The Choices We Make - 1. The Precursor

"Good morning, Mrs. Windham."

"Good morning, Dr. Lareaux."

"What brings you and Brody in this fine morning?"

"Well... I know he's not quite two yet, but he seems to sleep more than he should."

"Your mileage may vary on how much a child his age sleeps. There's no definitive rule about these things."

"Oh, I'm sure you're right. It's just..."

"Yes?"

"Even when he's awake, he seems... well... I suppose he seems lethargic."

"I see. Let me take a look at the little tyke. Anything else you've noticed?"

"Actually... yes. For the last week or so he can't seem to get comfortable, and I'd swear he acts like it hurts to be touched."

"Mmhmm... Interesting... Anything else?"

"Well..."

"Even the most minor thing can be important, Mrs. Windham. Don't be afraid to point out anything that concerns you, no matter how insignificant. If it's not important, we move on, but it just might be important. By the way, he looks somewhat pallid. Is that just from the stress of the morning—"

"No, actually it's not. I've thought for a week or so that he seems pale. I thought maybe he was fighting something, what with the fevers and achy behavior and such."

"Fevers?"

"That's what I was going to mention. He's had a temperature off and on for a week or so."

"I see... Anything else?"

"There is something—"

"Oh my."

"Yes, that's what I was going to tell you."

"Mrs. Windham, do you know where these bruises came from?"

"That's what I wanted to tell you, Dr. Lareaux. I'm not certain. Some of them seem to be where I hold him and some—See those on his arms?"

"Yes."

"Those seem to be where he leans on the crib railing."

"I see."

"I know what you're thinking. Trust me, my husband and I spent about five minutes being livid with each other thinking the bruises were signs of... well... I'm sure you can guess what we thought."

"Mmhmm..."

"But that's not the case, I assure you. He just seems to bruise so easily—"

"Mrs. Windham, I'd like to run a full blood test. Individually, these symptoms aren't troubling, but together they paint a picture worth some investigation."

"Do you think it's serious?"

"I won't lie to you, Mrs. Windham. They could indicate a significant problem. On the other hand, coincidence is the bane of medicine and these symptoms might just be a little of this and a little of that and none of the bad stuff. Let's run some tests to see what we can see."

"Of course. You're right."

* * * * *

"Any news, Dr. Lareaux?"

"Mrs. Windham, I think it would be wise to admit Brody to the hospital so we can run further tests while we begin treating some of these symptoms."

"Admit him? To the hospital?"

"Yes."

"What... what did you find?"

"His blood work is troubling, to tell the truth. He's anemic for one, which probably explains the bruising and fatigue. He's febrile—feverish—as you mentioned. His white cells appear... far too abundant. He's also cranky, as you mentioned, but that appears to be a symptom of rheumatism."

"Rheumatism?"

"Soreness of the muscles, bones or joints. Brody seems to hurt all over."

"What... what aren't you telling me? I can see it in your face and hear it in your voice. There's something you're not telling me."

"I don't want to cause undue concern, Mrs. Windham, so let's set aside conjecture for now until we know more."

"Well... well..."

"We should get him admitted, Mrs. Windham. I think it's important to run more tests in addition to treating the symptoms we can see at this time."

"Yes, of course you're right."

"Very good then. I'll have one of my nurses come in to finish up the paperwork and provide the hospital referral. Take him right next door to Baylor, to the outpatient admissions desk. I'll call ahead so they're ready for you. Dr. O'Neill will be taking over Brody's case."

"Okay..."

* * * * *

Three Days Later

"Mr. and Mrs. Windham, thank you so much for coming in so quickly."

"We're worried about our son, Dr. O'Neill. You call, we come."

"I understand, Mr. Windham. And I wish I could say your concern was misplaced."

"Oh God, what is it?"

"Mrs. Windham... Mr. Windham... Brody is showing all the signs and symptoms of leukemia."

"Oh God!"

"No!"

"Please calm down. I know this is upsetting, but it appears we've caught it early thanks to your diligence."

"What can we do?"

"Can you treat him?"

"First I need you to understand that we have more tests to run. It's important for us to identify the precise kind of leukemia and its various traits."

"But can't you—"

"Mrs. Windham, I promise we're moving as quickly as we can—"

"No, that's not what I meant. I know you're doing everything..."

"It's alright, honey. Calm down now and let's hear what the doctor has to say."

"The truth is, Brody's symptoms and test results thus far indicate acute lymphoblastic leukemia, or A-L-L. He has persistent weakness and fatigue, malaise, chronic fever, and rheumatism. More importantly, he has leukocytosis, meaning too many white blood cells; normocytic anemia, meaning too few red blood cells; and thrombocytopenia, meaning a low platelet count."

"What can we do?"

"Please tell me this is treatable."

"The immediate treatment is blood and platelet transfusions, as well as steroids and antibiotics. Concurrently we'll run further tests to determine the exact characteristics of the leukemia so we can implement an induction therapy regime that's—"

"Induction therapy? What's that?"

"I'm sorry. Sometimes I forget myself. Induction therapy is when we induce remission."

"You mean chemo and the like?"

"If appropriate, yes, along with other treatment options as applicable and needed."

"My God..."

* * * * *

Two Days Later

"Brody has precursor B-cell Ph1-negative acute lymphoblastic leukemia with L2 morphology."

"What does that mean?"

"Mr. and Mrs. Windham, I'm not going to gloss over the truth. Brody has a highly aggressive form of leukemia that requires an aggressive and prolonged treatment regimen."

"How long?"

"It could take two or three years to achieve complete remission."

"Years? Did you say two or three years?"

