Minimal Residual Disease (MRD)

On Monday Abigail had another lumbar puncture (LP) and bone marrow (BM) test.  The BM test is used at the end of induction to test for response to treatment. The scientists use a special test to look for the number of leukemic cells remaining in the bone marrow, which is called the minimal residual disease (MRD).  This test is 1000 times more sensitive than looking at the bone marrow under a microscope (that was the 'old way').   In order to be considered MRD negative, the result has to be 0.01% or less (leukemic cells present).  We were told it would be about 3 days, maybe 4, to get the results.

The MRD is only one factor that may predict a child's prognosis.  The other factors feel like they are already stacked against us: age and her chromosome translocation.  I was so very hopeful on the MRD results.

Monday's CBC result was extremely promising; I teared up when I told Susie.

WBC: 1.59

Hgb: 10.1

Hct: 31.1

Platelets: 264

ANC: 1081 (Over 1,000 is considered normal, and as you may recall the ANC is what we use to judge how strong her immune system is.)

Her labs are normalizing, and as her doctor Elaine put it, "That's what happens when the kid goes into remission."  So we went home Monday night with a light heart full of optimism.  Also Abigail tolerated the LP and BM better than when she had those procedures at UW.  She had no spinal headache whatsoever.  I did have to be demanding (read: bitchy) about the pre-bolus.  And after I talked to the anesthesiologist and explained what happened before, he reassured me that he felt this would not happen again.

It's hard to trust.  Especially when you don't feel heard.

She was able to lie flat for a little over an hour post-procedure, she got some tylenol and a caffeine tablet.  Our plan was to go to the Ronald McDonald House Monday night, but she felt so well, we decided to just go home.

Yesterday we were told her MRD, unfortunately, was positive.  I had a small breakdown, fear crept in.  Abigail was sitting at the dining room table with her tutor doing college algebra lessons, and I was on the couch feeling myself fall into the dark hole.  I started hearing that voice -- you know the voice, the one that's always there being negative.  The voice you don't even realize you hear sometimes.  The voice you have to fight to be louder than.  "What is the point of anything."

After a pretty lengthy discussion with both Elaine and Maureen,  I felt this news was less dreadful than I initially did.  Her MRD result was 0.036%, which I'm told is still extremely low, but also definitely positive.  This means she is in a very high risk category for disease relapse.  Elaine told me at this point we should not be worried about Abigail beating this cancer, but about it coming back.  She reassured us we are already in the very high risk category because of her age and her genetic report, so our plan does not change.  We continue with consolidation (the next phase) which lasts about 2 months.  At the end of the consolidation phase we will re-test the BM and hope for a negative MRD at that time.

I tried not to ask, and I tried not to want to know.  But I asked anyway.

What if the MRD is positive again?

We will consider transplant.

But I'm perpetually working on living in the moment.  And in this moment Abigail is doing college algebra with her tutor.  She has minimal pain, good blood counts, acceptable energy level.  She is smiling and laughing.  She has friends who love her and she is planning on going to homecoming in a few weeks.

In this moment we needed to decide whether or not to stay on study or go off.  I wanted to go off study.   Elaine gave us her HOME NUMBER to call her last night if we had any questions about the study at all.  Who does that?  I'm extremely impressed with her.  We presented the options to Abigail, after explaining best we could what her MRD results meant.

We are staying on study.  Today or tomorrow we will know the results of the randomization and will know which arm she has chosen (which treatment plan).  The study for those readers who are so inclined to want to know such a detail is called AALL 1131.

Monday if her counts are still good, she will have her port placed, and we will start Day 1 of consolidation which consists of a very, very long chemo day.  (Here is a website that explains what a port is.  Right now she has a PICC line.)   Here we go, another beginning.  Another Day 1.

"Be brave my darling.

You have faced dark times before

and you're still here now."

C.T.L.

Day 22; Trust

You need to be positive.

You need to stay strong.

You need to pace yourself.

You need to ask for help.

You need to eat.

You need to sleep.

You need to just be a mom and not a nurse practitioner.

You need to ask questions.

You need to have hope.

You need to not hover over her.

All of this is true; I really need to do/be/say/feel all of the above.  But I am getting tired of being told what I need to do/be/say/feel.  I know everyone is well-meaning, people are good and kind at their core, and no one really knows what to say.  But sometimes I get tired of it.  Sometimes I get tired.  Period.

Yesterday I was tired.  It is physically and emotionally draining for me to take her to the Children's Hospital.  This week was better though.

