Hard Questions



The plan was in motion before I got on the plane.

When your leukemia came back suddenly 3 years after your stem cell transplant, it was devastating. But we had a plan. Your cancer developed a new mutation we could target with a chemotherapy drug. If we got you into a second remission, we could consolidate it by infusing more of your donor’s stem cells.

We met in the hospital, but I was adamant to “keep” you as my patient when you got to the clinic. I made swaps to see you, to get the continuity I value so much but often lose as a fellow, rotating from clinic to hospital to clinic.

I was grateful to see how well you dealt with the chemotherapy. Typically it’s a tough regimen, but you hardly had side effects. Between visits, I would check your blood counts on my phone, watching your blast count fall and your normal blood cells rise. Watching the cancer disappear.

Your lumbar punctures were negative, negative, negative – my favorite word, I told you. I was involved in long email threads coordinating the timing of your stem cell infusion with the remission we were achieving.

We were on our way.

One day, your lumbar puncture came back with a few “atypical” cells. I called the pathologist, and upon further review they were convinced the cells were reactive, not cancer. The next lumbar puncture was normal, but it was hard to ignore.

“Are you worried?” I asked my attending in clinic.

“I’m always worried,” she said. Neither of us truly believed the leukemia was back, but with the odds against us, we pored over every detail, always on the alert for a clue to an outcome we feared.

By now, the stem cell infusion was all set up. The donor was ready; so was the medical team; so were you. It was exciting. I thought of how a different attending described his interest in leukemia: There’s a subset you get to cure. Yes, you were going to be one of them.

Your big day coincided with a vacation I had scheduled months before. I was sorry I would be missing the actual moment, but happy I would come back to good news.

I left my coat and badge at the hospital, packed my bags, and got on the plane. I refrained from immediately checking your blood counts on my phone as soon as we landed. That night, jet lagged, I let myself look before I go to sleep. Relief. Your numbers still looked good.

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Every day, I explored. My Internet was spotty during my travels, and when I would I finally get service I would peek at your latest blood tests.

Day 1. Cooled lava canyons. Black sand beaches. Circulating blast count: 0%.

Day 2: Glacier tour. A national park. Geysers. Blast count: 2%.

Day 3: We drive along the shore to see a famous waterfall, where you can climb a set of winding stairs to the top.

I check my phone before we start the climb. No service.

And so we begin. The wind cuts as I count steps. 403, 404, 405 … and 406. We are there. The air is thin, the world quiet. My nose is running from the cold.

We hike a bit, and I glance down again. Still no signal. It’s probably for the best. The scenery is spectacular.

Two miles later, I get service. I open the blood work first. Circulating blast count: 5%. But the other counts are okay. It could still be reactive, I say to myself, though on a deeper level I think of my attending’s words: I’m always worried. The stem cell infusion is scheduled for tomorrow.

I hear the rush of the water hitting the rocks below. Icicles form to our left. Sheep graze on our right. I appreciate the feeling of my muscles aching as we climb, higher and higher, a reminder of where I am and my place in it.

At the very top, we pause to take photos. And I get a signal again. I open the bone marrow biopsy report and skim the pathologist’s words. My eyes glue on the summary: 80% blasts, compatible with relapsed leukemia.

I let out an audible gasp.

Do you know? How will they tell you? I am painfully aware of the distance between us, in so many ways.

I want to be present. And soon I will be back, and I will be visiting in the hospital, and we will be having hard conversations and thinking about hard decisions.

Dr. Ilana Yurkiewicz is a fellow at Stanford (Calif.) University.

Dr. Ilana Yurkiewicz

But I’m not there right now. Someone else is. Here, now, I realize what I cannot do. The best way I can be present for you later is to be present where I am now.

I stuff my phone in my backpack and zip it closed. I step carefully forward on the rocks, slippery from the rain. My nose is running again, but not from the cold.

“What do you think?” my partner asks.

“The views are incredible,” I say.

Minor details of this story were changed to protect privacy.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.

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