Embracing Hope. Chronicles of Blood Stem Cell Transplants

Transcription

1 Embracing Hope Chronicles of Blood Stem Cell Transplants

2 Published by Grey Cells Series An imprint under SingHealth Academy, Singapore Health Services Pte Ltd 31 Third Hospital Avenue, #03-03 Bowyer Block C, Singapore SingHealth Academy Publishing Team: Publisher: Neo Chia Reei Editorial: Patricia Ng / Sukhvinder Kaur Marketing & Publicity: Michelle Lam / Lydia Ng Book Concept, Co-ordination and Doctor s Notes: Dr William Hwang Copyright 2010 Singapore Health Services Pte Ltd and Singapore General Hospital Pte Ltd All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. Request for permission should be addressed to The Publisher, c/o The Editorial Office, SingHealth Academy, 31 Third Hospital Avenue, #03-03 Bowyer Block C, Singapore Tel: (65) , fax: (65) publishing@singhealth.com.sg. The publisher makes no representation or warranties with respect to the contents of this book, and specifically disclaims any implied warranties or merchantability or fitness for any particular purpose, and shall in no event be liable for any loss of profit or any other commercial damage, including but not limited to special, incidental, consequential, or other damages. Disclaimer This publication is intended to help encourage, exhort and edify patients, laymen and healthcare workers around the world. Haematopoietic Stem Cell Transplants are for the treatment of selected diseases and selected subtypes of these diseases. They have not been employed in the treatment of many cancers and other illnesses. This book should not be used as medical reference material or a resource for medical information. Readers of this publication who have medical conditions should consult their own doctors to decide on appropriate treatments for their illness. National Library Board Singapore Cataloguing in Publication Data Embracing hope : chronicles of blood stem cell transplants. Singapore : Grey Cells Series, c2009. p. cm. ISBN-13 : (pbk.) 1. Hematopoietic stem cells Transplantation Patients Singapore. 2. Hematopoietic stem cells Transplantation Patients Care Singapore. 3. Hematopoietic stem cells Transplantation Patients Family relationships Singapore. RD dc22 OCN

3 Contents Contents 3 Foreword 8 Preface 11 Acknowledgements 17 About Haematopoietic Stem Cell Transplants 20 Perseverance and Faith by Grace Chan 22 Life is Full of Surprises by Madam Tan 27 Be a Fighter! by Candy Yeow 30 Don t Give Up by Edna Tan 37 The Power of Positive Thinking by Viji Ramakrishnan 42 Being Brave by Mimi 47 Coping with Life s Challenges by Jasmine Teo 49 Understanding the Process 54 Appreciate the Smell of Flowers by Chew King Mun 56 Sharing the Journey by Mrs Fam 62 Face Reality by Puah Chai Hock 67 Like Running a Triathlon by Leong Mei Fong 70 Taking Things as They Come by Betty 73 Have Faith by Azrul Hisyam bin Julaimi 76 Sibling Support by Fazali 79 Controlling the Monster by Lee Miow Kim 82 The Importance of Family by Low Jiunn Shong 85 Journey of Faith by Lim Soo Hoon 89

4 Dealing with Complications 96 Staying Positive by Andy Toh 98 Support, Optimism and Faith by Charmaine 106 Lonely, but Not Alone by Amanullah s/o S Nagoor Meeran 110 A Marathon, Not a Sprint by Sebha E P 114 Understanding the Diseases 120 Appreciating Life by Paul Lim 122 To Look After Her Kids by Maria 127 Never Give Up by Benny Lim 130 Dealing with a Silent Disease by Ralph Pattinson 138 A Holiday that Never Happened by Wong Suit Lin 142 The Will to Overcome by Ravinder Singh 149 The Right Attitude by Foo Chiow Kiam 155 Fighting the Fierce Disease by Lawrence 159 Be Optimistic and Seek Early Treatment by Cheong WF 162 More Than Just Hope by David Ong 166 From the Frontline 172 Making the Difference in People s Lives by Dr Yvonne Loh 174 Bone Marrow Transplants Save Lives by A/Prof Goh Yeow Tee 178 Feeling for Our Patients by Dr Linn Yeh Ching 181

