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Birds In Spring: This Is Your Brain On Myeloma

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Published: Feb 21, 2012 4:06 pm

Say, how’s your brain working these days?

That’s a question for many cancer patients and survivors, but it is particularly one for those multiple myeloma patients who have had at least one stem cell transplant.

Getting a stem cell transplant is pretty intense.

First you start treatment with a cancer drug regimen, or radiation, to reduce the level of myeloma cells in your body and to get your myeloma into the best remission that can be accomplished.

Then you take drugs to make your bone marrow produce more stem cells and “mobilize” them into the blood for harvesting.

A few days before your transplant, you get a lethal dose (200 mg) of melphalan (Alkeran) – it’s called MEL200 among the transplant doctors.  I say lethal, not because it could kill you on the spot, but melphalan targets and destroys your bone marrow.  By doing so, it also destroys your immune system, making you a sitting duck for infection.  Oh, and melphalan also gives you the plucked chicken look, since every single hair on your body falls out.

The stem cell transplant is just to rebuild your bone marrow that was destroyed by the chemotherapy.  It is rather anticlimactic and takes maybe 20 minutes.  They call it your new birthday, since it’s the day your immune system in reborn.

There is ongoing research into “reduced intensity” stem cell transplants, basically giving you a smaller dose of melphalan, but it’s not commonly used to treat myeloma yet.

This brings me back to the brain thing.

The question I raise is whether after you’ve been through all this, do you think, act, and feel differently than before?  Do you react to things differently? Are there changes in your values?  Are there changes in your mental abilities?

Take the last item:

Can myeloma or its treatment have a negative impact on your cognitive abilities?

No one considered the possible impact of chemotherapy on mental abilities until thousands of breast cancer survivors started speaking out, saying something like, “Hey, I don’t really think straight all the time any more.”

Thus, “chemo brain” entered our lexicon.

I’ve read estimates that as many as three-quarters of cancer survivors experience some change in their mental functioning, and that it can last for several years.  Most of the research into chemo brain has involved women with breast cancer, so it’s a fair thing to be a bit hesitant to extrapolate the findings across all cancers.

But let’s talk about treatment for multiple myeloma specifically.

A transplant is up toward the top of the list as a stressful and traumatic event on your body, particularly one that you are doing to yourself on purpose. Unfortunately, the effect of chemotherapy on cognitive function is one of the least explored areas of transplant and high-dose chemotherapy.

I also suspect that all of the challenges you face because of myeloma can cause some significant cognitive and mood disturbances, perhaps even something akin to post-traumatic stress disorder.

I’ve chatted about this possibility with various myeloma medical team folks.  One doctor commented that even though some patients say they are okay, they also say they “feel different.”

Can all that one goes through in dealing with myeloma, the disease itself and the treatments, make you a different person – spiritually, intellectually, and psychologically?

I start my conversation on this topic by talking about myself.

After my first transplant, I emerged with a greatly changed perspective about some of the significant things in my life.  Some things just aren’t as important to me as they were before.  Other things take a more important place in my view of the world than they previously did.

In addition, I quite possibly experience some chemo brain, and I am not always able to do things as easily as before.

I’ve never really experienced the depression- or “feeling down”-aspect of myeloma, but who’s to say that will always be the case?

One myeloma patient I know used to be one of the most positive people living with myeloma that I’d come across.  But since he’s experienced some significant setbacks in treatment, and things aren’t working as he expected, he’s changed.

There’s frustration, depression, and anger there now – an edge to him that wasn’t there before.  Anxiety and fear can do bad things to you.

Someone gave me another example of how this disease can change you:  Take a truck driver in complete remission.  He’s a “success story.” However, he can no longer drive a truck.  He’s now on disability with income that’s maybe one-quarter what he was making before.  We can make him a stereotype – maybe his wife leaves him, and he sits around, alone, drinking beer, and getting fat.

He looks in the mirror and doesn’t see “success.”  Instead, he says, “This disease has destroyed me.  It’s destroyed the person I used to be.”

From my perspective, I think that myeloma, treatment, and transplants can cause changes that are psychological, cognitive, attitudinal, and physical.

Are the causes of the changes chemical or biological?

There’s a little bit of research going on to answer this question.

For example, Shelli Kesler and her colleagues at Stanford University are trying to better understand what causes chemo brain.  Her recent research shows that chemotherapy has a negative impact on cognitive function, but she was also quoted recently as speculating that the cancer itself could cause chemo brain.

