Reassurance

Yesterday I wrote to our doctor to ask what the neuro specialists had said at the Multi-Disciplinary Meeting, on viewing Asa's MRI scans.

Did the meeting throw up any new information on what might be behind the head pain? 

And what was the implication of the gliosis that had showed up in the MRI?

The doctor's reply:

No - the scan was not thought to show any cause for his head pain – the area of gliosis is very small and non-specific and is probably related to minor trauma ?during delivery and is definitely not the cause of his pain.

One of the nurse practitioners wondered if the pain could be a manifestation of migraine which is sometime seen in 2-3 year olds.  However, we will check the IO [intra-ocular] pressure in the left eye at his EUA to rule out glaucoma first.

We're greatly reassured by this.

The question of what's causing Asa's head pain remains, but we're steadily eliminating some of the scarier possibilities. 

The next EUA is on Wednesday, 17 July.

For now, we're making the most of our freedom -- and a recent spell of good weather.

On the Millennium Bridge, July 10, 2013

Relief

We don't like to add unnecessarily to the sum of anxiety in the world.

So it's with both humility and gratitude that we confess our fears about brain tumours were unfounded.

I quote here from the email we received from our doctor on Friday night, summarising the scan results:

From the report and my untutored eye there is nothing on the scan to account for Isaac’s symptoms [i.e. head pain] – the report mentions a small area of scarring (gliosis) on the right side  but I am sure that this is not causing any pain - I will discuss the scans at the neuro-oncology MDT [multi-disciplinary team meeting] on Tuesday and get back to you if anyone has any further thoughts on the problem.

It's worth noting that although the doctor describes herself as "untutored" in interpreting MRI's, she does in fact have 30 years of experience in treating retinoblastoma. (She is a self-effacing but extremely competent consultant.)

Although not a specialist in neurooncology, she would surely recognise the kind of brain tumours that are most commonly associated with Rb if she saw them.

Further questions

Obviously there are questions that remain.

• What might have caused the scarring -- the gliosis -- that was mentioned in the MRI report? 

• If the scarring doesn't account for the head pain Asa's had, could it have other implications?

• And if there's nothing in the MRI to account for the head pain, what is then behind it?

These things we need more information on.

Focusing on the positive

The main thing to focus on for now is that the scan provides no evidence of brain tumours.

That, our greatest fear, is ruled out.

For now everything is cool

Asa's third summer

We ended with a cliffhanger last time, describing 3 possible outcomes of Asa's last EUA.

As it was, the results of the EUA were much better than we'd feared, but not quite as good as we'd hoped.

The tumours in Asa's eyes appear to be stable.

They didn't shrink much as a result of the second-line chemo, but nor did they grow.

That puts the results somewhere between options 1 and 2 in terms of the scenarios we'd anticipated -- No dramatic response to chemo, but no new treatment required, at least for the moment.

Looking for signs

One encouraging point is that the ophthalmologist who examined Asa under anaesthetic didn't see any blood vessels inside the tumours -- blood supply being one of the things that would keep them growing.

So it's possible that despite the lack of shrinkage, they may have had the life taken out of them.

The cataract

The cataract in Asa's left eye, however, has definitely gotten worse.

This may be a result of retinal detachment, which could be due to the tumours (the retina was already detached at diagnosis, 18 months ago) or to the treatments he's received.

Because the cataract obscures much of Asa's left eye from the doctors' view even when he's under anaesthetic, we had to visit Moorfields -- London's specialist eye hospital -- for a high-resolution ultrasound, a way of "seeing through" the cataract.

The ultrasound seemed to be consistent with the initial EUA results: The tumours looked no bigger or smaller than they were before chemo, and there's some evidence that they're calcified.

Summer holidays

In the 2 weeks since the exams, we've enjoyed ourselves.

We spent a weekend with the grandparents in Essex, and last week we took a trip to Liverpool, where I was attending a conference (which I blogged about here).