5 Individualism and Light-heartedness by Dr Mickey Koh 184 A Rewarding Challenge by Dr Colin Diong 187 Finding The Right Match by Lee Jing Jing 189 Helping Patients Make the Connection by Olivia Khoo 193 Patients Advocate by Ng Hong Yen 198 Admiration for the Fighters by Zhang Xue Hui 200 Support for the Patients by Sister Tan Chor Kien 202 Nurturing Frontliners by Jordan Hwang 205 Importance of Family Support by Elaine Lee, Tan Wei Ting, and Yvonne Tan 208 Supporting the Weary Battle-worn Patients by Erlinda, Hayati bte Mohamad, Jolene Guek, Kong Kam Yong, and Elaine Lee 210 Encouraging Patient Follow-ups by Clarice Chong, Huang Yu, Leong Hui Chien, Lily Suriana, Ling Wei Shan, Rohani bte Salleh, and Wahidah bte Sabtu 212 Haematology Support Group by Sister Chong Lai Ling 216 Doctors in the Department of Haematology, Singapore General Hospital With Gratitude 224

6

7 In loving memory of Dr Bobby Woo a cardiologist with a big heart and a patient who cared for those treating him

8 Foreword The process of transplanting haematopoietic stem cells from a healthy donor into a patient is one of the greatest breakthroughs in medicine. Transplantation of haematopoietic stem cells can now cure many blood cancers including leukaemia and bone marrow failure disorders. The establishment of registries of volunteer unrelated donors and cord blood banks around the world has opened therapeutic avenues for patients who do not have matched family members to serve as donors. In this sense, the process of performing a transplant for a patient can truly be an international endeavour. New research continually changes the landscape of transplantation. Patients today have choices and benefit from the advancement of knowledge in basic and applied immunology and improved supportive care before, during and after transplantation. Although the specific protocols or regimens may differ for each patient, what is universally experienced by patients, their family members, and the healthcare providers, is the intangible aspect of experiencing what is no doubt one of the most physically arduous procedures that a human being can undertake. Embracing Hope: Chronicles of Blood Stem Cell Transplants provides a glimpse into the innermost emotions of transplant patients and their medical team. The family provides integral support, helping the patient through the transplant in ways that only family can. Although it is the patient who is receiving the transplant, every member of his or her team is experiencing the transplant themselves in very different ways. From the tissue typing laboratory and co-ordinators who search for volunteer 8

9 donors, to the couriers who deliver the unrelated stem cell product from miles away, to the transplant nurses, physicians and support staff, each individual has a unique reflection on the journey of the patient through this process. These accounts collectively share a common spirit that of mutual respect of the patient and healthcare providers. These are stories that inspire. They are stories of bravery, of compassion, of empathy, and of hope. For students of medicine and nursing, these stories show us that compassion and being good listeners are an integral part of being healers. For the healthcare professionals who work behind the scenes to facilitate the transplant, you are as frontline as those who come face-to -face with the patient every day. For future patients who must take this journey, rest assured that your team of physicians, nurses, support staff, and above all, your family, have only one goal in mind to cure you of your cancer and return you to leading a life that is of the highest quality. Every patient teaches us something: sometimes we learn something new about a disease process; other times, we gain new understanding and appreciation of the human spirit. These vignettes provide a unique tool for teaching terms and phrases that are used frequently by healthcare providers but which may be foreign to the general reader. Use this as a tool for learning: to patients and family members, that the science of medicine is not always black and white; to students of medicine and nursing, that every patient teaches us something new. Above all, Embracing Hope serves a greater purpose in conveying the emotional aspects of healing, concepts that are 9

10 all too difficult to express. I hope you enjoy reading this book as much as I have, and leave inspired and full of hope, and learn something about yourself in the process. Dr Effie Petersdorf Dr Effie Petersdorf is currently President of World Marrow Donor Association and Professor of Medicine at the University of Washington. She is also serving as an Associate Program Head at the Fred Hutchinson/University of Washington Cancer Consortium. Dr Petersdorf s research is focused on human genetics in transplantation and cancer biology, in particular, genes within the major histocompatibility complex and immune response genes. She is Project Leader of the International Histocompatibility Working Group in Haematopoietic Cell Transplantation, a collaborative research consortium of transplant clinicians and immunogeneticists. 10

