The Right Size Bag for the Right Size Job

I worked my first job as a cashier at Cope Super Market in Ravenswood, West Virginia, decades before the "paper or plastic" era. In 1971, brown paper bags came in five standard sizes to accommodate everything from a piece of Bazooka bubble gum to a 25-pound turkey.

One of the first lessons I learned from the co-owner, Garland Cope, was, "Use the right size bag for the right size job." I was a penny-pinching high school student, but I couldn't understand why Mr. Cope, one of the richest men in town, zealously adhered to this mandate. If he witnessed one of his cashiers using an inappropriately sized bag, he would leap from his office perch and select and substitute the proper brown bag. (This only had to happen once before I learned the lesson.)

A few years later, in my early 20's, I began to understand that Mr. Cope's obsession transcended dollars and cents. I applied the lesson of using the right tool for the right job to my first elementary school teaching job. Some kids needed a whisper; others required a stern voice. Don't ever confuse who needs what.

Mr. Cope's maxim has served me equally well over the years through a mixed bag of careers: teaching, marketing, parenting and freelance writing and editing.

When I began to explore my treatment options for Mantle Cell Lymphoma (MCL), I could once again hear Mr. Cope's admonishment crackling in my ears: "Use the right size bag for the right size job."

Was Rituxin + CHOP (R-CHOP), a chemo protocol that had become the gold standard for MCL, the right bag? Would going for the more aggressive, intense approach - Rituxin + Hyper CVAD + Stem Cell Transplant - be like putting a piece of bubble gum into a turkey-size bag?

In my case, it became relatively easy to choose the right bag. Not only did the world-renowned Dr. Stephen Forman at the City of Hope make a case for Hyper CVAD, but MD Anderson Cancer Center agreed. MD Anderson also revealed that my cells are of the "blastic variety." There are three subsets of cells associated with MCL, and blastic is what you DON'T want your cells (or your children) to be. They're stubborn, aggressive and treatment resistant. At one time, in the not too distant past, this diagnosis was a death sentence.

But MD Anderson quickly countered the bad news with some good news. My written second opinion included the results of a 2006 MD Anderson study that announced that MCL patients with blastic variety cells have had excellent outcomes with the Hyper CVAD protocol.

R-CHOP would have been like taking a pop gun to a charging rhino. Or, to put it into Mr. Cope's vernacular, like trying to stuff a 25-pound turkey into a penny bag. Hyper CVAD + Stem Cell Transplant, on the other hand, appears to be the "right size bag for the right size job."

I think Mr. Cope (who passed away in 2006) would have been pleased with my decision.

(Do any of you have a Mr. Cope in your life who taught you a life-long lesson at an early stage of your work life? Please share in comments.)

Surprise, Surprise, Surprise

A funny thing happened on the way to the oncologist. Not funny as in "ha ha" or an evening at The Ice House or lunch with Paula, but funny as in surprising and unexpected.

I expected to start an 8.5 hour infusion of R-CHOP at 10 am today. I came prepared with my chemo companions, Cindy and Andrew, my Apple I-Book, a collection of DVDs, books and magazines. Cindy and Andrew had planned to read "The Notebook" to me during the infusion. (How clever I thought I was - providing entertainment for myself while getting my book-avoiding daughter to READ.)

But the books, magazines, DVDs and laptop were untouched. At 10:30 am, I learned that my chemo was cancelled. Before you start uncorking champagne bottles, let me explain. After closer examination of my PET scans, CT scans and recent MRI results, the team, led by the illustrious Dr. Stephen Forman, concluded that I need a more aggressive approach for my very aggressive mantle cell lymphoma (MCL).

They are recommending Hyper CVAD, a protocol that's highly toxic but highly effective. It requires that I check in to the City of Hope for four to five days of treatment, check out for two weeks and then repeat the process for a total of eight cycles. That adds up to about six months of my life filled with just one agenda item in my calendar: GET WELL.

The team is also recommending a stem cell transplant procedure immediately after the completion of Hyper CVAD, a process that requires a one-month hospital stay.

I had just come to terms with the effect that R-CHOP would have on my life and my calendar. But now I'm trying to wrap my brain around this concept of seven months of intensive treatment. At the moment, I'm in hyper research mode, reading everything I can find about Hyper CVAD and stem cell transplants. I'm also scouring the archives of the mantle cell lymphoma list serve for any mention of these two procedures and the patients' reactions. So far, a number of the "younger" (less than 60 years) patients have opted for this combo and have had overwhelmingly positive results.

I may fly to the MD Anderson Cancer Center in Houston, Texas, for a second opinion, but time is short. I'm scheduled to start treatment at CofH on March 26 and the doctors are uncomfortable with my putting off treatment any later than this. (I tried for mid-April, but I got the "What part of aggressive don't you understand" reaction.)

I'm in a bit of a daze. How can this insidious cancer be so aggressive when I feel so good?

And the Envelope, Please

The Oscar-nominated stars have nothing on me. Stars endure weeks of anticipation from nomination until announcement of winners. I've hung in for weeks between initial diagnosis (mantle cell lymphoma), test results and treatment recommendation. I wish that I could say that it's an honor just to be nominated for this disease. I am, however, in very good company of other stellar human beings who've received a point from the fickle finger of fate.

I went yesterday for the dreaded bone marrow biopsy, which will determine if the lymphoma has spread to the bone marrow. On Thursday, I go in for the final test, the spinal tap, which will show if the lymphoma has entered the central nervous system.

I start chemotherapy on Monday, March 12. (The doctors wanted me to start on March 5, but I didn't want to miss Paula's debut at The Ice House.) The regimen is called R-CHOP, a combination that's proven very successful in treatment of both mantle cell and follicular lymphoma. The C, H and O stand for various cancer-fighting chemicals, the P is for a steroid that's taken post infusion. The R stands for Rituximab, one of the latest new cancer fighting drugs. I like to call it a smart drug because unlike chemo drugs, which attack, the good and the bad cells, Rituximab zeroes in on the proteins of the bad cells.

And, to return to the Oscar analogy, I wish that there was just one "envelope" announcing the results and the treatment, but my life will temporarily be a series of mysterious envelopes.