"Some patients make it in less time, but Brody's young and small and the leukemic cell population is quite high."

"What stage?"

"I beg your pardon?"

"Well, doesn't cancer come in stages to tell the severity?"

"Normally that's true. With ALL, though, there are no stages."

"Why?"

"Because it's highly aggressive. If you have it, it's already as bad as it can get."

"Oh God..."

"What does he need? What kind of treatment?"

"He needs aggressive high-dose systemic chemotherapy, what we call multiagent remission induction therapy. You need to understand the treatment will be very hard on Brody. But induction therapy is only the beginning."

"What?"

"Tell us, please. Just tell us."

"We'll start with remission induction therapy, which, as I said, is an aggressive treatment. He'll probably be in the hospital for a month or more. Assuming that treatment's successful, we'll immediately begin consolidation therapy."

"Which is what?"

"It's an even more aggressive form of chemotherapy. It's sometimes called the intensification phase of ALL treatment. Given Brody's age and weakening condition, he'll likely be hospitalized for most or all of that phase of his treatment."

"Oh God... Is that all?"

"I'm afraid not."

"Afraid not? What else does he have to go through?"

"Assuming consolidation therapy is successful, which will last probably six to nine months—"

"Jesus..."

"—he'll face up to thirty months of maintenance therapy. It's a less aggressive form of chemotherapy."

"My God..."

"But? You have something else to say."

"It doesn't end there, does it?"

"No, Mrs. Windham, it doesn't. Somewhere along the way, Brody will need intrathecal chemotherapy, either as prophylaxis or as treatment."

"What's... what's intrathecal chemotherapy?"

"That's where we introduce chemotherapy directly into the spine so the cerebrospinal fluid carries it up to the brain. This can help prevent leukemic spread into the central nervous system or help treat it if it already has."

"Oh God..."

"How long does that take?"

"If we can perform the intrathecal therapy concurrently with his other treatments, it will add no time to the overall schedule. If we have to do it separately, it'll require another two to four months, assuming all goes well."

"Jesus Christ..."

"I can't emphasize enough the need to start treatment as soon as possible. ALL is highly aggressive, as I've explained, and any further delay will reduce the chances of success."

"He could die, couldn't he? Is that what you're dancing around?"

"Jayne Anne..."

"I'm sorry, Ben, but I need to know!"

"Mr. and Mrs. Windham, I understand this is overwhelming and seems to get worse with each minute that passes. Please know we'll do everything that can be done to make Brody well again."

"You didn't answer the question."

"The answer is yes, Brody's condition is critical, becoming more so with each passing minute. ALL is normally fatal if treatment is delayed too long. That's why I urge you to let us move forward immediately with the treatment regimen I've outlined."

"Honey..."

"It's okay, Jayne Anne, just let it out. That's it, just let it out."

"How... How soon does he need to start treatment?"

"Today."

* * * * *

Three Years Later

"He's in complete remission."

"That's wonderful!"

"We can't thank you enough!"

"We're not out of the woods just yet."

"What?"

"Why?"

"Brody will need monitoring for the rest of his life in case the leukemia comes back."

"How common is that?"

"More common than we'd like, though not common enough for you to worry about it. You just need to be mindful of the possibility. Brody will need to be monitored for the rest of his life, and he'll spend at least the next few years taking medication."

"What kind of medication?"

"To start with, an immunosuppressant, a systemic steroid, and a prophylaxis antibiotic. In three to six months, assuming all goes well, we'll take him off the immunosupressant. Again if all goes well, three to six months after that we'll take him off the antibiotic."

"What about the steroid?"

"He may be on that for life, though we'll only know for sure each time he comes in for testing."

"How often will that be necessary?"

"Every month for the first year. So long as there are no signs of relapse, every six months after that."

"For his whole life?"

"I'm afraid so."

"Oh God..."

"It's possible, after a prolonged period in remission, that we could go to testing once a year, but it's not recommended except in the rarest of cases."

"Well, we can always hope."

"Yes, we can always hope."

* * * * *

Two Months Later

"Honey, are you sure we should send him to kindergarten? All those kids with colds and flus and—"

"Jayne Anne, we can't keep him in a bubble for the rest of his life."

"Don't you think I know that?"

"Jayne Anne..."

"I'm sorry, Ben. I didn't mean to snap."

"Yes you did. But I'm not taking it personally, baby doll. You've been through the ringer with Brody these past years while I worked. I can't rightly blame you for being upset, overprotective, short-tempered, angry, frustrated—"

"Alright, you silly man! Cut it out already."

"It's going to be fine, Jayne Anne."

"But he still looks so sickly."

"He's getting better."

"Every day, I know. I see it. But what about the other kids..."

"Do you want to try home schooling so he's ready to jump into the first grade next year?"

"Of course not! He needs friends, he needs to socialize, he needs to learn alongside his peers— Oh you sneaky man. You just made me argue against my own point of view."

"And did we learn anything?"

"That my husband is a clever man who can always help me see the light."

"So... Kindergarten?"

"I suppose you're right. We can't keep him in a bubble for the rest of his life."

"And he's getting better, stronger every day, looking healthier every day."

"But you know how kids are, Ben. Looking like he does now, Brody'll be an outcast on his very first day."

"I'm not saying it is, but even if that's true, it won't last forever. He's gaining weight, gaining color, looking better."

"So you think being shunned will be temporary?"

"Assuming anyone shuns him, Jayne Anne. Kids are resilient, so he'll survive either way."

"And kids don't have the hang-ups adults have. Maybe it won't even matter to the other children."

"Right, baby doll."

"So maybe it won't be bad at all."

"We can certainly hope as much."