11 Preface I rushed into the room. The patient s family was gathered around him. I politely asked if they could step out for a moment. The patient lay still and motionless. His ECG showed a flat line. His heart had stopped. I examined him and tested his brain reflexes. He was dead. The year was Mr Tan (not his real name) had a bone marrow transplant a few months before for acute leukaemia. His leukaemia came back and he received chemotherapy to bring his disease back under control. However, his illness proved to be untreatable and, as he lay in a semi-comatose state, the family was told to prepare for the fact that he would die soon. True enough, after barely a few hours, the patient s heart stopped beating and I was called to certify death. As I held my stethoscope against his chest and examined him, I recalled the many months of struggle Mr Tan had against his leukaemia. Through it all, I got to know him and his family. I rejoiced with them when they had good news and agonised with them when there were disappointments. I thought about all that we had done to try and save the patient. Was it all worth it now that he did not make it? Was it worth all that effort? I said a prayer for him under my breath and, as I turned to give the final declaration of death to the patient s mother, I was somewhat surprised when she gave me a hug. She was distraught and heartbroken. But she seemed to 11

12 convey in that gesture that she was satisfied that all that could be done had been done to save her son. I gave her a hug back in return and shed a few tears with her. That same afternoon, a man stepped into the outpatient clinic. His eyes were bright and he walked with more energy and zest for life than me or the nurses who went up to greet him. He s an ex-patient, said one of the nurses to me. When I talked to him a while later, he told me that he would not still be alive if he not received had a bone marrow transplant from his sibling some years ago. I remarked at how energetic and full of life he looked. When you have been through what I have, he replied. You treasure life a lot more. At that moment, something in me clicked. An image of firefighters trying to save people from a burning house came to my mind. Sometimes, they can save some people from the fire. Sometimes, they cannot. The sights they see can haunt their memories and the fire can also leave the firefighters themselves burnt and badly scarred. However, for the sake of those who can be saved, someone has to do the job. I thought of Mr Tan who passed away earlier that day and I knew we gave the patient and his family the satisfaction of knowing that we did all that we could to treat his relentless disease. I knew that the field of bone marrow transplant would be one filled with happiness and heartache, joy and despair. I knew that I would see many patients die even if there were many others who could be saved. I knew that I could become cold, embittered, hardened or depressed. But I also knew that someone had to do 12

13 the work. I looked at what my seniors had done and was inspired. But I was also sure that we could do a lot more more patients could be saved and the transplant process could also be a lot safer and more effective. I think it was at that moment that I decided I would make the practice, study and enhancement of this field my goal. Today, the field of Bone Marrow Transplantation has progressed significantly. Besides using bone marrow as a source of haematopoietic (blood forming) stem cells, we now regularly use stem cells collected from the peripheral blood of individuals (so called peripheral blood stem cell transplants) as well as from the umbilical cord of babies after birth (umbilical cord blood transplants). In addition, we can also, to some extent, manipulate and grow these cells outside the human body to make them more effective. In the last decade, many new drugs have been developed to be given to patients in preparation for and after the transplant. Thanks to the work of many researchers around the world, results for these all haematopoietic stem cell transplants have improved tremendously. While it is true that these transplants are not needed for many illnesses, it is also true that the role of these transplants is clear in the treatment of many fatal blood diseases and aggressive blood cancers. Currently more than 200,000 of these transplants have been performed and many thousands of lives have been saved. At the Singapore General Hospital alone, about a thousand such transplants have been carried out. With the use of stem cells from the umbilical cord as well as other family members, we will soon reach the day when almost everyone who needs blood stem cells for transplant can have access to a donor. While the journey that each and every individual patient goes through is unique, there are many challenges that they can all identify with. In fact, there are many themes common to many patients going through difficult treatments for difficult diseases. To this end, we decided to compile our patients personal 13

14 accounts of their struggles, written as personal testimonies of their journey through sickness. We asked them to write as if they were writing to another patient in the future. We asked them to especially write those things which they wished someone could have shared with them when they were sick. Having seen how our own staff are dedicated to the patients, we have also asked them to share their personal testimonies of how they saw their own struggles and their own role in the patient s journey. I became most convinced about the need for a book like this when I started speaking to some patients. You know, I would ask. We are putting together this book for patients who have gone through a bone marrow transplant and we would like you to write something for it. I would usually get a wary look from the patient at this point. A friendly look, yet wary of what I was asking. You see, I would continue. Although we can try to encourage patients who are going through the transplant process, we can only do as much. Patients would like to hear from someone or some people who have been through it. At this point, eyebrows would lift and I would see a spark of interest. As you probably know, I continued. Although we have seen all these patients and know all these medical facts, there is no way we can actually truly KNOW all that you guys are going through. At this point, eyes would brighten and the response would inevitably be, You are so right, doctor! You have no idea! 14

