Sunday, March 30, 2008

Dex and Blood Sugar, Part 1

We myelomiacs are all aware that dexamethasone (dex) can cause type II diabetes, sometimes permanent and sometimes reversible after discontinuing dex. This is most common among people who have taken "high-dose" dex, typically 40 mg per day four days on and four off.

I am taking "low-dose" dex, 40 mg once a week, Friday night before I go to bed. Nevertheless I already have a blood glucose monitor which I bought for another reason (not diabetes) and wanted to see what happens to my own blood sugar when I take dex. I decided to take a measurement about every half hour between waking and bedtime on three days: (1) Saturday, the day after taking dex, also called "buzz" day; (2) Sunday, "recovery" day; and (3) Wednesday, the fifth day, when effects from dex should be minimal.

The graph will be much easier to read if you click on it to enlarge it.
Blood Glucose Chart

Here is a table with the actual numbers, exact times, and comments.

This experiment is only two thirds complete, but already somewhat instructive. I couldn't wait to post:
  • About two years ago I ran a similar experiment for different reasons, and got an average reading of 104 mg/dL over parts of three days.
  • Saturday's average reading was 144 mg/dL, much higher.
  • None of my readings quite reached 200, which some say can be a signal of diabetes.
  • Sunday's (today's) average is 101, even with big meals, much lower than Saturday.
  • Glucose pretty much went up after eating carbohydrates, then down again, but with a few surprises:
    • The highest Saturday spike, 193, was measured shortly after finishing a big oatmeal breakfast with fruit and juice.
    • Later, a large serving of homemade chocolate fudge pudding, about 270 calories, seemed to raise glucose by only about 10 points. Are chocolate and milk able to slow absorption of sugars?
    • Still later, a slice of gluten-free bread with honey seemed to raise glucose by about 20 points.
    • All but one of Sunday's readings were lower than the lowest reading of Saturday.
I'll post about this again after Wednesday's test.

Friday, March 28, 2008

Drug Study Day 21

I am on a study of the new drug CC-4047, with once-weekly dexamethasone. This morning was the third weekly blood draw, results already by fax. Here is a table showing several CBC values on four different dates:

  Mayo   SMG   SMG   SMG
CBC   Mar 3   Mar 14   Mar 21   Mar 28   Minimum
WBC (leukocytes) K/uL 5.6 4.8 5.8 5.3 2.0
NE# (neutrophils) K/uL 3.5 2.1 2.9 2.6 1.0
PLT (platelets) K/uL 211 220 245 232 50
RBC (erythrocytes) K/uL 4.62 4.50 4.28 4.54
HGB (hemoglobin) K/uL 15.4 14.9 14.3 15.0

The top three counts are ones that Mayo is particularly interested in watching, because the CC-4047 trial drug may eventually depress those numbers. If any of those three counts falls below its minimum, the protocol will be changed for me, or, eventually, I could even be dropped from the study.

No problems yet. The three key counts are all down slightly from last week, but still higher than two weeks ago. Red blood count (RBC) was a little low last week, back in range today.

Dexamethasone again tonight.

Salad Recent dinner salad: Organic romaine lettuce with sliced cucumber, blueberries, cashews, blue cheese, corn bread, clementine, organic apple cider vinegar.

Friday, March 21, 2008

Day 15

I went into the local clinic this morning for the second weekly blood draw, and received the results by fax. Here is a table showing several CBC values on four different dates:

  MOHPA   Mayo   SMG   SMG
CBC   Dec 26   Mar 3   Mar 14   Mar 21   Minimum
WBC (leukocytes) K/uL 3.9 5.6 4.8 5.8 2.0
NE# (neutrophils) K/uL 2.2 3.5 2.1 2.9 1.0
PLT (platelets) K/uL 188 211 220 245 50
RBC (erythrocytes) K/uL 4.44 4.62 4.50 4.28
HGB (hemoglobin) K/uL 14.4 15.4 14.9 14.3

The top three counts are ones that Mayo is particularly interested in watching, because the CC-4047 trial drug may eventually depress those numbers, as does the analogue drug Revlimid. The minimum counts shown are well below the reference range in each case, and if any of those three counts falls below its minimum the protocol will be changed for me, or, eventually, I could even be dropped from the study.