“When you get a disease like cancer, it activates your immune system.  Sometimes you can have increased inflammation for a really long period of time, and inflammation can affect the brain,” she said.

My additional thoughts on the topic:

Unfortunately, though, much of what I’ve written about here isn’t being addressed by the medical community in general.

For those of us who are transplant patients, we often find that we aren’t always able to function as well as we used to.  Very little has been done in the post-transplant setting to understand cognitive dysfunction, post-trauma implications, stress, depression, and attitudinal and physical changes.

From an overall physical health perspective, the medical teams treating myeloma patients/survivors are doing a great job.  The medical community has invested a lot in helping us “get better.”

Those things that help us get better, however, may be affecting survivors in ways no one anticipated in terms of stress and dysfunction – in ways that can impair recovery.

It would certainly be great if there could be more research about this, and perhaps some solutions.

Lou Ganim is a multiple myeloma patient and columnist at The Myeloma Beacon.

If you are interested in writing a regular column to be published by The Myeloma Beacon, please contact the Beacon team at .

Photo of Lou Ganim, monthly columnist at The Myeloma Beacon.
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28 Comments »

  • Tia said:

    Lou,

    Thank you for your article. I really like that it is from the perspective of an actual patient and not that of the drug companies or the doctors who have not gone through it. I agree there needs to be more research on the after effects of this procedure, and even the prolong use of revlimid, dex, and any other drugs the docs want an individual to use as “maintenance”.

    Thank you!

    Tia

  • Tim Brinker said:

    Lou,

    Excellent article, you descibed the Stem Cell Process nicely. I had an SCT in July 2011, I do think at times I do suffer from Chemo Brain or maybe old age, though I am only 43. The worst for me is I will go to do something that maybe requires me to go downstairs, when I get downstairs I forget what I was going to do. My mind can only focus on one thing at a time. I still work fulltime as a computer programmer, the only affects I have seen there is it is harder for me to juggle multiple projects like I did before SCT/Myeloma. I tend to be less organized.

    Thanks for sharing your article.

    Tim

  • Lori Puente said:

    It is indeed quite subjective as well. My husband worked through his tandem SCTs and many of his colleagues and co-workers were abreast of the situation. He managed his “chemo brain” by professionally and competently say, “Could you refresh my memory on this?” Very quickly he would remember what it was about and be able to move it forward. They were all very generous and kind about it. Me, on the other hand was teasing him that between his chemo brain and my menopause we didn’t even make a real person and we could lie like rugs!

    Our world view did very much change. For us it was mostly for the better. Though I know that is not true for everyone.

  • christad said:

    Thanks for this story. I am far enough along in my treatment (with the cancer cells down from 70 percent to under three percent at my biopsy last week)that my doctor wants me to start thinking about stem cell transplant. Except every patient account I have read talks about failed transplants, pain and minimal improvements and these other side affects. So, if Velcade maintenance (even without Doxil) accomplishes the same thing without all these side effects, why consider it? I have to work and be clear thinking while I’m there and it sounds like this takes a long time. I’d like to see some real case histories where stem cell transplants really did the trick in the long run. Are there any out there I can look at?

  • Pat Pendleton said:

    I have become somewhat different since my ASCT 8 years ago and also more myself. One of my stratagies has been to read a lot and take notes. That has helped me remember things. I tend to speak my truth more frequently…often wishing I had not. I need to pace myself in life…become more easily overwhelmed. The cells definitely are rearranged in the process of chemo and transplant, but it’s all workable.

  • nancy shamanna said:

    Hi Lou…thanks for the thought provoking article about ‘chemo brain’ . I had the worst of that after my transplant, and was also very tired at that time. So I was mainly at home reading a lot of books, playing scrabble and working. That seemed to help with the ‘focus’ , but of course a lot of brain cells must have gotten lost at that time!

  • Mark said:

    Lou – Excellent article, as usual. I used to have a great memory. Now I have to keep notes on everything or I will forget them. On the plus side, I can get through complex problems once I get started – though it seems I never feel like starting them. I have read it takes 5 years or so to get back to normal – I hope so.