15 Some of them would then go into a long explanation about how we, as healthcare providers, could not possibly know all the physical turmoil and emotional anguish that they as patients go through. How true! A humbling moment for me as I realise that, while I can understand with my head and maybe even perceive with my heart some of the things they go through, there is so little that I truly share in the struggles a patient has to go through from the initial diagnosis of disease to treatment and also, in dealing with complications and other hurdles along the way. This is something that only those who have travelled this road can fully appreciate. Actually, this book has another important readership: our hospital nurses, social workers, physiotherapists, dieticians, pharmacists, students and doctors. Our dedicated staff spent countless hours looking after our patients and they often grow attached to them. Unfortunately, the patients whom our staff grow close to are also those who come into hospital repeatedly for relapsed disease or various complications. The patients whom we grow most familiar with have a high chance of not doing very well eventually and our staff become disheartened when these patients die. That is how I felt too when I was a medical officer in the department; but when I covered the post-transplant clinic, I was amazed to see that there were many patients who were doing well years after their transplant. These patients looked healthy, well and apparently cured of their disease. Yes, really and truly cured! That was an epiphany for me and certainly a big factor that motivated me to join this field of medicine. Patients are our best teachers and the process of reading and editing this book has enriched me greatly. So whether you are a patient, a relative, a healthcare worker, or simply an interested concerned individual, we hope that this book will give to you an 15

16 epiphany of sorts. Maybe you will read it and say, Hey, I didn t know that or Wow, that really inspires me to Whatever your conclusion, we hope that you will come away encouraged and blessed with a different perspective on life. Dr William Hwang Dr William Hwang is Senior Consultant and Director of the Haematopoietic Stem Cell Transplant Programme of the Department of Haematology, Singapore General Hospital. He also serves as Medical Director of the Singapore Cord Blood Bank and Assistant Professor of the Cancer Stem Cell Biology Program at the Duke-NUS Graduate Medical School. He is currently also Chairman of the Medical Advisory of the Bone Marrow Donor Programme in Singapore as well as Vice President (Asia and Pacific Islands) of the World Marrow Donor Association. He hopes, with his colleagues in Singapore and around the world, to make Haematopoietic Stem Cell Transplants safer and more effective for patients with each passing year. 16

17 Acknowledgements We would like to dedicate this book to our patients. They are this book s reason for existence. Some of them are its authors. They are our friends and our teachers. We have learned so much from each and every one of them. Thank you. We would especially like to dedicate this book to Dr Bobby Woo, a gentle and courageous person who was always concerned about the welfare of those around him. He was a cardiologist who was big of heart and a doctor who understood that true healing comes from deep within the soul. He fought a good fight against his leukaemia and, even though he could not control it with chemotherapy, he managed to get remission of his disease after a transplant. He had more than a year free of leukaemia, touching and encouraging many people, before he finally relapsed from his disease. When he was able to go back to work for a period of time, he was so happy to see his patients again. It brought him such joy to heal others. Through his life and death, he was an inspiration to us all. It is through a generous donation from his family through the Haematopoeitic Stem Cell Transplant and Research Fund (administered and managed by the SingHealth Foundation) that we are able to publish this book and be able to devote all proceeds from sales of this book to the welfare, education and research of patients undergoing haematopoietic stem cell transplants. We would like to thank our fellow transplanters and mentors through the years. Some of them have retired and others are working in other hospitals locally and abroad. To our current Head, Dr Lee Lai Heng, thank you for your amazing support. Our former Heads of Department, Dr Kwa Soon Bee, Dr Ong Yong Wan and Dr Patrick Tan have also laid the foundation for us through the years. Many of 17