But no problems yet. The three key counts are all UP, actually. That's very good news.

Red blood count (RBC) is slightly below the reference range, but this has happened before. My RBC is always at the low end. I do wonder why that is - shouldn't a runner's system create EXTRA red cells to carry the oxygen that s/he needs when consuming 700-800 calories per hour? Guess not, in my case, but if it did then maybe I could run faster :-) Anyway, hemoglobin (HGB) is nicely within the reference range, so I'm not concerned.

My doctor ordered two extra tests this time: (1) Prothrombin time (PROTIME) with International Normalized Ratio (INR). This is a measure of the time it takes for the blood to clot under specific laboratory conditions. PROTIME is specific to the particular laboratory and the conditions that it sets, and INR is calculated from the result based on those conditions. Happily, my INR is 1.0 and PROTIME is 9.9, very close to the center of the reference range for this lab; and (2) Partial Thromboplastin Time, for which the result was 26.9, also quite normal. No warfarin for me unless a clot shows up.

Dexamethasone tonight - I should be on my game tomorrow!

This morning's breakfast: Irish oatmeal with organic flame raisins, Sunshine's teff bread with dates and nuts, dried dragon fruit, organic walnuts, Don's nut/fruit/berry mix, banana, organic nonfat milk.

Today's lunch: Organic brown rice pasta with homemade organic pasta sauce and parmesan cheese, naval orange, organic vegetable mix, organic pure pomegranate juice.

Recent dinner: Free-range no-hormone no-antibiotic bison, clementine, organic squash with organic salsa, Sunshine's teff bread with dates and nuts, local honey, organic sweet corn, Dove dark chocolate.

Wednesday, March 19, 2008

Bone-Strengthening Exercises

Tuesday I spent an hour with Angie, our personal trainer. She knows that I have myeloma and that there is active disease in both shoulder blades and in the T10 vertebra, weakening those bones. I asked her to show me some exercises for strengthening the muscles in my back, because we know that bones will strengthen themselves wherever the muscles that attach to them are strengthened.

In that hour she showed me some lower-body stretches in addition to those that I already do, to improve my running. Then she gave me five upper-body exercises, which I tried this morning for the first time at home:
    Reverse Fly with cable and weights
  • Reverse Fly: The focus is on the back part of the shoulders. Equipment: Resistance band attached to a fixed object. Start with the band in hand at the opposite hip, keeping arm straight swing hand from hip across the body to shoulder height on the other side. Try to keep trapezius muscles (traps) relaxed. Three sets of 12 repetitions (reps). Alternative method (from the internet): work one arm against the other, see graphic. I tried this alternative today.
  • Reverse Fly with only a resistance band
  • Cable Row: Simulated rowing. Face toward a weighted cable or resistance band, pull both elbows backward to bring the handle to the body, keep shoulders down, imagine trying to grasp a marble between shoulder blades. Slowly return. Three sets of 12 reps.
  • Stability Ball Push-Back: Lay on back on stability ball holding a 10-lb medicine ball against the stomach, bend knees and slide down to bring butt to heels, then push back up. Cable Row with cable and weights I'm not sure what this exercise is for, actually, because I feel it primarily in the quads. I'll have to set up another appointment and ask Angie. Three sets of 12.
  • Assisted Pullup: A pullup is the same as a chinup except with palms facing away instead of toward me. I can do unassisted pullups (at least one, I tried it) but that may put my back at risk so we're going with assisted pullups which do not require me to lift my entire weight. At the gym, there is a machine for doing this with a very precise amount of assist. Floor-Assisted Pullups At home, today, I put a chair under the pullup bar, which brought my chin right to the bar at full height, and then used my legs to provide an assist. See the small graphic, where that same principle is applied but the bar is lower, making the chair unnecessary. The amount of assistance is uncalibrated, but it seemed to work fine. Three sets of 8 to 10.
  • Stability Ball Cobra: This is a sort of "reverse crunch" using the back muscles instead of the muscles in front of the body. Lay stomach-down on the stability ball, feet against the wall for stability. Cross arms, slowly let upper body down as far as it will go, slowly raise again, but only until body is straight. Pull shoulders back, again grabbing the imaginary marble with the shoulder blades. Three sets of 8 to 10. Sketch of Stability Ball Cobra
That was ONE hour with Angie. No doubt the list of possible and beneficial exercises is incomplete, as my understanding certainly is. Hopefully, by blogging about these and (therefore) looking each of them up on the internet I will learn enough to make them stick in my alleged mind. But I suspect that our family will need a few more sessions with Angie to get everything right.

