my light chains jumped from 150 to 410. The conclusion was that the lenalidomide hasn’t worked.

So, that means we’ve tried two different lines of treatment, both unsuccessfully. It appears my ‘eloma is refractory to proteasome inhibitors (bortezomib and ixazomib) and to imids (thalidomide and lenalidomide). According to The NHS, the next drug to try is daratumumab, a monoclonal antibody. This is a completely different approach to attacking the myeloma. I need to hope that we are successful, 3rd time lucky. Dara works by bonding to a surface protein (CD38) which is present on plasma cells but not much else. The dara triggers immune destruction of plasma cells - hopefully very specifically my myeloma, though it is likely to leave me immune suppressed too. Dara is a different kind of proposition. It’s much less likely to trigger normal chemo side effects (nausea, hair loss, neuropathy etc). But much more likely to cause infusion reactions. So the first time I take it, they put it in really slowly over the course of 10 hours, with all of us watching out for any reaction. It turns out to be very uneventful - I avoid any of the infusion reactions I had been warned to expect. But it still makes for a very long day in the ward. I am grateful to have a visitor to while away the time with chat (and frothy coffee, once we are >4hrs from my daily dose of eltrombopag).

For the time being, the plan involves weekly daratumumab infusions. Hopefully, they will continue to be uneventful. Though they will also be slow. I’m also needing to make a second trip to the hospital each week, to check in for support and, as necessary, to drop up my platelets, or administer G-CSF, or get ticked off for my poor electrolyte levels. For at least the next couple of months, that’s my routine. It will be a while (I don’t know how long) before we have any robust indication whether this approach is truly working. The initial response seems very positive - KFLCs dropped from 410 to 272 in the first 3 weeks. And the side effects are not too bad. Nothing at all as the drug goes in. Only limited amounts of drowsiness from the antihistamines or insomnia from the steroids (a different steroid - methylprednisolone, which is much less potent than dex). I’ve felt ”flu like” symptoms at the end of the week, but even those seem to be waning with each succeeding dose (#5 yesterday).

It’s easy to forget that all the treatment - 3 different protocols over more than a year - has been directed to a single destination: to have another stem cell transplant. We harvested new stem cells for this purpose; and in November we came within a week of doing it. The stop-start experience, and never quite knowing what time horizon I can hope to be “recovering” over, has been difficult to process mentally. But despite the frustration, I accept that we can only make plans on the basis of the circumstances. Statistically, a stem cell transplant is likely to be more beneficial if carried out when my myeloma is in remission. And that just hasn’t happened. If we had carried on regardless, the prognosis would not have been great - we’d likely have “wasted” the potential benefit. And we won’t get another chance: realistically, I will only be young enough and strong enough to undergo that kind of procedure once more.

However, another worry has grown, as we’ve struggled to find a drug regimen that works. Even assuming we get my myeloma into remission, we know it won’t stay there forever. I could continue on daratumumab for along time, if it works, but ultimately, it will fail. Similarly, another transplant might last many years,  yet not forever. And actually, the likelihood is that it will last less than the last one - so I’m looking at another relapse in 3 or 4 years, if I’m lucky. Given how difficult this relapse has been - how long it has taken, how much bone damage I sustained again, how many treatments we have tried and failed, and all the complications - I’m prepared to admit to being a little frightened at the prospect of the next one. Likelihood is it will be even rougher. I don’t really fancy my chances.