    Tia – Agree 100% with the need for studies regarding side effects with regard to long term use of “maintenance” drugs/steroids. If you notice, studies show greater Progression Free Survival (PFS) with long term “maintenance” but they cannot show a statistically significant increase in Overall Survival. For truth in advertsing, any PFS survival statistics touted by Doctors should have notations that show what (if any) parts of them are achieved without Drug/Steroid “maintenance”. Sadly, I do not think many of them would look very impressive. The only PFS statistics that I take seriously are one’s that do not need the aid of “maintenance”.

  • suzierose said:

    Hey John S!!
    you write:
    “chemo brain beats flat-line all day long, doesn’t it!”

    YES!!! Darn skippy!! Well,said.

    In the end, it’s all about choices.

  • John S. said:

    Thanks for another well-rendered post, Lou. Always a pleasure when I see your pic on the front page: “Oh, good!”

    I think the regimen I undertook between February and October of last year (radiation, followed by Velcade/Dex, followed by an ASCT) has had a profound effect on me. I cannot really speak to the physical aspect as being exclusive to that regimen, as the cancer fractured two vertebrae the September prior to the aformentioned regimen, resulting in being bed-ridden for 3 months, and not much better for a long time after. However, I can say that my level of motivation, my cognitive abilities, and my mental stamina have all been significantly depreciated during the course of this period. Can I attribute to a particular element? With the possible exception of the Dexamethasone, not really. I *know* it affected me, but on the other hand I am not at all sure it is still doing so. It may well be that the Melaphan took over where the dex left off, but that’s conjecture on my part.

    I do have to say, though, that it may not be sever on a long-term basis, at least not for me. A couple of months ago I couldn’t read a long newspaper article without forgetting the beginning by the time I got to the end. There was no way I was able to deal with work issues relating to database or web coding… but slowly I am able to engage in those activities again. Very slowly, mind. It typically takes me 6-10 times longer to do something nowadays than it did in the fall of 2010, and that time has to be spread out significantly further as I don’t have the stick-to-it abilities I had then. In other words, a project item that might have taken me a half-hour to deal with then now takes me 3 or more hours, and that period of time can be spread over three days. But that’s already a big improvement over what I could do a mere 2 months ago, so I am very encouraged.

    It seems obvious to me that this cancer and it’s treatment would have an effect on my mental activities… the body is a whole, and a particular system is badly damaged there can be little doubt that other systems will feel the impact as well.

    But hey… chemo brain beats flat-line all day long, doesn’t it!

  • Jan Stafl MD said:

    Thank you Lou for another well thought out article. You are right, the is a dearth of scientific studies on this chemo brain phenomena, but those of us who have gone through high dose Mephalan prior to stem cell transplant, or similar regimens, can attest it is real. I am on day 20 after my ASCT today. My observation is that while my logical, intellectual left brain has definitely been suppressed, my intuitive, emotional right brain has been stimulated!

    My meditation and depth of feeling is deeper than ever, and I enjoy just being, not doing, with the fatigue that accompanies this recovery. Of course, having over 100 days to recover before seeing patients again gives me time to explore this facet of my personality. Usually I push myself, and am an extrovert with much energy, but now is my time for introversion, and I embrace this opportunity. I do believe that these biochemical effects on the brain may be used to discover a side of ourselves that may not be accessible to us in our normal consciousness state.

    I’m interested in the experience of others in this regard. Namasté, Jan

  • Alyssa said:

    Oh yes, after my transplant I had a big issue with speaking. I mean I could have a normal conversation, with the typical one line answer but anything more complex, I couldn’t remember what I was saying, and I had issues with word recall. I wouldn’t even be able to use the word “complex” in a sentence shince I would be thinking or saying out loud, “you know, that word, the one that means something is hard, or harder….?” my family… “ummm?” and would try and say the words I was trying to come up with! was pretty bad!

    It did improve after 8 months or so post transplant. Going back to work and forcing myself to start functioning at a more academic level (I work as a law clerk) brought back my higher thinking. Also I did a lot of reading from a few months post transplant that help (check out the “girl with dragon tatoo” books ;) )

    Also I think the drug “Lyrica” was negatively impacting me. Going off this drug I felt a little clearer in my head.