Our nurse practitioner at Children's, Maureen, is growing on me.  I feel like she listens to me.  She read me the results of her CBC and my instincts were that her counts were falsely high due to dehydration.  I asked for a BMP and while they don't normally order them for routine chemo days, she did it anyway.  Abigail was dry!  She got a fluid bolus right then and there, and Maureen ordered fluids for home that I can give her at night to keep her hydrated and to keep her home from the hospital.  

This morning when I got up at 7am Abigail was making herself breakfast and she asked if we could go to the school today so she could find her locker and get ready for her first day tomorrow.  WHAT THE WHAT?  She has totally perked up from the fluids.  It really is amazing to me what dehydration looks like in young people and how fast it happens.  I emailed Maureen and asked if we could hold the fluids tonight and if I need to restart them this week, I would like to reduce to 1.5x maintenance (she had her on 2x maintenance last night).  

She replied in 20 minutes.  She wrote:

I trust your judgement.

I think this might be the first time I've heard that in the past 3 weeks from a medical professional.  It was definitely the first time I heard it and believed someone meant it.  Maybe I am starting to trust myself.  Maybe I'm allowing myself to trust them.

Day 20; I'm Positive This is Shitty

So it's happening.  This is a reality.  I have a kid with cancer and this is our new life.  We discuss platelet counts, ANC, and PICC line flushing at the table now like it's basic dinner conversation.

Last week, Thursday to be exact... 3 days ago... I had a breakdown.  A literal nervous breakdown.  The scary, I can't breath, and I might actually be having a heart attack breakdown.  I was moments away from calling it quits and heading for the hills.  Only 3 days ago and yet it feels like another lifetime ago.  I reached out, which isn't always what I feel comfortable doing.  I texted friends who are local, and asked for help.  I didn't know then what I needed, but I knew I did not want to be a crying, slobbering mess alone.

"Please come lay next to me while I cry."

Or something like that.  And you know what?  A friend did come over, and I just laid there, and I cried.

I also texted a friend who is one of my surrogate mothers.  She has gone through hell and back, a couple of times.  One of her trips through hell also included having a child with cancer.  Her love and support, and the practical advice she has for me, has been invaluable.

So I am trying to see the positive things that have happened because of this really shitty thing my family is going through.  Trying to remain grateful.  Attempting to live in the moment, and be glad to be here, in this moment.

1. I've learned how to ask.
2. I'm learning how to say no.
3. My co-parenting skills with my ex-husband are on fleek.
4. My younger kids can see us go through this shitty, hard thing, and yet we still laugh.
5. The amount of love and support we are getting from so many people, even complete strangers... is humbling.

Tomorrow we go back to Lurie's Childrens Hospital, and she will have her Day 22 Chemo.  Then the Monday after that is our very important, scary important, Day 29 - the bone marrow, lumbar puncture, MRD test day.... the day when we will know how she is responding to treatment.  (Well it will actually take a few days to get the results, but you know what I mean.)  So while I am so very proud of Abigail and our family for making it through Induction (almost there gang!), I am still so scared that it's not working.

Every time I flush her line, each time she is nauseated or has a headache, and after we endured the painful day of shaving her head... I can't help but ask myself, "Is this working; is this worth it?"  Because if it's not working, then what are we doing?  I'm letting them give my baby girl poison, over and over, deadly poison that makes her sick, causes her hair to fall out, ulcerates her mouth and throat, and you know what, this better fucking work and it better fucking be worth it.

Warrior Girl

This is happening.

an update TO THE update

The doctors and I agree she has been stable for long enough now on only PO pain medications, and is taking in enough to eat (fluids are questionable) to go home.  There will be no transfer today to Lurie's in Chicago.  We get to sleep in our own beds tonight.  And I am planning on having some girls over for wine and pedicures.

But first she will get a unit of blood; her Hgb is down to 8.4, and Lurie's threshold for transfusion is different than UW.  She has an appointment on Thursday at Lurie's and will have labs that day as well.

I have spoken to her new Nurse Practitioner in Chicago and I'm very comfortable so far.

Sadly we must say goodbye to Abigail's primary nurse, Jenny.

I am oddly looking forward to starting the next chapter, with our new team and our new rockstar nurses.

And of course, updates will follow.

Day 15; New Friends

There's a 16 year old girl here at UW who's mother I met the first day of our readmission.  She and Abigail have met and are doing that snap chat thing.  I can't say they are friends yet, but they are connecting and I think that's remarkable.  Though the two have different cancers, they have more in common than they have differences.