After the session we stopped at Target to pick up a nice 65-cm stability ball and a couple of resistance bands. We already had a pullup bar, and that's all I needed for this morning's routine.

Friday, March 14, 2008

Trial Drug, First Labs

I went into the local clinic this morning for a blood draw. They faxed the results to me this afternoon. Here is a table showing several CBC values on three different dates:

  MOHPA   Mayo   SMG
CBC   Dec 26   Mar 3   Mar 14   Minimum
WBC (leukocytes) K/uL 3.9 5.6 4.8 2.0
NE# (neutrophils) K/uL 2.2 3.5 2.1 1.0
PLT (platelets) K/uL 188 211 220 50
RBC (erythrocytes) K/uL 4.44 4.62 4.50
HGB (hemoglobin) K/uL 14.4 15.4 14.9

The three counts with a "minimum" value are the ones that Mayo is particularly interested in watching, because the CC-4047 trial drug may eventually depress those numbers, as does the analogue drug Revlimid. The minimum counts shown are well below the reference range in each case, and if any of those three counts falls below its minimum the protocol will be changed for me, or, eventually, I could even be dropped from the study.

But so far so good - these tests don't show a convincing drop in any of the three critical counts. They were performed at three different laboratories: Minnesota Oncology (MOHPA), Mayo, and Stillwater Medical (SMG), so they may not even compare very well. Indeed, the different laboratories do have different reference ranges for many of the counts. However, the next two blood draws will be at SMG, so those should be comparable. Even so, I know that my WBC bounces all over the place, ranging from 3.7 to 5.6 in the past 18 months, so one dip may not be of great concern; it's the longer-term trend that will matter.

Recent breakfast: Organic irish oatmeal with organic flame raisins, banana, papaya, organic walnuts, organic ginger, blueberries, organic nonfat milk.

Recent dinner: Wild-caught Alaskan salmon with organic yogurt, organic sweet relish, organic mixed vegetables, watermelon.

Visit to Naturopath

Sunshine and I visited our naturopath Dr. Healy Wednesday, to deal with several questions raised by the new CC-4047 drug trial that I have started:

Bone Building:

At Mayo, Dr. Lacy and I discussed a prescription for generic fosamax to strengthen my bones. I don't actually have that prescription yet - perhaps she's rethinking it. Dr. Healy seemed uncomfortable with the fosamax, partly because of the risk of osteonecrosis, and referred me to a recent article in WebMD explaining the benefits of Vitamin K2 for rebuilding bones AND for scavenging calcium away from places it shouldn't be, such as arteries. A double-good whammy!

The issue is complicated for me because Vitamin K1, the most readily-available form, enhances the ability of the blood to clot. In my case, the CC-4047 drug that I take brings its own modest risk of blood clots, usually seen as a "deep vein thrombosis" (DVT). I don't want to increase that risk by taking the wrong supplement. Most Vitamin K supplements contain a lot of K1 and a little K2, but happily there are a few that are Vitamin K2 only, such as this Carlson brand. Until I get a better handle on this issue I am going to take only a modest amount of K2, in the range of 5 mg, with no K1 except what I get in food.