Fulfilling a wish of Selam and grandma Kuri, Asa visited Anfield Stadium, home of Liverpool FC.

Our warrior in Liverpool

An audio recording of 30,000 people singing "You'll Never Walk Alone," played over the stadium tannoy -- a sound rather like a rising and falling wind -- made an impression on Asa, and he's since been imitating it, singing to himself.

Another exam

Tomorrow Asa has an MR (magnetic resonance) scan at Great Ormond Street, to check out some recurring head pain.

For several weeks now he'll be playing happily, or just hanging out with us, and all of a sudden he'll grab his head and cry.

This began during the latter part of chemo, and at first we assumed it was a side-effect of the drugs, which can cause discomfort and pain.

But it's persisted long since the chemo drugs left his system.

The scan might shed some light on this.

Our worst fear is that a brain tumour could be to blame. We've hardly spoken of this, because it's such a hard thing to contemplate.

The results, which should be available by Thursday, will, we pray, put those fears to rest.

Speaking and seeing

This week I got back to London after two months in Congo.

During the first weeks away I was able to talk with Selam by phone; after that we communicated mostly by text message. 

Asa didn't do all that well on the phone (when we'd talk, he'd often just laugh), but on my return I've discovered that he's made amazing progress in speaking.

His vocabulary reflects common preoccupations of children with animals (dog, cat, bunny, bear, and ait [Amharic for rat]) and vehicles (car, truck, plane, tractor, bus, and train). These things recur in his picture books and in toys; some of them he can also see through our front-room window, or on walks around the neighbourhood.

A lion driving a car... Asa digs this book.

Other words reflect experiences that are less common in childhood.

"Chemo", for instance, Asa uses to refer to a drip set. (He used the word when he last had a blood transfusion.)

And “ambulance” means something different to him than to many kids, because he’s used to riding to hospital in them.

A conversation

Yesterday, Selam and Asa were still in bed when I was about to head out the door, and I crawled over to them to say goodbye.

Asa opened his eyes and looked at my clothes.

"Yellow. Jacket."

"Yes, Daddy's wearing a yellow jacket," I said. "I'm going to ride my bike."

"Bike," he said. "Motorbike."

"Not a motorbike, just a bike," Selam corrected.

"Out?" Asa said.

"Yes, I'm going to work."

"Not yet."

This caught me by surprise.

I couldn't bear to say I was going right away.

"Not right away. Soon," I said.

"Back?" Asa asked.

"Yes, I’ll come back later."

That was by far the most complete conversation we've had so far.

The cataract

While Asa's language abilities have improved, his vision has deteriorated during the time I've been away.

As we learned in April, there's a cataract developing in his left eye. It's now visible in the form of a milky whiteness in the pupil.

The left eye was formerly his stronger eye. Now, apparently on account of the cataract, he's switched his preference to the right eye. When he's looking at books, or at images on his mum's smartphone (a favourite new toy), he'll cock his head and orient towards the right eye.

This right eye, however, has a centrally located tumour. And so the window he's peering through must be very small indeed.

Unexpected by the doctors, it’s unclear whether the cataract is a side-effect of the cancer, or the chemo, or independent of them.

Getting through chemo

Another wild card that came up in the past two months was a bacterial infection in the Hickman line, during the second cycle of chemo. This had us scared. Asa was in hospital for 8 days.

The Hickman line was eventually removed, and then reinserted a week later.

Thankfully the third and fourth cycles of chemo have gone relatively smoothly, without infections or long spells in hospital.

This is likely due at least in part to the presence of grandmother Kuri, who’s been living with us since April, and who provides such help around the house that Selam is able to concentrate better on keeping Asa happy.

Asa and grandmother Kuri, in the garden

Prospects

The prospects after the next EUA on June 19 are difficult to gauge.

There are at least three possibilities.

1. The most optimistic scenario -- the chemo has caused the tumours to recede dramatically, and no more treatment is needed.
   