  • David Keegan said:

    Very good article. Took the words right out of my mouth. (Now if I could just remember where I left my keys)

  • Lou Ganim said:

    Thanks for sharing so many excellent thoughts on this subject. One of the problems is that there is no constant when it comes to how treatment, and the disease itself, can affect us. Everyone is different. It’s more than just chemo brain, I think. Mark – I share your thoughts about progression-free survival versus overall survival. From a quality of life perspective, we should consider whether maintenance, for example, is the right way to go, given the side effects, if it only means an extension of PFS, not overall survival. Pat – As a longer-term survivor, your comments attest to the fact that whatever physical/spiritual changes myeloma, SCT and high-dose chemo bring about, some of them can indeed be long-lasting. Dr. Stafl – your comments about emotional stimulation are right on. Consider what Johnny Cash said after he almost died from pneumonia in 1998, reflecting that confronting great physical stresses can be life-altering: “I . . . cry at almost anything. It can be something as profound as the beauty of a grandchild in my arms or as trifling as the smile of a pretty girl winning a skating championship on TV. Life has become very moving.”

  • joyce said:

    Hi Everyone,

    I am learning a lot about Myeloma. Diagnosed in 2007 after routine check -up.
    Went thro the initial shock/crying/anger for 2 weeks.
    Then saw oncologist.
    Started onV.A.D(Vincristine/Adriomycin+Doxyrubin)
    Achieved Remission after 3mths.

    TRANSPLANT:
    Had to do every blood test possible!
    Check my heart and lung functions were normal.Finally ,after 3mths..went for Autologous transplant`.

    No one prepares you for this! not even the doctors..
    First youre given lethal dose of Malphalan(chemo) that wipes out all ur cells! Your hair falls out in chunks in 2 days,ure bald!lol…prepare urself to take cap or scalves as ur head can get very cold!

    Then you can go home and give urself Neupogen x2 day injections ,to stimulate formations of new cells.

    after week, new cells are taken out(like taking blood for test). and put through machine..to filter out any abnormal cells.
    The normal cells are collected and stored for tandem use(2transplant)

    Then u get new healthy cells in a drip.

    This is the critical phase!!!!!!!!
    i was put in specialised transplant unit..as my white cells went to zero! risk of infection.

    YA,no one tells u what happens next! Advice: Gargle your mouth after every meal with Andolex mouth wash…no mouth sores if u do this.

    Some people can eat normally,i was sick and nausea was +++++ and then followed by diarrhoea and constipation and extreme fatigue! Dont panic if u have blurred vision and cant focus properly..just sleep.Cause you need to reserve all energy for ur cells to take over bone marrow(new ones)

    white cells go up..u know that bone marrow transplant is grafting!
    Be patient…After dischrage..eat proteins, and drink lots fluid.You need energy..SO EAT! drink soups.Blood pressure may drop. Good idea to check ur pressure everytime u feel faint.

    During the 2 mths,keep away from all people except ur immediate family…Unless ,if you must..let them and you wear good face mask(one that u would use if there was outbreak of infectious diseases..(Get it in pharmacy)
    By the 5th week..you can go out to mall(go early when there is less people in morning and dont stay till mall is full)

    Dont spray chemicals that you can breathe in…(my husband sprayed ant killer doom even though i told him nt too-he was desperate)

    after 3 years of being free Myeloma..my protein went up to 78 and my M protein 33!

    I didnt do the second transplant! so first one was done only once!i was supposed to do tandem..

    started Velcade Jan .after 3 doses,levels”protein down to 64 and M protein 8. JUST STARTED ON 2 CYCLE(4TH DOSE) My doctor suggests that when i get to remission..like for me to have transplant again….Dont know what to do??

    Anyone went for transplant and replased and went for 2 transplant??

    kind regards,
    joyce.

  • Tia said:

    Joyce,

    Thanks for the detailed patient view of this procedure, it is so helpful for people who are on the fence or who have not decided which way to go. I think the more information a person gets, the better they can decide which route to go. My husband is at a crossroads right now with whether or not to go straight into SCT. Oncologist and Blood Doc keep suggesting that the protocol is to go straight into it to really knock out the cells. We are talking about 0.6 m-spike being detected as of now.

    He was on CborD for 4 months, once a week, every week. His numbers are all back to normal, except m-protein as of 2/6 was 0.6. He is 40 and has no other issues. Never had any bone problems,full body bone scan showed normal bones, no lesions. For him the blood just started affecting his kidney in October 2011. But as of the last blood work, after last chemo, his creatine is now in the normal range, 1.3. Which is a wonderful improvement from 3.5 in October.