I'm sad we have to leave UW and go to Children's in Chicago this morning, and I hope she stays connected to this girl.  I hope she makes some other cancer-friends.  I hope I do.  

We have amazing, wonderful, friends already, but there's something about looking in the face of another mother who is numb from the reality of having a child with cancer, who has slept 10 days out of the last 14 on a vinyl "mattress," who is trying to juggle her personal life-mom life-work life, who is walking a tightrope everyday and trying not to lose balance.

Yesterday was a good day.

1. Abigail's abdominal pain is under control with oral pain medications.

2. Switching from ranitidine to pantoprazole has made all the difference in controlling her gastritis.  

3. She likes chocolate boost!

4. Her appetite is returning.

5. My favorite attending physician was on yesterday and after rounds he explained more fully the type of genetic mutation of her ALL.  He has such a way of reassuring, and it doesn't feel trite or cliche.  Also, I think he complimented my clinical skills and told me that I'm a good nurse practitioner.  The resident also told me that my intuition is good and that I need to alway listen to it.  

How are we doing?

We miss Ana.  We both miss our alone time.  Abigail misses her independence.  I miss working. Abigail is anxious about school and really wants to be able to go on the first day (next week).  I need my hair colored, my feet are begging for some attention, and personal grooming of any kind has fallen to the bottom of the list of priorities.  I don't know what it says about me that those things are on my mind.  Maybe it's a coping mechanism.  I miss taking my youngest daughter to Target and telling her "no we aren't getting that" every 5 minutes.  I miss watching my son play baseball in the back yard with the neighbor.  I miss the intimacy and closeness of my family.

But - we can't look back.  We can only look ahead.  Moving forward we will all find a new normal and adjust.  

The Fam

Last night the fam pulled together (minus Aly) .... And today Abigail's spirits are soaring.

Joseph is camera shy... I guess. But that's the back of his head, trust me.

Day 13; Pardon My Vulgarity

We were admitted back to UW Children's 2 days ago, on Friday afternoon.  Abigail had a spinal headache and nausea which we were unable to control at home.  I had made several phone calls to her doctors in the days after discharge.  But the medications and regimen changes only made her sleepy, not less nauseated, and when she was awake, her head was throbbing.  The only time she felt good last week was if she was flat on her back, sleeping, with a cool cloth over her eyes.  As you can imagine, she was not eating or drinking very much.  This contributed to her dehydration.

Once we were admitted, and fluids were started she began to become more alert.  For a while she was what I (as a nurse practitioner, not a mom) would call lethargic.  And that scared me (as a mom who is a nurse practitioner).  Medical professionals do not use the word "lethargic" flippantly.  Also when we first got here there was some question over whether or not her central line was clotted.  It was flushing with no issues, but the nurse in the outpatient setting could not get a blood return or draw any blood from either lumen.  A peripheral IV was necessary to hydrate her while we awaited testing to confirm the PICC line status.  For those who know Abigail, this was very difficult for her.  All of this needle stuff, and the blood... she's very sensitive, even phobic about it.

Luckily after we were admitted and one of the inpatient heme-onc floor nurses assessed the line, it miraculously began working just perfectly.  I was extremely worried about this.  And now I am extremely grateful.  

So our HMO has approved this hospitalization and according to our case manager, they have approved an ambulance transport (non-emergent) to Lurie's Children Hospital in Chicago.  However her doctor here at UW asked we stay until Monday and get her Day 15 chemo here (allegedly also HMO approved).  I felt good about that decision because I think it would be better to meet her new team and get acquainted PRIOR to her receiving therapy from them.  But that's just me feeling out of control.

The weekend has been a real fucking circle-jerk.  Between having a resident who is both very young, and very condescending to Abigail (his patient!), and having seen 3 different attending physicians in a matter of less than 12 hours, there were so many different providers with different plans that eventually my claws came out a little.  Finally last evening around 1800 I saw a different resident and basically tried to give the floor nurse my own orders.  FUCK THIS, I thought.  I shared my unfiltered, raw, emotions with our nurse who agreed with me nearly verbatim.  FUCK THIS.

The nurses are the only people helping me maintain my sanity.

You see we were starting to get the feeling that the doctors were thinking she was doing better and able to be discharged.  But what got us to the point at home which led to her dehydration (her abdominal pain) was not yet fixed at all.  The resident told me "Well we are giving her protonix and prevacid"  Finally I said, "I don't give a shit; it's not working.  When will it work?  And when will we reevaluate our plan of care?"   Or something like that.  If one more person tells me to give it some more time and wait and see, I may be arrested.  Also, I do not need one more fucking person telling me that she needs to eat with her prednisone.  