   
2. Less optimistically, four cycles of chemo might have produced modest effects on the tumours, and two more cycles could be given before reevaluating progress.
   
   
3. The least optimistic scenario is that the chemo hasn’t had any substantial effect, and we need to consider other treatments.

It impossible to know which of these scenarios we’ll face – or whether, instead, we’ll receive another surprise.

Mixed results

Last Wednesday Asa was put to sleep and underwent an eye exam under anaesthetic. 

The first since the beginning of the new chemo, the exam showed that the drugs have had a "partial effect."

Asa and dad at the Royal London Hospital, before the EUA

In Asa's left eye, the tumours responded well to the chemo. 

But in the right eye, there's been a slight increase in tumour activity.

And in the left eye there's a cataract developing.

A mixed bag

This was not what we'd hoped to hear.

We had reason to expect that the TVD (topotecan-vincristine-doxorubicin) combination would lead to shrinkage of the tumours in both eyes. 

And the appearance of a cataract -- a clouding of the lens -- at this stage is unusual: puzzling to the doctors as well as us.

While cataracts can be removed through surgery, cutting into the eye when there are active tumours inside is not advisable. So treatment for the cataract itself will have to wait until the tumours are stable.

The main risk in the near future is that the cataract may make it difficult to monitor the activity of the tumours in that eye. 

Sight and development

An optometrists' exam the day after the EUA suggested that Asa's sight has not gotten appreciably worse over the last two months.

It was a relief to hear this.

Indeed to us -- his parents -- it seems that his sight might be improving. 

But how could this be, given the equivocal changes in the tumours, and the cataract in one eye?

The thing that suggests improvement is that Asa is increasingly naming the things he's seeing -- a "doggie" on the other side of the street, "Mama" in a family photograph... 

Evidence of the extent to which Asa's childhood is now medicalized:

1. The first time he uttered the word "arm," a couple of weeks ago, was when a nurse was asking where she should place his blood pressure cuff. 

2. For several days after his last admission to hospital, he walked around proclaiming his most recent temperature reading (proudly and unprompted): "[Thirty] six [point] nine!"  

It’s a form of words he's heard us use all too often, as we monitor him for signs of fever.

In the last week, he's made great progress in discriminating letters and numbers, pointing at and naming them in books, on toys, and anywhere else he finds them.

Sharper-sighted, or just smarter?

But there's a danger here of confusing the ability to name things with the ability to see them.

The gains Asa seems to be making in visual discrimination are probably due more to a spurt in language development than to improvement in his eyesight. 

In other words, they're the result of potential that had been untapped while he was unnable to put names to things.

While his progress is wonderful to witness, we're also seeing signs now of how he's adapting to compromises in his vision. 

Playing with an electronic toy that speaks and spells words to him, he'll occasionally hold the letters close to his face, or bend down from the waist to position his eyes close to them, with a twist of the head to get the best part of his visual field working for him.

Onwards

Despite the equivocal results of the chemo so far, the doctors have recommended proceeding with at least two more cycles (each lasting 3 or 4 weeks). 

The 3rd cycle was to begin on Monday, but Asa's had diarrhoea the last few days -- and he's lost a kilo in the last 2 months -- so he's been given a breather until later in the week.

Tomorrow he'll be reevaluated; we hope he'll prove to be stronger. 

With grandma Kuri in Whitechapel

With luck, the tumours in the right eye that haven't yet responded, simply need a more prolonged exposure to the drugs.

Jed is in Congo for the next several  weeks; Selam and grandmother Kuri are caring for Asa in London.

The first cycle / Ethiopia

I got back from Ethiopia two weeks ago, and went straight from the airport to the hospital.

Asa had been admitted two days before with a fever, and according to protocol he was put on IV antibiotics, to be kept under observation until 48 hours after the fever subsided.

I found him and Selam in good form, Asa chatting away (sometimes incomprehensibly) to anyone in range and -- something new, since I'd been away -- saying “Thank you” for the least courtesy anybody paid him.