    Should we or should we not? Definitely something to think about and weigh the risks and factors. I really appreciate your info, but don’t have a good answer for you. I hope you will find individuals who have gone through it twice so can will have a better idea for yourself.

    All the best!

  • Lou Ganim said:

    christad — Perhaps this article will address some of your concerns about transplant — http://www.myelomabeacon.com/news/2011/08/05/role-of-autologous-stem-cell-transplantation-in-multiple-myeloma/. But, speaking only for me, I had tandem autologous transplants in 2007 and the result was a complete remission that lasted three years, during which I was pretty much my old self again. There are challenges one faces in the stem cell process, to which everyone reacts differently it seems. And the results of course can very — unfortunately multiple myeloma is a cancer with a whole lot of variables. Speaking only for me again, from a quality of life perspective, my results were great. If there is anything that I wish for, it would be that I’d certainly have liked for the remission to last longer.

  • Lou Ganim said:

    John S.: Always good to hear from you…and you are always too kind. A great post, by the way, that gives more insight about how all that we go through can impact our abilities and thinking. Thanks!

  • Bob Kirkpatrick said:

    The compounds we take for chemo have side-effects on more than merely the nerve endings in our hands and feet. Just a while ago I wrote an article on how I was affected and commented that those involved with patients undergoing therapy might watch for changes; everyone experiences some degree of change while others experience more profound effects. Fortunately, they seem to be temporary.

    It’s great to see your article: good job! I wish more people would speak up about the less discussed aspects of our illness and the treatments we take for it. Well done!

  • Jan Sealover said:

    My ASCT was 2.5 years post diagnosis after trying treatment with 100mg Thal/with high dose Dex (blood clot, almost died), then 2X weekly Vecade (couldn’t walk after 6 cycles), then 1X weekly Velcade with Cytoxan (stopped working after about 8 months). I’ve been on maintenance 10 mg/day Revlimid since 3 monhts post transplant (18 months so far). What a long strange trip it’s been, but hoping it continues even longer…I am 53.
    “Rehab” post transplant (cognitive and physical) is not something docs talk about and reading about others’ experiences echos my own. I can look back at each stage of recovering cognition from being able to do small crafts, then reading the newspaper for short periods, then attempting “small scale” organization activities, then reading a book all the way through and keeping track of the plot (well, most of it), then writing short speeches and delivering them through Toastmasters. At about 6 months post-transplant my cognitive improvement was leveling off, so I upped the physical activity and began walking 4-5 times a week with some friends who were training for the 3 Day Breast Cancer walk. I took steps to protect myself as I walked 6, then 8, then 12, then even 20 miles at a time. Some days I’d come home and basically lay in bed the rest of the day, but the cumulative effect of the physical training gave me another cognition “bump”.
    I still have days when organizing my kitchen counter can feel overwhelming, let alone dealing with paperwork of various kinds. I still have many moments when I can’t remember my train of thought and I really identify with what John S. said about not having the “stick-to-it abilities” that he once had. I am trying to go back to work again for the third time, but am really feeling that with everything taking longer I’m not sure I can be economically viable. I love the days when I get even 3 hours of activity where my brain doesn’t keep de-railing. This requires tremendous patience on my part not to become completely exasperated with myself.
    This comment track is aimed at those considering transplant though, so I’ll get on point. I would do it again in a heartbeat and will likely need to at some point. Yes, I cry unexpectedly at all kinds of stuff. Yes, my mind wanders like a minstrel. Yes, I feel like I had a sort of PTSD (riding in the passenger seat of a car was almost unbearably frightening for me for a year post transplant for no understandable reason, but is better now). Yes, I have to exercise regularly and enthusiastically to keep feeling my best. I love what Jan Stafl MD said: “My meditation and depth of feeling is deeper than ever, and I enjoy just being, not doing, with the fatigue that accompanies this recovery.” Been there. Continue to be there.
    I have experienced so many amazing things during and post transplant…greater clarity about what matters, greater peace with myself, greater appreciation for the miracle we experience as patients when so many others in healthcare “care” for us.
    My mother died of MM at age 71 just 3 months post diagnosis in 1996 and I pinch myself every time I realize I am 4 years out and currently holding remission.
    The challenge for me as I go up this next hill on “The Coaster” is to keep seeking what nurtures the cognition. Emotional stress constipates my thought process and causes headaches-it’s just plain harmful. For me, joy, fellowship, beauty/creativity and being outdoors help my memory as well as my spirits and keep my thoughts calmer and more focused.