Yeah.  

I got that.  

I'm still paying about $1,000 a month in student loans in order to prescribe prednisone and tell my patients the same mother fucking thing about prednisone.  Moreover, anyone with a smart phone or any access to Google, will easily come up with the same information about prednisone on a simple web search.

What we were trying to get them to hear is that her stomach hurts too badly to eat, and after she eats, the pain gets even worse.  

I'm going to stop now; I can feel my blood pressure rising and now my stomach hurts.

She is on mostly IV medications, and is on clear liquids (which she hates) and her stomach pain is tolerable.  Chicken broth aggravated the pain though.  I'm frustrated beyond frustration.

The patho/genetic report is final and I have a copy.  We will likely not be staying on study, her genetics came back in a way that requires a very intense treatment plan, not the standard.  I am waiting until we get transferred to our new team before I ask the million questions I have.  I have also tried hard to stay off the internet researching this myself.  

How is Abigail doing?

I'm worried about her.  If you are reading this, my dear Abigail, please stay strong.  Please know that you are loved and cherished by so many more people than you will ever be able to grasp.  The enormity of how your life has changed feels as deep and as wide as the ocean.  And it is.  But you are not alone.  

How am I doing?

I am strong and I am holding on tightly.  I am grateful for anyone and everyone who has sent messages and kindness to our family.  I am also tired.  I'm frustrated.  And I probably need to apologize to that sweet dietitian who was only trying to offer help yesterday. 

Day 11; readmission

Actual details will follow later, but for now wanted to let my family and friends know that Abi has been readmitted to AFCH in Madison.

She's dehydrated and needs blood products. She has uncontrolled nausea, vomiting, and recurring headaches.

Our plan was to transfer care to the Lurie Children's Hospital in Chicago, but we are stabilizing her here first.

I'll be more detailed and thorough later, but that's the important stuff.

Continue your positive thoughts.


Sent from my iPhone

Day 9

Today I tried very hard to parent my other kids. I took a walk in the forest preserve with the dogs and Avery.

"I'm thirsty," Avery says.
I tell her, "Here, drink this." The last 3 oz of water in my bottle...
She says in disgust, "Ewww. Gross. No."
Then 2 min later, "I'm thirsty."

Fuck. Parenting is hard. Even harder with no emotional capacity.

1. Abigail's nausea is better.
2. She showered! Yay! Thank you Niccole for the shower seat!
3. Chris came for dinner.
4. I'm down to 2 bottles of red. If anyone is keeping track.
5. Her UW team is working with our HMO, our PCP, and the children's hospital in Chicago to transfer care ASAP.

Overall - a very good day. I have zero complaints. Thank you to every single person who's sent me a card, a text, or a virtual message.

Tomorrow Susie and Ana travel to Smith College in Northampton, MA for a tour. Life goes on. Next year we will be doing the same with Abigail. I know it.

Day 8; Midwives, Chemo Nausea, and Fuck HMOs

Today was our first full day home.

And it was horrible.

I'm not going to lie, part of me missed the hospital.

The safe, calm, clean, quiet hospital.  Not the chaos of my house.  The Children's Hospital where the nurses grind the prednisone and put it in gel caps.  Where the nurses page the doctors when I have concerns about her pain or nausea.  I miss the nurses.  I miss the safety net.  At home I'm flying with no net.  At home I am the one paging the doctors.  And at home I am the one cutting and grinding her prednisone and carefully filling gel caps.

Abigail's nausea has not been well controlled today at all.  We have tried everything from the prescriptions, over the counter, homeopathic, and non-traditional.  Nothing seemed to really help at all.  But now with our new regimen of Zofran, Benadryl, and Ativan every 6 hours she is feeling much better.  However, she fell about 45 min ago trying to get to the bathroom, and she is now considered "High Fall Risk" at my house.  I blame the meds.  Up until tonight she has been very steady on her feet.  So now I get the added excitement of monitoring her new bruise.  The other horrible side effect of the Benadryl is restless legs.  She is finally sleeping.  I think the side effects of dizziness and restless legs far outweigh puking all night long.  I love that my boss, who also happens to be one of the smartest NPs I know, has been available to me all night.  I've called her several times.