And I think I should talk to my doctor about getting my INR checked once in a while. INR is a measure of the blood's ability to clot.


Tetrahydro-iso-alpha acids are derived from hops (who knew?) and sold under the brand name Kaprex AI. It is advertised for joint support and for normalizing the immune system. Recently, however, scientists have discovered that THIAA has anti-angiogenic properties - it inhibits the growth of tiny new blood vessels. This is one mechanism by which thalidomide is thought to go after myeloma. Therefore, it is possible that Kaprex AI or an equivalent product might have some of the benefits of thalidomide without its side effects, though I am not aware of any studies to show this. Dr. Healy suggested that an appropriate dosage might be one tablet three times per day.

I am already taking a thalidomide analog, CC-4047, so Dr. Healy and I agreed that it would be quite inappropriate for me to take this as well. But in the future, if my participation in the CC-4047 trial ends, I may want to remember this product.

Side note: The manufacturer of Kaprex AI does warn against use by pregnant women, but the warning is generic and not very emphatic. If it really is anti-angiogenic, Kaprex AI should carry a very strong warning which would include mention of birth defects as a likely consequence of taking Kaprex AI.

Borage Oil:

Dr. Healy suggested borage oil instead of evening primrose oil, because borage oil contains about two and a half times as much GLA. I seem to recall that a blog reader also made that comment. GLA has several benefits, but in particular it is an anti-inflammatory and may combat myeloma in the same manner as other anti-inflammatory agents. She suggested organic borage oil, but I was unable to find it in organic form. Barleans Organic Oils is one company that sells borage oil, but theirs isn't organic, though they do make it hard to figure that out. Isn't that false advertising? I think so. Anyway I ended up ordering it from LEF because they have a special going. If you have a source for organic borage oil, please comment.

Recent lunch - Homemade pizza: Gluten-free brown rice pizza crust, chunks of free-range bison, organic parsnips, fresh pineapple, homemade organic pizza sauce, parmesan cheese.

Recent dinner: Turkey curry (organic turkey, organic peas, coconut milk, more), clementine, organic medjool date, cantaloupe.

Sunday, March 9, 2008

Mayo Wrapup

Four trips to Mayo, 680 miles, and oh so worth it.

Today's dex headline:

I had a little trouble sleeping last night, awakened early and laid there with my brain buzzing most of the time. Otherwise the Sunday morning after Friday night's dexamethasone (dex) is uneventful. I feel fine, and not so hopped-up as yesterday.

Analysis of test results:

Here is a little table of some of the important results, with the "bad" ones first, then the "good":

Test & units Dec 26  Mar 7   Comments
M-Spike g/dL 2.05 2.70   I don't quite believe it, see below
BMB Plasma cells % 6.7 5-10   Another result showed 22% - ??
Calcium mg/dL 10.0 10.2   Above Mayo normal range of 10.1
FreeLite mg/dL 4.67 5.88   Gives credence to the M-Spike
PET Scan   Pos   Showed up VERY clearly
Bone Survey Neg Pos   Vague area of lucency in scapula
All CBC values Lo RBC OK   No anemia or any "penia"
IgG mg/dL 3000 2960   Unchanged
Creatinine mg/dL 1.0 0.9   Lowest ever, test difference?
Albumin g/dL 4.2 4.5   Best in 18 months
Beta-2 M mg/L   1.89   Lower than a year ago