  • Lou Ganim said:

    Jan — What a wonderful and illuminating post. Thanks so much for sharing.

  • PATTY said:

    Dear Lou,
    Thanks for the very thoughtful post. And I would only add that after two of the transplants and all the “stuff” before and after, I am thankful. Lots of issues and minor problems but dealing with them and more importantly talking about the whole MM trip. Brain or no-brain, let’s all just put one foot in front of the last……..

  • Sean Murray said:

    Lou, thanks for this very thought provoking post. I underwent tandem stem cell transplants (with unfractionated melphalan)in early and mid 2008. Things definitely got ‘fuzzier’ after the transplants.

    I am grateful for a 3 year complete response and like you, I hope that it lasts for a long time. One of the most significant effects of my treatment has been an inability, at times, to focus and concentrate. Not in detail oriented tasks, but in creative pursuits such as writing, composing, directing, etc. The tasks aren’t impossible, just more difficult than in my pre MM days. I am in the last year of a 3 year maintenance protocl (VRD) and am curious to see if my ‘focus’ difficulties will change when the maintenance is completed.

    I would love to know if this side effect is caused by chemotherapy (dosage, frequency), transplants, MM, a combination, or by something else entirely. Great article, Lou.

  • Celinda Lovett said:

    Outstanding Article. Well written and so very informative. Thanks Lou. I am still in the induction phase and have been taking Rev/Dex/Velcade and now I am on Cytoxan/High dose Dex/Velcade over the past 7 months. The plan for me is to have a SCT when and if I can reach or get close to a complete Response. I already have Chemo Brain and I haven’t even had the SCT. My short term memory is aweful to the point where I often don’t remember if I’ve taken my medication a few minutes after I just took them. That and the Dex-mania of ups and downs have me being a basket case. I attended my bible study class and either I can’t complete a thought or (on high Dex days) I’m chattering like a Chatty Cathy doll. I find myself withdrawing, spending more time alone and using this phase of my life to read and mediatate. I’m quite a different person and I’m trying to learn myself all over again. But, I Still Here.

  • Jillian said:

    Hi everyone,

    I am so grateful to have found this website. My father was diagnosed in October 2011 and before this I was only vaguely familiar with this confusing, complex disease. He is 47 years old and his myeloma has damaged his kidneys. He had his first SCT last week and has been hospitalized since. He has recently begun suffering from confusion and hallucinations and the staff doesn’t know why. Last night, he got out of his bed and fell. I am unsure if he has been injured because of this. The Neurologist has been called but I don’t yet know the results of the evaluation. Have any of you or your loved ones had this sort of side effect after a SCT? I haven’t been able to find anything on the internet…I would appreciate any information anyone can give me, or even just a simple prayer as my family struggles through this very difficult time.

    Thank you.

  • Lou Ganim said:

    Hi Patty, Sean, Celinda and Jillian — Sorry I’m a little slow in posting, but things have been a bit hectic lately. I think the impact of all the “stuff” they do to us can change us in many ways. While we need to adapt, we could also use some help in knowing what might be the cause or causes. Jillian — I hope things have improved with your dad.

  • Jillian said:

    Thankfully, he has improved. He has come out of his confusion and hallucinations and the seizures he was also experiencing are being controlled with medication. He is now home and recovering.

  • Lou Ganim said:

    Hi Jillian — That’s good news. Thanks for the update.

  • Claire Danielson said:

    SO informative, everyone. My husband had his first transplant last week , so we are still in the hospital. He was diagnosed in March, and by mid April his kidneys failed. I’ve noticed a marked decline in his cognitive abilities, especially during this transplant time (same problems as Jillian’s dad s/o the seizures).

    My husband is a corporate communications guy and writes for a division of a national company. Just a year and a half ago, we moved from our home town for his job. We got a 2nd opinion for his MM in our home town, so he’s being treated there. I’d love to move back home to be close to our team, friends and family.

    I am wondering if he will be able to go back to work. Critical thinking is a major part of his job, and I fear he may not be able to continue. His boss and co workers are very encouraging, and work is very important to my husband.

    I read many of the posts above, and I’m wondering of some of you could offer advice how to broach this subject with my husband. I’d wait until we are home from the hospital, of course, but we need to talk about it I think. Or is it too soon?

    Claire