Rebecca Lang - The Perfect Treatment

She knew now that the prognosis for anyone over the age of sixty was not as good as for a younger person, mainly because the greater a person’s age the less likely they were able physically to tolerate the toxic effects of the very potent chemotherapy treatments that were required to put the disease into remission.

‘As I’m sure you know,’ Dr Contini said quietly, looking over her shoulder at the open chart, addressing both her and the patient, ‘the cause of acute leukemia is unknown, although some links with toxic chemicals have been demonstrated in some cases. We’ve been discussing possible future treatment, Dr Gibson.’

‘I see,’ she said.

Mr Simmons nodded his understanding, his eyes on Dr Contini. From before his admission to hospital, he had known the probable diagnosis from his GP, and had insisted on being told the truth. ‘I would like to know as much about it as I can,’ he said.

‘It’s a disease characterized by the proliferation of immature blood cells arising in the bone marrow, where blood cells are made,’ Abby’s colleague continued, addressing Mr Simmons. ‘All it takes is the transformation of a single bone marrow cell into a malignant form…From then on, this one cell produces clones of itself, which gradually spread to other parts of the body, especially to the spleen and liver, where they accumulate and cause problems.’

‘What sort of time frame are we talking about here?’ Mr Simmons asked.

‘Well, acute leukemia can develop in three months,’ Dr Contini said, while Abby kept her eyes on the chart, ‘which seems to be so in your case.’

What he did not say, Abby noted, was that some patients had a preleukemic syndrome, which could last for very much longer than three months. The ultimate outcome for patients who had that syndrome was not as good as for those who developed the acute phase more quickly. From the evidence before them, it seemed that Mr Simmons had had a fairly abrupt onset, if he were not glossing over any earlier symptoms.

‘Mmm…that’s about right,’ their patient murmured. Apparently a very intelligent and perceptive man, he would have a good idea of his chances for recovery.

‘He’s had a lot of investigations,’ Abby commented quietly to Dr Contini as she carried the chart to the end of the bed and stood there, looking through it.

‘Yes,’ he murmured, having moved to stand beside her, his head close to hers as they looked at the hematology lab reports together. ‘As you know, it’s a guide in good medicine that when making a diagnosis one should think of the common things first, before going on to the more unusual and to the exotic. Hence all these blood tests.’

‘Yes,’ she agreed, conscious of his closeness.

‘You may know the saying with regard to making a diagnosis—“When you hear the sound of galloping hooves, think of horses, not zebras.”’

Abby smiled. ‘Yes, I have heard that. And certainly not unicorns,’ something prompted her to add.

‘No, not unicorns.’ He smiled slightly in return. ‘Not that leukemia is difficult to diagnose. We have to be sure of the type, though.’

Abby nodded.

Dr Contini turned again to their patient. ‘These immature cells—which never develop to full maturity, Mr Simmons—are unable to perform the functions of the mature cells that they gradually replace…thus the symptoms that you experience, especially the anemia,’ he said.

‘Yes.’

‘Because you have fewer and fewer normal red blood cells, with less and less hemoglobin as a result, you gradually become unable to carry as much oxygen on your red blood cells…which is why you get breathless on exertion.’

Their patient nodded. He seemed avid for information, as though that in itself might help him to fight this vicious disease, if only on a psychological level.

‘Mr Simmons has been in here for two days, Dr Gibson, waiting for the results of more blood tests. I’m here today to discuss treatment with him. Any questions you want to ask him?’

‘Has a bone-marrow biopsy been done?’ she asked.

‘Yes,’ Dr Contini said. ‘That, as you know, is the other diagnostic test, which shows up the abnormal bone marrow cells, the immature forms.’

Although most of the background information was already in the chart, Abby preferred to hear it directly from the patient. He would most likely have a need to talk. ‘What were your initial symptoms, Mr Simmons?’ she asked, moved by his air of abject exhaustion, his outward calm, she suspected, masking a great deal of underlying apprehension.

‘Well…I was pretty tired all the time, much more so, I suspected, than was warranted by my age,’ he said, ‘although I lead a hectic life. I teach at the university—political science—and this is a busy time, coming up to the end of the academic year. Even so, I suspected that something was wrong with my health.’

‘I see,’ Abby said kindly, encouraging him to go on.

‘Also, my skin was very pale and I got breathless easily on the slightest exertion, whereas before I could walk for miles. I felt unwell for a lot of the time and I got several colds, as well as chest infections, which I couldn’t shake off.’

‘Do you smoke?’

‘No. Never have done.’

‘Anything else?’

‘I noticed that I bruised easily, and I couldn’t remember having injured myself in any way to cause the bruises,’ the patient went on. ‘Then my dentist noticed that my gums were bleeding more readily than usual, so when I told him my other symptoms he advised me to see my doctor right away. Then when I went to my GP for a check-up he found out I was very anemic…Then things progressed from there.’

‘He had some nausea as well, which indicates some involvement of the gastro-intestinal tract—either infection or bleeding, or both,’ Dr Contini said quietly.

‘I see.’ Abby nodded. ‘And what is the planned treatment?’

‘I’m getting on to that now,’ Dr Contini said. ‘What I’m going to do, Mr Simmons, is build up your general resistance before we start you on a course of chemotherapy. If you agree, that is. Since you’re very anemic, I’m going to give you a blood transfusion of packed cells, plus some fresh plasma which will help the clotting function of your blood, which gets out of whack with this disease.’

‘When am I going to get that?’ Mr Simmons asked.

‘We’ll start this afternoon. The hematology lab is getting you cross-matched. When we’ve done that, we’ll discuss the treatment further. If we decide on chemotherapy later, you get a combination of drugs over a period of five to ten days—that’s called the “induction therapy”.’

‘I’ve read something about that,’ Mr Simmons said ruefully. ‘It kills off all the abnormal cells. Right? Or almost all? I guess it makes you feel pretty awful, as well as making your hair fall out.’

Blake Contini nodded.

WHEN the consultation was over and the two doctors were out in the wide corridor again, divested of their protective clothing, Blake Contini drew Abby to one side, out of the way of the pedestrian traffic, and queried her about aspects of the disease.

‘How would you make the final diagnosis here, Dr Gibson?’ he asked, fixing her with an astute glance from those rather unnerving blue eyes.

Abby cleared her throat, feeling a little like a student taking an exam. At the same time, she was grateful to have this opportunity for learning—even if her feelings towards her teacher were a little mixed. There was no time now to dwell on that.

‘Well,’ she began, ‘there are abnormal cells in the blood and in the bone marrow—tests for those would be decisive. The cells in the bone marrow never mature beyond the myeloblast level.’ Abby met his glance squarely, warming to her subject. ‘And, of course, the proliferating leukemia cells accumulate in the bone marrow, eventually suppressing the production of normal blood cells and the normal bone-marrow elements.’