The other blow today... we will likely have to move Abigail's care outside of UW health system.  We found out this evening they are out of network and her hospital stay will be payed for, but no further care or treatments will be.  So first thing in the morning we will be calling our case manager, social worker, and the insurance to figure out what the fuck to do now.  I am still hoping that there is a chance to stay there.  But like I said, it's unlikely.  Fuck insurance.  Fuck cancer.

I had a minor breakdown today.  Fortunately I have friends who are aware of what I need (chocolate and red wine, perhaps Xanax even) and I had a nice long cry.  And I reminded myself that I am really glad to be here.

It was overall an extremely long day with her dad here (he had a sleep over with Joseph), then our oldest came with her husband for the day.  We had our home health nurse visit (more on that later, ugh).  Just long.  Tiring.  At one point Abigail was in my jet tub, I was holding a cool cloth on her head and a puke buket in another hand, and her older sister Aly was in the room supporting her as well.  I had a moment where I felt like I was on the outside looking in, and it looked like one of the many birth rooms I have attended.  I told Aly, "We are midwifing her through this."  I miss my midwifing days.  But I never want to have to relive Day 8 again.  I have a feeling Day 15 is going to be very similar though.

I'm coping with everything by making more spreadsheets and check lists.  Aly and Victor (my son in law) helped me make a week's worth of gel caps.  And I also started the day off with some well deserved girly pampering and primping.  I am ending the day in a nice, warm, fuzzy haze of red wine.

Our friend Jessica set up a Gofundme account to help us with some of the financial burden.  At first this embarrassed me, but now I understand.  People want to help and feel helpless, donating even small amounts really adds up for us, and helps other feel like they are contributing.  The link is here.  If you are unable to donate, please just consider sharing the link.  If you already have donated, please know we are graciously accepting and are unable to put into words the depth of our gratitude.

When it was time to update Chris about how she did today, I made Susie do it.  My breakdown was so profound I couldn't even text him.  My heart is sad and broken and it feels like it will never be the same.

Make Like A Fetus and Head Out

It's happening. Taking our girl home.

Day 7; Positive Image

Today was the day Abigail went to a place called Positive Image.  It is a salon at the hospital where kids can get a new haircut, shave their head, get fun hats and scarves, or even come up with a wig they would like.  Abigail and I looked yesterday at new hairstyles and she chose a new, shorter style.  I heard the specialist give her tips on how to deal more easily with the hair loss.  It was a pretty emotional morning; but I was able to hold my shit together.

This experience was further complicated by a migraine headache (her not me!).  I think it is complication of polypharmacy.  We are weaning off the morphine and using more Tylenol and PRN pain medications.  By the time she was finished with the cut she could not tolerate a style or to look at any hats or scarves.  

I will wait for Abigail to feel like showing off her new hair before I post any pictures.  I'll describe it as: at the shoulder and very fresh looking.  I hope when she wakes up and has a chance to really style it, she will feel good about this.  But still, it's shitty.  It's hard.  There is nothing that will make this part easy for her.  And having your mom sob while your hair is being cut off certainly does not make it any easier or less shitty.  So I held it together, and later tonight in the shower I'll have my usual cry.

She had her chemo (VCR and DAUN) and now she is just resting until she goes down for sedation and the LP.  She will get her IT chemo this afternoon as well.  Something about knowing chemo is going into my child's cerebrospinal fluid makes me feel good.  It's so strange to me...  I feel GOOD there are chemicals being put in my kid's body.  But - yeah - let's give everything we can to fight this.  

The other thing I don't feel comfortable with is the Lupron injection today.  It's basically inducing menopause with a chemical.  I'm worried about this a lot and I cannot rationalize why.  I am worried about her future fertility, and that's all I am willing to say right now.  If I write about it, it makes it more real, and I'm not ready for that to be a reality yet.  I know the Lupron is meant to help preserve her ovarian function, and I know that she needs this, but I still feel so sad about it.

She is still sleeping.  It's been about 90 minutes now and I'm so grateful she can sleep off the migraine.  

Our nurse practitioner is coming by very soon to do some more teaching for discharge.  I have a lot of questions that I have been waiting to ask her.  I love that this hospital incorporates NPs in the medical team.  The hematologists and oncologists are extremely important, but the support and education we get from the NP is invaluable.  

I have nothing but good things to say about UW Children's Hospital.  They've really figured this shit out.  It feels like a true partnership.

To her aunt, cousins, and friends who have visited:  she told me yesterday that your visits really raised her spirit yesterday.  Thank you so much.  It wore her out, but I'm telling you, I could see her heart swell.  You made a difference.