Tuesday April 16, 2002

'Today is full of possibilities'

Marge Sherman Eagle-Tribune Health Writer

Depending on the day, sometimes even the hour, Ric Blake will tell you one of two things. He is either fighting his battle with terminal illness for the long haul or he is ready to hang up his gloves.

The uncertainty of living with an aggressive form of thyroid cancer was never more clear for Blake than last week, as events unfolded hour-by-hour during his stay at the government's pre-eminent research hospital, the Clinical Center at the National Institutes of Health in Bethesda, Md.

Ric Blake looks at his body scan in search of hoped-for signs of radiation absorption by his bone cancer. There were none. One day, he was ready to continue the good fight, prepared to start yet another round of chemotherapy and considering surgery for a possible bone lesion on his rib that appeared in his final scan that morning.

Twelve hours later, after vomiting through the night and spiking a fever, he wanted to go home. Permanently.

He pondered calling his physician, Dr. Nicholas J. Sarlis, and giving up.

"I was ready to call Nick this morning and say that I'm going to stop. I'm going to go home,'' said Blake on Saturday morning from his hospital room. "But today's a different day ... because I feel better. Today is full of possibilities.''

As The Eagle-Tribune follows Ric Blake's journey with thyroid cancer, readers have read of his highs and lows along the way for the past 16 months.

Blake now finds himself at the point where doctors say there is no cure, no certain way to control the lesions that have popped up in his bones. They are just buying time.

Thyroid cancer is usually quite slow-growing, unlike cancers of the lung or breast, but in Blake's case his type of follicular thyroid cancer, the Hurthle cell variety, is more aggressive and lethal than usual.

Blake, 57, was diagnosed in 1995 and he began sharing his story with The Eagle-Tribune when he first realized that the cancer would kill him one day. He wanted to begin a conversation about the need for palliative medicine, the care and comfort for people with terminal illness. In these pages he has ranted about patients' rights, the right to be informed of options, of treatment plans. He has talked about the possibilities of alternative and complementary medicine from acupuncture to music therapy. And most of all, he has promoted the need to be a pro-active patient and advocate for one's self.

Yet despite all of his efforts, Blake often finds himself in the position of many other patients -- waiting alone in pain and fear, for the medical establishment to react to his problems.

Taking a chance

There is a significant change in the outlook of cancer patients once they learn that their disease has spread to the bones or brain or lungs. They lose the leisure of looking years or decades down the road.

In Blake's case, that news came in January.

"It's enough to really make you stop and pay attention,'' said Blake. "All of a sudden, we really don't have a lot of time. Once you have bone mets (metastases) in thyroid cancer, you're in big trouble.''

Despite the prognosis, Blake was feeling quite well when he returned to NIH two weeks ago. He had starved his body of iodine in preparation for another round of radioactive iodine therapy, the standard treatment for thyroid cancer, even though he knew that the chances or success were slim. It did not work in the summer of 2000 for the bulky tumors in his neck, but his doctor wanted to see whether it might work on his bone lesions.

He swallowed the radioactive material on Monday, April 8, his 35th wedding anniversary, spending the next 48 hours in total isolation, to avoid contaminating others with the radioactivity he emitted. He sat alone in his room, talking to medical staff who chatted from the hallway, and taking his meals on trays delivered outside his door.

Checking for hot spots

On Wednesday afternoon, a health physicist dressed in a white lab coat with blue paper booties covering her shoes, arrived with tools in hand to test his radioactivity. Beth Reed stood about 3 feet away from Blake, moving a small box, an ion chamber, up and down to check his readings.

"Oh, you're not hot at all,'' she announced.

Reed discharged him from the isolation room with a list of precautions. Then she took out her Geiger counter, slid it along the surface of every item he had touched while in isolation, setting aside the items that made it rapidly go clickety-click -- a jar of coffee creamer, music therapy tapes, headphones and his books.

Blake went to the nuclear medicine department the following day for a scan under a gamma camera to see whether the radioactive iodine treatment worked.

Weighing the options

There would be no good news this time. Blake lay on a table that slid him between two gamma ray cameras which read the radioactivity his body emitted. The machine produced a scan showing a ghost-like image of his body, with black splotches where the radiation was taken up. There was no uptake in Blake's hip or shoulder, but a follow-up scan showed a curious spot in the area of his rib.

The procedure had failed once again.

The big meeting with doctors came Thursday afternoon. Sarlis and a team of consulting doctors from the National Cancer Institute stood in a semicircle at the foot of his bed and, one by one, offered their best advice for future treatment.

First Sarlis explained that the radioactive iodine (RAI) for Blake had failed, as he expected, and it would not be a possible treatment in the future.

"The RAI is out of the question, I think forever,'' said Sarlis. "Bone mets in thyroid cancer are, for the most part, incurable. At this point, we can't even make them controllable in the future.''

The oncologists then listed their options -- starting with a typically well-tolerated drug called pamidronate and extending into standard chemotherapy drugs such as Taxol and adriamycin, ending with highly experimental options with no proven track record such as thalidomide and a drug so experimental it is referred to just by a number.

Earlier in the day, Blake had gone upstairs to the 5,000-volume patient library on the 15th floor and printed out studies of some of the chemotherapy agents he might try. He sat on his hospital bed, flipping through the pages.

"Here's one,'' he said. "There were 14 patients. One patient responded. In three there was no change. Ten progressed. The mean survival time was 3.4 months. ... Some people didn't die. That's the bottom line. Did they get any better? No.''

Still, here he sat now, listening attentively to the doctors.

Dr. Tito Fojo of the Cancer Institute explained he wanted to try the least aggressive treatment first, then re-check Blake in three months. If the pamidronate worked, they would continue with that. If not, they might add in adriamycin.

"Sounds like a plan,'' agreed Blake.

Ric Blake was feeling positive by the end of the day. He felt good, and was ready to try new treatments.

"Life is good. I'm not ready to give up yet,'' he said. "Two years ago, I didn't believe there was any point in doing anything because I didn't know anyone with thyroid cancer who lived, once you start external beam radiation and chemotherapy. But hell, I feel too good.''

He was ready to try all that the doctors offered.

"My reaction is, 'I'm not ready to go.' So long as I feel good, as long as I think the benefits outweigh the cost, I'm willing to consider almost anything,'' he said.

Then came the nausea and the fever.

Blake's wife, Diane, worries that the very treatments meant to buy her husband time could kill him before the cancer does. But she is the first to admit that the decision about further treatment is ultimately her husband's to make, not hers.

"It's his life. He has to do what he has to do. It's hard. It's very hard,'' she said, as she waited at home in Londonderry, N.H., for further word from her husband.

The Blakes have found ever-deepening meaning to their lives as Ric's illness has progressed. They try to appreciate life's day-to-day moments and plan in the short term. The latest plan is a cruise to Bermuda on April 28.

"You know the old salt, 'One day at a time'? Well that's where we are,'' said Blake.