At the Queen Elizabeth Hospital in Woolwich.
I’d sat the doll on the side of the bed; Asa quickly adopted the same position.

That was on Thursday.

By the weekend we were all back home together.

Second-line chemo, so far

On balance, the first cycle of this second course of chemo went better than we’d feared. There were no mouth sores, no need for an NG tube, and only one day of vomiting.

But it didn't go quite as smoothly as we’d hoped. 

There were 3 episodes of infection: a bout of conjunctivitis which gooed up his eyes, and 2 other infections that caused fevers. 

And he needed 3 blood transfusions: two for platelets and one for red blood cells.

We don't yet know what effect the drugs have had on his tumours.

For that we have to wait until the next EUA, in 3 or 4 weeks time.

A heart murmur

When Asa was admitted with the second fever, doctors detected a heart murmur.

Asa was anaemic at the time, and the murmur was put down to that.

But on reexamination this week -- with the infection gone and his blood counts back to normal -- the murmur was still there.

One of the chemo drugs, Doxorubicin, can affect heart function. To check whether he was fit to receive it, Asa received an echocardiogram exam a month ago.

At that point he was given the all clear.

Might the drug have caused some damage to his heart since then?

Another echo yesterday suggested that his heart is normal.

We hope the murmur is innocent.

 
Meetings in Ethiopia

During my visit to Ethiopia, I met with some families whose children are affected by Rb, and doctors who treat the condition.

“It's really devastating to think about,” said Dr Emebet Girma, a doctor who runs the Ophthalmology Department at the main referral hospital in southern Ethiopia.

“I send children for chemo [in Addis Ababa], but I don’t know if they get it. I do exenteration, but I don’t know [if they’re going to make it].”

Exenteration is a drastic operation that involves not only removing the eye but also cutting away surrounding tissues.

It’s done in cases where the cancer has spread beyond the eye, and where there aren’t better options.

Dr Emebet sees more than 100 cases of retinoblastoma per year in Awasa Hospital. 

That compares with about 50 per year in the U.K.

The majority who turn up in Awasa are children whose eyes bulge from tumours that are very advanced.

Success stories

More hopeful was the meeting with families in Addis Ababa whose children have received treatment for Rb.

These are success stories.

But that’s not to say that things have been easy for them.

The three families I met had to leave Ethiopia to get the treatment their children needed -- traveling to Nairobi, and in one case to the U.S.A.

The children -- Abel, Bisrat, and Edelawit -- are now apparently cancer-free, and full of life.

It was great to meet them and their families.

Meeting of people concerned about retinoblastoma, in Addis Ababa, February 2013: L-R: Jed, Emebet Mammo, Etseganet, Getahun, Abel (in Getahun’s arms), Netsanet, Ermias, Bisrat (in Ermias’ arms), Dr Abu, Edelawit, Mekonnen.

We’re all keen to do something to help improve the state of Rb surveillance and treatment in Ethiopia.
 
At the same time Selam and I are reminded of how lucky we are that Asa can get the treatment he’s receiving in London.

Thanks to my mum and dad, and to all our neighbors -- especially Luke & Sophie, and Fireweyne -- for keeping Selam and Asa company these past weeks.

Relapse. Birthday.

Wednesday's  Examination Under Anaesthetic yielded some unexpected news. 

In Asa's left eye, which had been stable since the end of primary chemo in June, there were 4 or 5 new tumours, and one previously treated tumour that was growing slowly. There were also some new seeds.

In his right eye, moreover, the tumours that had earlier responded well to Melphalan had started to relapse.

These areas are at the front of the eye -- as the doctor put it, "almost where the retina finishes."

And the seeds that were there last time had not responded to the cryotherapy.

Asa looks out the window of the Royal London Hospital, before his EUA.

Treatment options

When Selam picked Asa up from the recovery room, both of his eyes were red and swollen from cryotherapy.

Cryo is a stop-gap measure: Since too much of it can cause retinal detachment, this approach doesn't hold much promise for controlling the tumour growth in the long term.