18 us have been for a period of training in transplant centres overseas like the Fred Hutchinson Cancer Research Centre in Seattle, Duke University Medical Centre in North Carolina, Stanford University in California, Northwestern University in Chicago and others. To our teachers and mentors at these centres, thank you for sharing your knowledge and imparting your skills to us so generously. We would like to thank the staff of SingHealth Academy, who have helped us in the publication of this book. Our special thanks go to Patricia Ng and Sukhvinder Kaur who spent many hours interviewing patients and revising the testimonials written by patients. They are the wordsmiths who helped this book take shape. We would like to thank our friends and collaborators in other institutions. Our friends at the National Cancer Centre, Singapore (NCCS), National University Health System and many other hospitals in the region have been our close collaborators through the years. Our friends at the Duke-NUS Graduate Medical School, the Health Sciences Authority, the various A*Star Institutes and other research institutes have been our fellow researchers for many projects that have made a difference to transplant research. Special mention must be made of our friends at the Health Sciences Authority who, besides providing us with various blood products through the years, are now also helping to provide us with various engineered cellular therapy products through the Cell Therapy Laboratory. We are indebted to the support of charitable institutions like the Leukemia and Lymphoma Foundation for their generous support, as well as the Singapore Cancer Society, and the Make-a-Wish Foundation among others, for their support of our patients. They step in to significantly augment the generous support given by the Ministry of Health for our Singaporean patients. The support of the Singapore Bone Marrow Donor Programme and the Singapore Cord Blood Bank have also helped us to find matches for our patients when there are no siblings who can match the patient. On behalf of our patients, thank you for the work you do. 18

19 Last, but most importantly, we would like to thank our fellow colleagues in the Singapore General Hospital. Haematopoietic stem cell transplantation is a team effort and our Haematology Nurses, Haematology Pharmacists, Medical Social Workers, Haematology Laboratory staff, Physiotherapists, Dieticians and many others have been an invaluable and treasured part of our team. Our other wonderful colleagues in the Department of Haematology (Doctors Tien, Lim, Wong, Ng, Chuah, Tan, Yiu, Ang, Kam, Diong, Lee and others) have been instrumental in referring and looking after our patients. Our sincerest gratitude goes to all the other Departments (Gastroenterology, Infectious Disease, Medical Oncology, Orthopaedics, Radiology, Radiation Oncology, Renal Medicine, Respiratory and Critical Care, Surgery and many others) that have helped us treat and manage our patients when they are sick. We also thank our administrators, human resource personnel, finance executives and IT staff who have helped sustain the normal functioning of the entire hospital machinery without your help we would not be able to do what we could. For every one of you, and the many others we have neglected to mentioned, thank you for being part of our team. We hope you will all be richly rewarded by the difference you have made in the lives of these and many other patients. This book was written from first-hand accounts of patients, caregivers and healthcare providers from the frontline in haematopoietic stem cell transplants. Our contributors have graciously shared personal and intimate accounts of their journey and battle against illness. It is our hope that it will bring encouragement, enlightenment and exhortation to patients, public and medical staff everywhere. 19

20 Life is Full of Surprises Madam Tan* It was just six months after my last check up when I started feeling an uncomfortable pain in my chest and noticed some unexplainable bruises on my hands. I went to see a doctor at the Singapore General Hospital who admitted me for observation. After doing several blood tests, the doctors told me that I had leukaemia. I was stunned, especially since I lead a healthy lifestyle and go for my annual check-ups promptly. Other than chest pains and bruises, the only other symptom I had was a sense of tiredness that I attributed to age creeping up on me. Having been through a scare, Madam Tan* now takes each day as it comes. She keeps positive by spending time with her family and pursuing the simple things in life. *not her real name Facts in a Capsule Diagnosed with: Acute Myeloid Leukaemia Date of Diagnosis: 2006 Type of Transplant: Nonmyeloablative Allogeneic Peripheral Blood Stem Cell Transplant (Matched Unrelated Donor) Date of Transplant: November

21 Doctor s Notes Finding a Bone Marrow or Blood Stem Cell Donor for Transplant Only one out of four patients is able to find a sibling who is a HLA (Human Leukocyte Antigen) match for transplant. When a sibling match cannot be found, we will look for an unrelated donor by searching bone marrow registries throughout the world. The process is not easy because HLA typing is a type of tissue typing that is extremely stringent and an almost perfect match is needed for a bone marrow or blood stem cell transplant. HLA typing takes precedent over many other factors like donor s ABO blood group and, in fact, the blood group can be different because the patient s blood group will change to that of the donor s after the transplant! The doctors advised me to call my family and inform them of my diagnosis. After the initial shock wore off, I accepted my condition and started on treatment. I had to go through four chemotherapy sessions and the last was a radiotherapy session. During this time, I felt nauseous and started losing my hair. My Bone Marrow Transplant was done in November 2006 and I spent one month in hospital. Unfortunately, none of my family members was a match so I received my stem cells from an unrelated donor, thanks to the efforts of the hospital staff and the bone marrow registry who conducted the search for a donor. After being discharged, I took great care to eat healthy organic food. I was mostly a vegetarian and only ate fish to replenish my energy needs. I am thankful that my treatment went smoothly and I did not develop any graft-versus-host complications. I spent several months resting at home and went back to work only in March My life is almost back to normal, although I 28 Embracing Hope