So, the doctors’ most recent suggestion is that we might head in a different direction, and they have put my name on their list for the CAR-T trial which has recently opened at Kings (so far they are treating 3 or 4 lymphomas/leukaemias this way and due to begin for myeloma imminently). CAR-T therapy harvests T-cells, modifies them to become myeloma antibody producing cells, and then reintroduces them, hopefully making one immune to one’s own disease. It has the potential to be curative, though it’s too new to be sure - there hasn’t been enough time to show whether the modified T-cells persist, or whether the myeloma eventually mutates to avoid them. I have assumed for a while now that this is the treatment I should ultimately be heading for. But there’s always an advantage in letting other people do the early trials, and following on when there’s more established experience. People have died in early CAR-T trials. It’s not without risk. However, I’m increasingly thinking that the biggest risk, for me, might be the next conventional relapse, by which point it may prove impossible to get my myeloma back in to remission, and where I might be too frail to withstand the CAR-T process. My best option may be to take my chances while I can. I’m lucky that the trial is available at Kings, and I am eligible (at least, I will be once I’ve had a course of daratumumab). That’s “the plan” as it stands - some combination of ongoing Dara, SCT and/or CAR-T. My hunch is that the docs will want me to have them all, if I can hack it. I have no idea how soon we’ll be ready. I guess it depends on my response to the daratumumab.

So... 2019 is proving a lot better than 2018... I’m sick of having my life put on hold by endless dramas... a period of relative peace would be invaluable. I think there’s a chance we might be able to book a last minute holiday for half term. I’ve even provisionally rebooked the recently abandoned weekend break. Maybe this summer, I’ll actually enjoy instead of merely endure.

The thing about myeloma, is it's relentless. There's never a day off. Never 5 minutes off, really. And when things get really hard, it's like being dropped down a deep hole. Sometimes (often) good and bad days alternate. But one wakes on the good mornings at the bottom of the hole, and sometimes can't be bothered to drag oneself out. Especially if tomorrow is likely to involve being pushed back in. Which is all to say that though there have been plenty of respite days, these last 18 months, it has been impossible for me to commit to anything, or achieve much against any set of tasks I might set myself. So many things I want to do and be, but can't. I'm hoping that, at last, treatment becomes sufficiently uneventful to let the rest of my life begin to regrow.

Thanks, as always, to those who have propped us up, in the last few months. Our needs are sometimes invisible, from the outside, but up close, the intensity and unpredictability of this whole journey is quite debilitating for all 5 of us. We’re grateful for the support: flattered that people care and haven’t succumbed to compassion fatigue by now. Our needs probably won’t diminish much over the coming months. Thanks for sticking with us. It’s all a lot better than it was, but still quite challenging. Lyndon turned 7 a few weeks ago. Back in the early days, when I was pretty much bedridden and he was a bouncing baby, I used to take much solace in his smile. “You’re the reason” I would remind myself: hope and potential, to incentivise me; sustain my willingness to succumb to whatever treatment is proposed; and to live through whatever sickness and pain the myeloma doles out. 7 years later, my kids are still smiling (Marisa and I must be doing something right!) I’ll try to match them. “Garde ta foy” as my college motto goes ( = “keep the faith”, though we used to mistranslate it as “look after your liver”. We were so droll).

Monday, 4 March 2019

Clotless

One reason I am reluctant to write here more, or more frequently, than I have to, is because it perpetuates the sense that this is some kind of soap opera. But although it has some soapy characteristics, and endless plot twists, I certainly don’t find it entertaining. However, if I don’t post, it’s hard for anyone else to have any awareness of what’s going on. Those who have seen me recently will know I look well enough. But looks can be deceiving. (Though if I showed you the track marks up my arms, you’d get more of an idea of what’s been going on.)

There was a glimmer of good news last week, with my light chains down for the second month in a row. That is positive, important, and rare. Only the second time, since I started treatment, that I’ve had 2 consecutive “good” months. Worthy of celebration.

Unfortunately, at the same time, we have a new drama: abruptly, I have very few platelets in my blood. (Over the last month, my platelet count dropped from 195 to just 8, and it is stubbornly staying that low, despite several transfusions to top it up.) These are the cells that enable blood to clot: being without is frankly dangerous. After some investigation (including an emergency bone marrow biopsy - yippee), the Drs believe that the cause is “treatment toxicity” - ie the drugs are to blame. So, I’m off treatment (even though it was working) and awaiting a decision on whether we’ll attempt to restart, or try to move on to transplant.