The area of tumour activity is also too wide for the more gentle kinds of radiotherapy -- such as radiation delivered through a "plaque" inserted into the eye, or so-called lens-sparing radiotherapy.

The treatment options therefore boil down to second-line systemic chemo, or whole-eye radiotherapy.

The decision is difficult.

Second-line chemo involves drugs that are more toxic than the ones Asa received during the first half of 2012.

The drugs are doxorubicin and topotecan.

We've not been able to find out much about their effects in retinoblastoma.

This is because it's rare that they're needed for Rb. Usually the first-line regimen -- in combination with other treatments such as laser and cryotherapy -- is enough to control this cancer.

In the US, our doctors tell us, topotecan has been used intra-arterially (directly to the eye) with some success. This hasn't yet been done in the UK.

More commonly -- on both sides of the Atlantic -- the topotecan and doxorubicin combination is used for neuroblastoma, a cancer that affects the nervous system.

Because the prognosis for neuroblastoma itself is worse than for retinoblastoma, it's difficult to gauge precisely the chances of success in Asa's case.

But the doctors tell us that these drugs are very effective against neuroblastoma, and in the few cases they've seen that merited it, against Rb too.

Side effects

We do know that the side-effects of these drugs can be severe.

Doxorubicin can lead to mouth sores when blood counts are low, and -- if dosage is too high -- cardiac fibrosis (stiffening of the heart muscles), which can be fatal if it's not checked.

Topotecan's side effects include diarrhoea.

And this is on top of the immunosuppression, nausea, malaise, and hair-loss that chemo drugs generally cause.

Going with chemo

Despite all this we've come down on the side of chemo.

Whole-eye radiotherapy, while less traumatic in the short term, would lead to scarring and long-term damage to the tear glands, which can be debilitating in later life.

We can't commit Asa to that, when there's a chance that chemo might produce equivalent results without lasting damage.

The new schedule

Asa will be given the drugs every 3 weeks, over the course of a week each time, with EUAs every 2 cycles.

There may be between 4 and 6 cycles in all.

We'll be spending a lot of time in Great Ormond Street over the next few months. 

And probably a fair amount of time in our local primary care centre -- King's College Hospital -- when Asa picks up opportunistic infections.

A change of lifestyle

On Friday Selam took Asa to a singalong session at the local library, and Soft Play at the Peckham Leisure Centre -- a sort of padded playground, with slides and ladders and a sea of plastic balls.

These are some of the things he's taken pleasure in over the past months.

These activities take on new value as we realise he'll likely have to withdraw from them when the chemo begins.

Only within the past month has Asa started to establish friendships with other children -- notably Angel, the daughter of our neighbours Luke and Sophie, who's just a couple of months older than he is.

Asa and Angel

Hopefully Asa and Angel will continue to play together. But it will be a while before Asa returns to the daycare centre he's been attending.

Asa's birthday

Today Asa is 2 years old. Yesterday (Sunday), friends gathered with us to celebrate his birthday.

Selam coaches Asa in blowing out his candle.

Asa paid little mind to the toys he was given, but enjoyed the attention and the sweet things to eat.

"Happy Birthday, dear Asa." Vanita and Deia, and Millie and Nathan applaud.

Selam and I enjoyed it all. And it gave us a chance to explain to some of the friends we're closest to here in London what we're expecting as Asa begins the new course of chemo.

By the time he gets his first dose of the new drugs, I will be in Ethiopia on a work trip. So we're relying on friends and relatives to help out in the meantime.

It will be hard for all of us to be apart at this time. But we're determined to go on with our lives as close to normally as we can, while doing our best to keep Asa healthy.

World Cancer Day

By coincidence, February 4 is also World Cancer Day.

Check out the website, and consider the messages of the organisers on common myths about cancer.

 

Cancer is not a death sentence; it's not a matter of fate; it's not a disease of the wealthy, elderly, or developed countries; and it's not just a health issue.