Long-term historic values from many tests are displayed graphically and numerically on separate pages, see "related Links" below.
PET Scan Report.  Click to enlarge, 'back' to return
My interpretation:
  • The M-Spike reading may be high because of laboratory differences. In any case this test, while important, is not altogether reliable.
  • The normal CBC, albumin, creatinine, and stable B2M values indicate that my soft tissue organs are not being harmed yet.
  • The high calcium, the bone scan, and especially the PET scan clearly indicate damage to bones. Dr Lacy toggled through the entire computerized PET scan from my head to my knees and those active areas showed up very graphically.
  • Damage is thus far limited to both scapulae (shoulder blades) and the T10 "spinous process," which I believe is NOT the load-bearing part of the vertebra.
  • I do not feel pain in any of those places, but I sure am curious if that's the same vertebra that DID hurt five years ago and which led to the myeloma diagnosis. I will try to find out.
  • Click on the little graphic to see the written PET scan report. Click "return" to get back.
Related links: Back to Mayo in one month. Meanwhile: CC-4047, Dex, Zantax, aspirin, acyclovir, and selected supplements.

Saturday, March 8, 2008

So What's All the Fuss?

I'm sure that I will find out! But so far, the first morning after the first dose of CC-4047 2 mg and dexamethasone (dex) 40 mg, I feel quite normal. I was a little restless toward morning, but that's not unusual, and not surprising in these circumstances. I got back to sleep and awoke refreshed. Are my thighs a little tired feeling, or am I imagining that? Time will tell.

This is Saturday morning, so normally I would be running with the St Croix Valley Runners right about now, but it's six degrees BELOW zero and I have wimped out! I'll run on the indoor track at "the club" later today, with my sweeties. That will be an interesting test.

Yesterday's visit to Mayo was uneventful, really. No more holes poked in me. We did a lot of talking and I picked up the CC-4047 and dex. A few things got resolved:
  • Logistics: I will get weekly blood tests (CBC) at the Stillwater clinic, faxed immediately to Mayo, to be sure that my blood counts remain within a normal range.
  • For a few months I will return to Mayo every month; I already have an appointment for April. If things go well, I will later have some of my monthly appointments with Dr Petryk at MOHPA, to save the drive down.
  • Dr Lacy does NOT think that the lambda light chains are a sinister part of my myeloma, so she has not ordered 24-hour urine collections. That's a minor inconvenience (major for women) that I will not face every month.
  • WITH the CC-4047 and dex I also take:
    • 325 mg aspirin daily, half at night and half in the morning, to ward off deep-vein thrombosis (DVT) from the CC-4047,
    • Ranitidine (generic Zantac) tablets 75 mg, one in the evening with the dex, and one the morning after, to reduce stomach acidity and hopefully ward off ulcer,
    • 400 mg acyclovir to ward off shingles, because I'm messing with my immune system.
  • Dr Lacy gave me a 2006 Mayo Clinic study of the clinical effects of green tea (especially EGCG) on patients with early-stage chronic lymphocytic leukemia (CLL). The results were quite positive, and even though myeloma is different from CLL I will continue with the EGCG.
  • I will continue with the curcumin as well, but haven't decided about other supplements. Need to make an appointment with my naturopath.
  • My electrocardiogram shows "marked sinus bradycardia" (slow heart rate). That means I'm a runner!
  • The bone survey shows "generalized spotty osteopenia" (between normal and osteoporosis) but no lesions from the myeloma. We know, though, that x-ray doesn't always show lesions before the bone breaks.
  • After seeing that, looking at my previous bone density results, and knowing that I would be taking dex, Dr Lacy decided to prescribe pamidronate (Aredia) in a modest amount. But as we discussed this, she guessed that she didn't really care what bisphosphonate we use, and thought that Boniva or Fosamax would do as well. Those simple pills are much more convenient than 90-minute Adedia infusions at a hospital. I got away without the prescription actually in hand, but will eventually probably be taking a generic version of Fosamax weekly to maintain bone density.
  • She volunteered that the running certainly helps as well.
  • I intend to have a visit with a physical trainer to learn some good exercises for strengthening my back muscles, because (as the naturopath HH points out) bones will strengthen wherever the attached muscles are worked and strengthened.
I feel good about being personally proactive. If I had not made the desision to go to Mayo, I would not have had the PET scan and would not have learned about the lesions in my shoulder blades and spine. Further, I would not be in the CC-4047 trial.