In the meantime I’m tied to the hospital. I spent half of last week in the treatment room, and I am there again now awaiting yet another blood transfusion. For the time being, I think that’s how it will be. My nurse asked me this morning how I’m coping. If I’m honest, I’ve stopped worrying about the bigger picture and the long term. It’s so endless, relentless and unaccommodating that I’ve given up bothering to try to interpret what each twist and turn might “mean”for my prognosis. Whatever we’re fretting about today, it will probably be something wholly different in a few days time. There’s no point trying to read the runes. I’m pretty much beyond caring.

The short term is where it’s at. In the short term, I’m doing my best to accept my circumstances. I cannot make a plan from one week to the next - and that’s been true largely without exception for well over a year now. I waved my kids off to school today, not even knowing whether I will be able to pick them up this afternoon. I make plans and appointments... and then cancel most of them. I have moments of lucidity when I can think ahead, imagining projects I might undertake or participate in. And then I have the rug pulled from under me again, and am humbled by the realisation that I have absolutely no control over my life from one day to the next. I don’t know which days this week I will spend in the hospital. I don’t know if I will restart chemo next week, or not. I still believe that I will, eventually, have my transplant, but whether that is going to happen this month, or next, or whether it won’t be for another six months, I haven’t a clue. I will be out of circulation for several months, but I don’t know which ones. You can probably appreciate how difficult it is to process that kind of information. But unless you’ve been there, I don’t expect you to be able to comprehend what it feels like. I don’t know whose birthday I will miss. I don’t know whether I will be able to witness any particular performance or milestone. Will I be there for your class assembly? Will I watch your next match? Will I speak to your violin teacher? I don’t know. Will we go away for the school holiday, and if we do, will I come too? I don’t know. Right now, I’m waiting for my platelets, and that’s my horizon.

And all the time, we’re heading for this mythical time, post transplant, when I will be in remission and living a “normal” life. But I find it hard to form a mental picture of that phase of my life-to-come. It seems almost implausible. Certainly it isn’t sufficiently compelling for me to use as a mental anchor through the storm. I must navigate the now, accepting simply that it is what it is, and that what will be will be.

So... that’s where I am... There’s not much anyone can “do” - I have the NHS by my side, and they will keep propping me up. Spare a moment for Marisa and the boys, though: they too have to live my uncertainty.

Thursday, 31 January 2019

A corner?

I think, at last, things have turned a corner. So it seems appropriate to bring you up to date.

Treatment

I was on ixazomib & thalidomide from January until September last year. At the end of treatment we thought it had worked, if not amazingly, at least adequately. But in October the doctors decided that the response wasn't good enough and we needed to do something else. Looking back now, it is clear from my results that the treatment worked for a brief while. But having reduced my light chains by 50% after the first 4 months, it stopped having any effect, and by the end they were going up again.

I started on lenalidomide & cyclophosphamide in November. After three months, this seems to be working, though my myeloma insists on making it a two steps forward one step back experience (only once in the last year have I had 2 consecutive "good" months). At the end of cycle #2 my numbers were going the wrong way again, and my nurse was forewarning me that the likely third line of attack would be to switch to a regime called DT-PACE. Chemo is never easy, but I'm terrified of "intensified" protocols like DT-PACE, which consists of 6 drugs, continuous infusions over multiple days, and requires hospitalisation for part of each month. And anyway, there is a negative prognostic implication every time my myeloma it resistant to another drug. Especially so for lenalidomide, which is one of the real workhorses of myeloma treatment. So I was intensely relieved, yesterday, to find another big drop after cycle #3. Two steps forward, I hope.

I know it is entirely possible that cycle #4 will go the other way again - my myeloma's most distinctive feature is utter unpredictability - but I'm cautiously optimistic. My light chains (199 @ 24th Jan) and k/l ratio (24 @ 24th Jan) are now the best they've been since early 2016. And, although I know my subjective experience doesn't always align with the numbers, I have been feeling so much better, the last few months (pretty much since I started on the new regime), that I am inclined to believe that these drugs have now knocked out areas of myeloma that had until recently stubbornly refused to succumb.