22 do feel tired and cannot do very long hours of work. Otherwise I am doing fine. When my chemotherapy sessions were completed, I was hit by infections three times. I also developed ulcers in my mouth. What kept me going was my religious faith and my faith in the doctors. Only when you co-operate with the doctors can they help you get over the illness. I feel that when I accepted the illness and proceeded with the treatment, things worked well. I have friends who have gone through treatment for breast cancer and colon cancer and they have had a difficult time. These days I take things in my stride and I do not let anybody s comments bother me. I pray for peace of mind. My advice to those who have an illness is that they must seek treatment and be positive in their outlook. With a positive mindset, they will be able to cope with their illness better and be on the road to recovery. About Haematopoietic Stem Cell Transplants 29

23 Bone Marrow Transplants Save Lives A/Prof Goh Yeow Tee A/Prof Goh s involvement with leukaemia spans many years. He joined the Singapore General Hospital (SGH) Haematology Centre in 1987 and has the honour of being the longest serving doctor in the area of Bone Marrow Transplants. He has been active in wide ranging areas of research involving many drugs that have made a difference in the treatment of blood disorders. He is currently a senior consultant in the Haematology Department and Director of the Clinical Trials and Research Centre, Department of Clinical Research, SGH. There have been vast improvements in the area of Bone Marrow Transplants (BMTs) since it started in I have been privileged to be a part of the evolution, seeing first-hand how this area of transplantation has gained importance over the last two decades. This is evidenced particularly by the increased number of supportive drugs available to patients as well as the staff dedicated to this area of treatment. Compared to when we first started, there are now many more nurses, ancillary personnel, and pharmacists who specialise in the care of BMT patients. In addition to these, there are also specialist physicians that we can turn to if our patients have co-morbidities or infections. New developments in the field have also led to more effective ways of treating the patients. In the past matching donors were needed before a transplant could take place. Today, other means are available and transplants are possible with unrelated donors, cord blood and purged blood (autologous). We have managed to reduce 178

24 Some members of the transplant team. Seated, from left to right: Dr Yvonne Loh, Dr Ang Ai Leen, Dr William Hwang, A/Prof Goh Yeow Tee, Dr Grace Kam and Dr Linn Yeh Ching. Standing, from left to right: Dr Lee Yuh Shan, Ng Hong Yen, Lee Jing Jing, Jordon Hwang, Zhang Xuehui and Kathleen Cheung. the intensity of the regimens so it is less toxic and we are able to extend the treatment to a wider range of people. Previously the cut-off age for a person to undergo BMT was 40. These days the bar has been raised 60 years of age for allogeneic transplants and 70 for autologous. BMTs have become safer, more effective, and more widely available. This has been made possible because of the research and development done in this field. Yes, some people still think that there is no cure for cancer. It is like in those popular Chinese serials where the word leukaemia means a death knell has sounded. You can almost hear the ominous music in the background. But this is far from the truth in reality. There are so many more clinical trials being conducted and tonnes of research being done in the area of blood cancers and its treatment as well as stem cell transplantations. Look at how From the Frontline 179

25 much we have accomplished over the last 20 years. Think how much more we can achieve! Transplants have been saving lives for a long time. About ten years ago, we had a gathering of transplant survivors at the Raffles Hotel. It was like a family reunion and marked a milestone in the history of BMT. I was extremely gratified to see how many lives had been saved and how they were now living a normal and fruitful existence. Some have even gone on to have families of their own. The smiles on their faces spoke a million words. The smiles on their families faces spoke a million more. Of course not all leukaemia patients who we treat are saved. Sadly there are casualties. In the past, we use to lose a lot of patients. That was about 20 to 30 years ago. I consider that the Dark Ages. Now things have changed and when a patient is lost, I try not to dwell on this too much. I do feel upset but I have to harden my heart as I cannot let that loss stop my work. I tell myself to focus on the future and think about how I can save the next life. That is what keeps me going. That is what keeps a lot of us going. 180 Embracing Hope