The CC-4047 is 2 milligrams. How can two little milligrams of anything be so potent? Better living through chemistry (I hope).

Live well and long.

Thursday, March 6, 2008

New Chapter

I now officially have active, ISS stage 1 myeloma. It's not MGUS (monoclonal gammopathy of undetermined significance) or "smoldering" myeloma, and it's not what I was hoping for. That's the bad news.

The good news is that my myeloma is growing only very slowly, with a Mayo Clinic labeling index of 0.2, described as a "VERY LOW proliferative rate" (their emphasis). For anyone with myeloma this is very good news and cause for a lot of hope, for both the short and the long term. Dr. Lacy said that a person with this labeling index can expect to live a long time with myeloma. I didn't press her to quantify that, because we all know that the doctors can't give us hard numbers on our survival.

I will digest the results more and post again in a day or two, but here are some highlights. Bad stuff:
  • In two months, M-spike jumped from 2.05 to 2.7 g/dL. I suspect (and hope) that some of this jump is due to a difference in testing - this is my first-ever set of labs from Mayo.
  • Calcium, Beta-2 microglobulin, and lambda free light chains are all up from two months ago and all higher than they should be.
  • Most sinister: The PET scan clearly shows three very active regions in my bones: one in each shoulder blade, and one in the T10 thoracic vertebrae midway between the waist and the shoulder.
Good stuff:
  • Platelets, red blood cell count, hemoglobin, creatinine, and albumin are all well within the normal range.
  • Same with LDH and C-reactive protein.
  • IgG is the same as the last test at MOHPA, suggesting that the M-spike may not really have changed as much as the numbers indicate.
  • No abnormal proteins were found in the 24-hour urine.
Especially because of the PET scan, Dr. Lacy thought it was time for treatment, to deal with the hot spots in my shoulder blades and spine before those bones fracture. I reluctantly agreed; the last thing I want is a broken back. She suggested two possibilities:
  • Revlimid with low-dose dexamethasone (a steroid), or
  • A phase-II trial of a brand-new not-yet-approved drug with the code name CC-4047. This is a new Celgene drug, intended to be an improvement on Revlimid, which itself is an improvement on thalidomide. This too would be taken with dexamethasone.
I chose the trial.

When the drug-trial coordinator asked Dr. Lacy how soon I should start, she replied "yesterday!" Since then I have taken an EKG and had another full x-ray bone survey, and I will see her again tomorrow to wrap things up and start the trial.

Dex tomorrow night. Oh my.

Today's lunch before traveling to Mayo: Papaya, pineapple, organic medjool dates, pistachios, orange, organic fat-free yogurt.

Tuesday, March 4, 2008

Mayo Clinic, Day 2

A Positron Emission Tomography (PET) scan employs a radioactive isotope which acts like a tiny lighthouse within the body. The body is transparent to this radioactive light (gamma rays), so the PET scanner can see it and can locate the isotope with precision. The isotope is attached to sugar (glucose) molecules, which are injected into the body and taken up in greater amounts by hungry cancer cells than by the body's other cells. Thus the scanner can see a lot of these tiny lighthouses wherever there are concentrations of cancer cells. In myeloma patients, the PET scan can spot hot spots capable of causing bone damage, before the damage is ever done.

PET scans are expensive, Sandy the nurse said $3500, and for myeloma patients they are not covered by Medicare. However, Medicare is currently funding a study of the usefulness of PET scans for myeloma, so scans are available to a Medicare patient if the patient's doctor is willing to do the paperwork required for the study. Happily, Dr. Lacy was not only willing but suggested the PET scan, for which I will always be grateful.

