A Sliver of Hope

On October 29, 2008, my parents and Dalal were back in Philadelphia. In the morning, Dalal felt a swell in her throat. As soon as my parents knew about this, they became horrified as if their souls were about to leave their bodies. They immediately headed to the ER (Emergency Room), and the scans showed what they all feared; the tumor had started growing again. It turned out that the doctors in Memphis knew that the tumor was active again and that the chance of performing the transplant was close to impossible. Since it is common that such bad news is delivered to the family by the patient's main doctor, they did not tell my parents about it at the time and instead had them return to CHOP. For the first time, Dalal's oncologist explicitly told my parents that her chances of being cured were diminishing.

With this unexpected development, the oncologist met with my parents to lay down the fourth line of treatment. After discussing it with the other oncologists in the department, she explained that the best option was to double the chemo doses. This raised a major concern in Dalal's capability of withstanding the potency of the new treatment line, but there were hardly any other options left. Halfway through November, her body began to reflect the damages done by the therapy. I vividly recall how swollen her face, hands, and feet were. It got to the point where she couldn't even walk; her feet were unable to carry the weight of her frail body. The doctors claimed that the swelling was a side effect of Cortisone injections. On November 23, 2008, while we were in our apartment, Dalal suddenly had difficulty breathing and her hands and face became even more swollen. My parents were not convinced that this was caused by Cortisone, so they immediately rushed her to the hospital, and what all of us feared happened. The fourth line of treatment was a failure; the tumor was able to withstand it and grew back rapidly, causing blood clots in her hands, hence the swelling. The table below shows the fourth line of treatment that was in Dalal's official treatment plan.

For the first time since being in the United States, the doctors took Dalal to the ICU (Intensive Care Unit) in an isolated room to meticulously monitor her condition and prevent the clotting of her respiratory pathway and major arteries. Words fail to describe how my parents felt during those moments; they had never seen her in such condition. They prayed to god that he engulf her in his mercy and not torture her. On that day, they prayed that he relieve her from this suffering with a cure, or if it was best for her, with her passing. With broken hearts, they met with the oncologist the next day to discuss the fifth (and final) treatment line. She told them that chemotherapy was no longer effective. The final option left was to use a salvage treatment protocol combined with intense radiotherapy (radiation). My parents understood (indirectly) that the chances of their one and only daughter to survive were slim. They could not contain themselves and cried so much, unable to imagine what it would be like to lose their precious angel. On the same day, Dalal was taken for a CT scan to accurately locate the tumor and determine where the radiation will be concentrated. She was scheduled to receive radiotherapy three times a week. My parents were also given a consent form for the salvage treatment called ICE protocol. The table below lists the drugs of the protocol.

With both therapies combined, the side effects were worse than they had ever been. The radiotherapy alone caused burn marks in her skin where the radiation was pointed, a severely sore throat, mouth sores, and breathing difficulties. She was given two Heparin injections everyday to prevent blood clots. As the intense therapy progressed, there was a sliver of hope left. Dalal responded well to the treatment; the tumor began shrinking gradually, her hands were no longer swollen. Even though her face was swollen, it was in a significantly better shape than it previously was. On November 27, 2008, her condition stabilized and she was taken out of the ICU. After my father made sure she was stable, he asked for her permission (more than once) to travel back to Saudi Arabia for a few days to tend to his mother and attend important work meetings. She kept rejecting the idea and my father kept postponing his flight. But as mentioned previously, Dalal was a rarity even among amiable people. Despite all her pain, she was very compassionate and deeply loved everyone in the family. On the morning of December 6, 2008, she woke my father up and told him go see his mother and not miss his flight that was due in a few hours. Although in retrospect he wished he would have stayed with her during that time for what was about to happen, it was impossible for him to predict how things unfolded because not even the doctors saw it coming.

Even though my father was gone, Dalal had her siblings, my mother, both of our grandparents, and even two of her aunts who rushed to be by her side. On December 10, 2008, the first stage of the therapy was over. The doctors performed a CT scan to check if she responded well to it. We were very pleased to learn that she responded significantly well and the tumor had completely shrunk. In addition, the fluid buildup in the mediastinal (chest) area was almost completely gone. However, my mother was not fully content with "almost". She asked the radiation specialist about the remaining fluid, considering that those fluids were the main cause of the cancer back in 2006. He explained that the tumor tissues that got burned by radiation transformed into fluid. My mother was still uncertain even though the explanation made sense. No one predicted that my mother's feelings were right. As it turned out later, those fluids were in fact cancer cells beginning to spread. Three days later, the "Hajj" vacation was over, so my aunts and Yazeed had to return to Saudi Arabia. Around that time, I was rarely able to see Dalal due to her intensive therapy. Most of my time was spent with my older brother Sultan, who took the role of a household leader and walked with me to school everyday. For her 16th birthday (December 14), we wrote her celebratory and encouraging letters on a pink birthday card.

On December 15, 2008, Dalal's body temperature spiked to 40 degrees Celsius (104 fahrenheit) and she was rushed to the ICU where she was given two anti-inflammatory drugs. The doctors expected the fluids in her chest to dry out without the need of surgical intervention, but instead they increased and the fever continued. After three days of continuous monitoring in the ICU, the doctors performed a pleural tap on her right side followed by her left side on the next day. Her body was very fragile, surrounded by tubes. She suffered constantly from severe abdominal pain and had almost no appetite; she got her nutrition through parenteral feeding (intravenously). Her blood test results showed no signs of any infections, which came as a surprise because the doctors thought the fever was caused by pneumonia (lung infection). It turned out to be much worse; what we all dreaded had happened. They immediately stopped giving her any antibiotics or anti-inflammatory drugs because there was no infection to begin with. The bitter truth was that the cancer had metastasized and spread to both of her lungs.