"Don't come around here no more" Tom Petty and the Heartbreakers

I don't feel you anymore
You darken my door
Whatever you're looking for
Hey, don't come around here no more

Tom Petty and the Heartbreakers

This is similar to a letter I wrote to a CLL group about a possible reason that patients that are disease free or in CR (complete remission), for years can have a late reoccurrence:

CR, MRD (minimal residual disease) negative is great news, the best news a CLLer can get, and bodes well for the future, but it does not mean there is no cancer in our body. It does not necessarily mean disease free.

Remember that even PCR (polymerase chain reaction), the most powerful tool we have to search for our enemy, has limits in its ability to detect cancerous clonal cells. PCR may find 1 in 100,000 bad boys, but not 1 in 10,000,000. And we have billions and billions of white cells. Remember that nodes <  1 cm are considered normal but they can harbor huge numbers of cancerous cells. Remember a sample is just a sample. 

Let me use another disease as an example. I have patients who after treatment for confirmed AIDS have no detectable HIV virus in their blood, but believe me it's there. Just stop the treatment and see what happens!

Remember also the fable of the doubling of the rice grain. The Chinese emperor was so happy with the invention of the game of chess, he asked the inventor what gift he would like. He replied only that 1 grain of rice be placed on the first square of the chess board, 2 on the next and then 4, 8 16 constantly doubling until the 64th square was reached. The ruler was insulted by the meager demand, insisting that such a request did not befit an emperor. The inventor persisted asking only for the emperor's promise to comply or the throne and all it's wealth and power were his. Agreed. You know the rest of the story: 2 to the 64th power is approximately 2 followed by 19 zeros, more than the world's production of rice.

I tell this apocryphal tale to emphasize that it all starts with just one bad cell or one grain of rice, but given enough time and enough doubling, the numbers can become scary. Add to this the survival of the fittest. The few clonal cells not destroyed in the battle are the most robust, the most resistant, and are very pissed off. And their competition for space and resources has been eliminated.

I don't say this too dishearten, just to prepare. This does not mean there is no escape. Many of us will die years down the line of other cause before CLL reoccurs. For others our more healthy immune system rebuilt during a long remission or with a transplant will be constantly finding and destroying any clonal activity before it is even apparent. The price of freedom is indeed eternal vigilance.

That's my take.