I was seated in a recliner chair, and Sandy first took a blood sample from a finger, and then injected the isotope (looked like clear water) into a vein. There was no sensation from the injection, except a slight, momentary coolness at the site. Then I sat for an hour, mostly dozing, to give time for the body to distribute the isotope to the organs that were most hungry for the glucose. During that hour I was instructed to be as still as possible, to avoid using muscles, because working muscles demand a refill of glucose, and we wanted as much of the glucose as possible to be free to go elsewhere.

Then I walked to the scanner and laid on a table in front of a big horizontal tube that looked like an MRI scanner, except larger in diameter and shorter in length. As with an MRI, the table scooted me in and out of the tube, but unlike an MRI it was almost silent. It was far less intimidating than a normal MRI. My arms were in an uncomfortable position over my head, or else I would have gone to sleep. The scan itself took about 30 minutes, after which I waited a few minutes more while they checked to see if they got what they wanted. I did ask the technician if there was anything that she could tell me, but she winked "that's what the doctors get the big bucks for."

For me, this seems like the big test. My blood tests have thus far always been negative for the other C.R.A.B. symptoms (organ damage), as have all of the x-rays, so this one is most likely the key test. Sunshine and I agree - whatever the answer, we want to know it, and treatment decisions will probably hinge on it. We'll know in a few days.

Recent lunch: Organic chard with pistachios and cranberries, organic vegetable mix with shredded asiago cheese, two clementines.

Monday, March 3, 2008

Mayo Clinic, Day 1

I like Doctor Lacy. No nonsense, but caring and not authoritarian. Some of the things that we discussed:
  • My history with myeloma, from my own perspective. She said that she takes it in best that way,
  • My lifestyle, especially my interest in running. She is a runner too,
  • All of my previous test results, of course (I showed her some of my charts),
  • The fact that I have no apparent C.R.A.B. symptoms yet (far from it),
  • The possibility of getting into a Celebrex trial (I brought it up, but she did not dismiss the idea),
  • Possible stem cell collection,
  • The difference between treating symptoms and treating numbers, and
  • Additional tests which Mayo can do, including
    • Another bone-marrow biopsy; the last one was a year ago,
    • FISH studies on the bone-marrow aspirate, and
    • A PET scan to look for hot spots in my bones.
Most of that was done today, actually. Things seem so easy at Mayo. I was most impressed by the bone-marrow biopsy. My previous biopsies were done in a hospital, and required check-in, gowning, and a long wait afterward before I was allowed to sit and then stand. It seemed like a major deal.

In contrast, at Mayo I walked into the procedure room, disrobed only enough to expose my hip, and was walking out within 20 minutes. Didn't even have to take of my shoes! These guys checked the aspirate with a microscope right then and there, to be sure they got what they needed. It was easily the least-painful BMB of the four I've had. I think it's the difference between doing a procedure occasionally, and doing it all day long. One trick: the person doing the procedure applied pressure to the incision afterward until he was VERY SURE that the bleeding had stopped completely. I don't recall anyone doing it quite that way before. And because he did that, there is still no trace of red on the bandage now, hours after walking the hallways of Mayo and then driving the 90 miles home.

Further tests are scheduled for later in the week.

Finally, toward the end of the week, I have another appointment with Dr. Lacy. In my best, most hopeful scenario, she will tell me that the PET scan shows no lesions, that my particular myeloma is not as aggressive as most, that my numbers are stable, and that watchful waiting is a reasonable choice. If so, I will choose it! If she does recommend treatment, we will discuss the risks of different treatments, including the risk of postponing.

Recent breakfast: Organic oatmeal (under there somewhere), Don's berry/nut/fruit mix, fresh mango, organic blueberries, banana, Hershey's dark chocolate, organic nonfat milk.

Recent lunch: Sunshine's gluten-free lasagna with brown rice pasta, organic spinach, organic ricotta cheese, organic pasta sauce, and organic yogurt, orange, organic apple.

Dinner salad
Recent dinner (salad): Organic romaine, fresh mango, toasted sunflower seeds, avocado, dragon fruit, organic cottage cheese, organic red wine vinegar.