Shortly after starting my new compassionate use protocol with elo­tuzu­mab ^[1], which I described in my previous column ^[2], I began to have elevated levels of my liver enzymes.

It initially was unclear whether this was occurring due to a reaction to the drug, a tumor in the liver, or other possible causes.

After several tests, including an MRI, a PET scan, and blood workup, the source of the problem was found to be unrelated to my new treatment. It was instead due to a condition I had developed called hemochromatosis, commonly known as iron overload.

As its less technical name suggests, hemochromatosis is a buildup of iron in the body. When it occurs, the result can be damage to the liver as well as other organs, including the heart and pancreas.

Iron overload, it turns out, is not uncommon in people like me who have become transfusion-dependent. While the condition is treatable with drug therapy that removes the excess iron, I still was somewhat taken aback by the diagnosis.

I had come to think of the blood transfusions as second nature and rarely gave them much thought. In fact, I would almost look forward to them. Like Lance Armstrong, I appreciated the extra boost they gave me.

I mention this story because it gave me pause, leading me to think of all the unseen effects the myriads of treatments I received over the years are having on my body.

It then struck me that these unseen effects can be thought of as collateral damage.

In the military, collateral damage refers to unintended injury or death among innocent bystanders during attacks on enemy targets.

For those of us with multiple myeloma, or any other cancer for that matter, the enemy target is of course the cancer.

The innocent bystander is the rest of the body and all of its vital organs, including the brain, heart, liver, kid­neys, lungs, muscles, eyes, and skin.

The collateral damage of our treatment includes the obvious side effects we all must endure. Neuropathy, fatigue, low white blood cell counts, and increased risk of infection are all things we are familiar with.

Yet some of the unintended effects of our treatments are more subtle and insidious. Liver and kidney de­te­ri­o­ra­tion, cataracts, diabetes, and muscle wasting from steroids are conditions that can sneak up on us. They may be taking their toll in ways we don’t even realize but the effects add up.

I have been told that myeloma patients may not die of the disease but that years of treatment just wear the body down until it gives out.

Cancer treatments, including the treatment of multiple myeloma, have evolved over the years.

Traditional cancer treatment relied on high-dose chemotherapy. The idea was to blast the body with poisons that would hopefully kill the cancer cells faster and at a higher rate than normal healthy cells. However, these drugs were non-targeted, and collateral damage was therefore high. Plenty of multiple myeloma treatments, including those used in the stem cell transplant process, rely on this approach, and I have had more than my share.

Almost all of the new multiple myeloma treatments are based on targeted therapy. They target specific path­ways of the myeloma cells, disrupting their function and minimizing the damage to normal cells.

However, even with these targeted therapies, there is no free lunch. No cancer treatment is free of some downside or consequence. It is a necessary evil, a price that must be paid in order to fight the disease.

As a practicing physician, I was always acutely aware of the tremendous power of modern medicine. It has the potential to do great good, but also the potential to inflict great harm. I saw the good, the bad, and the ugly.

I think that is partly why, as a patient, I have always tried to be hypervigilant about my own care.

I am obsessive about following my labs in an effort to head off any potential problems. My liver, kidneys, and heart are subjects of great interest to me. I try to do everything I can to keep myself in good enough shape to tolerate the next round of treatment, whatever it might be.

I have to admit I have been very fortunate. Despite all of the treatments that I have undergone, I have man­aged to bounce back after each one. But I can’t help but feel each one takes a little chunk of me. I also know that one of these times I will not be as lucky.

With all that, there is only so much that can be done. The treatments have extracted their price and will con­tin­ue to do so.

Unfortunately, as in the military, collateral damage may be unavoidable.