18 3.22.20 Photo illustrations by Ina Jang
Diagnosis By Lisa Sanders, M.D.
‘‘Have you read this?’’ the 61-year-old man
asked his newest doctor, Madan Jagasia,
as they sat in an exam room in the can-
cer center at Vanderbilt University Med-
ical Center in Nashville. The book, titled
‘‘Dying Well,’’ prompted a concerned look
from the oncologist. You know we’re not
there yet, he said he told the patient.
Jagasia had only recently taken over
the patient’s care, but he knew the man
had been through an awful 14 months.
Just a few weeks before Christmas in
2016, the athletic and active lawyer dis-
covered he had an aggressive leukemia.
The patient fi rst went through months
of the brutal chemotherapy that makes
up the fi rst-line treatment, followed by
a stem-cell transplant — in which pro-
genitor blood cells from a donor are
transfused into circulation to replace
the patient’s diseased cells.
The treatment had been tough, but as
he approached the next Christmas, the
patient was fi nally feeling more like him-
self. He was still on immune-suppressing
medications to keep his new immune sys-
tem in check as it settled into his body. He
had started a new job — one that would let
him work at the slower pace he now need-
ed. And he was getting his tennis game
back into shape. Then, on Christmas Day,
after the joyful orgy of presents with chil-
dren and grandchildren and their tradi-
tional huge holiday breakfast, he started
to feel unwell. He excused himself and
hurried to the bathroom. It seemed that
everything he’d ever consumed came out.
The cramps twisted his insides in excruci-
ating waves that left him breathless.↓
Immune System Gone Wrong
When the paroxysms fi nally stopped, the
man felt exhausted — as if all his energy
had left with the contents of his digestive
system. He made it to his bed and wasn’t
strong enough to get up again for hours.
That evening he felt better, and a few days
later, when it was time to go back to work,
he thought he was ready.
But in a couple of days, he again had
devastating diarrhea, which left him too
weak to leave his house. Those episodes
became a near daily occurrence. When
he reported his symptoms to an oncol-
ogist on his cancer-treatment team,
the doctor made the diagnosis of graft-
versus-host disease (G.V.H.D.). That is,
his transplanted immune system wasAfter a stem-cell transplant, a
man’s immune system seems to
go out of whack. The usual
treatment doesn’t work. Why?