My current expectation - though this changes all the time - is that I will continue on this regime until the end of April, and finally be ready for stem cell transplant in May.

A couple of months ago I found myself doubled over in pain that turned out to be a kidney stone. I'm pretty certain that this is the third time I've had kidney stones since my myeloma diagnosis. There's some disagreement between my medics about how likely myeloma is to cause kidney stones, but I believe this stone was calcite, and I live in a permanent state of calcium supplements and with a disease that deposits calcium in the blood... it seems reasonable, to me, to point the finger at the myeloma. One facet of myeloma is its ability to cause such a wide range of knock-on issues. One has the sensation of making incremental visits to more and more corners of the hospital. So, off I go to the awkward and embarrassing men's problems clinic. On previous occasions, I must have passed my stones. But this one was too big (8mm): I had to have it operated on this week. It's best not to think too much about the operating process, and just be grateful for the general anaesthetic. Suffice to say they gain access without making any incisions. When I woke up they told me they'd left a "stent" in the tube between my kidney and bladder, with a string to enable its removal. I'll admit to not feeling quite right while I had this string hanging out, and I was glad to go get it removed yesterday. I was shocked to see the stent: I hadn't imagined it would be about 30cm long. Having that pulled out of... well, it's done now. 

Life (quality or lack thereof)

I won't dress it up: last year was awful. My time on ixa/thal was grim. I was hospitalised twice with flu and pleurisy. I had a lot of physical symptoms and side effects: a bunch of new rib fractures (including my sternum), a lot of bone pain, posture problems, shortness of breath and generally feeling unwell. I had no energy. If anything, the mental side effects were worse. It was only after I stopped taking the drugs that I realised quite what they had been doing to my head. I was, I’m certain now, suffering treatment-induced depression, to the point of being suicidal. (It’s not hard to be suicidal with myeloma. The train of thought goes something like “You have no quality of life. The only reason to go through treatment is to be around for your family. But when you feel so bad, what good are you to them? So... what are you going to do about it?”) It was only when I came off the drugs that I gained any perspective on what had just happened to me. I'm sure plenty of people observed, during the course of the year, that I wasn't in a good place. But, one inevitably bottles a lot of it up. I can recall thinking that the only useful function I could serve in my family was to carry my burden quietly, so that Marisa and the boys didn't have to share it with me. So... that added loneliness to the symptoms. It was just horrible.

The good news is that the current drugs don't seem to give me any serious side effects. I've had some problems with neutropenia, which is pretty common on lenalidomide, and could be dangerous if not managed (I'm taking G-CSF several times a week to counter it). And I still get the ups and downs from steroids, which is no fun for me or those around me. But these are minor things in the broader scheme. I have energy. I have motivation. I am largely pain free. I no longer crack ribs every time I stretch out my arm. And now the kidney stone is gone, too.

It has been nearly 18 months now since I was able to work, and I am very, very bored. One consequence of my myeloma's zig-zag response to treatment is that I never know what's coming. I started treatment thinking I'd have a transplant in summer 2018. As recently as October, I thought it was imminent - in which case I'd have been back on my feet (with a following wind) by now. Now it seems that it will be 2019. But only last week, I was steeling myself for yet another change of treatment and prognosis. It's impossible, with all that going on, to commit to anything. Just when one gets to the point of making any kind of plan, or pledge to oneself, something unanticipated (and usually awful) comes along to wreck everything. When you think you're trapped in an endless cycle of miserable, painful experiences, you lose all your willpower.

I'm certainly not robust enough that another knock back wouldn't have exactly the same effect as has happened to me repeatedly during the last year. So, if this proves to be false hope - if the last downward zig were to be offset by an upward zag next month, and I were to fall back into despondency (which I most certainly would do), then you can read all of this as a cry for help - not just from me, but on behalf of the people who have to live with me.

But maybe, just maybe, I have finally turned enough of a corner to put this particular phase behind me. I feel I can tentatively begin to imagine doing things. Living. Which is, after all, the point.