Meet Carol Ramnarine, multiple myeloma survivor

Carol Ramnarine has always been a silver-lining kind of person. So, when layoffs ended her school administrator job, she spent more time at the health club.

Blue skies. California sun. Carol Ramnarine finds new life in every day.

“I was exercising and noticed a bruise on my leg,” says Carol. “By the weekend, that bruise became a hematoma and I found myself in the hospital.”

Because Carol’s family nurse practitioner, Kathy Herrera, had been concerned about the rapid change in the bruise, she sent Carol to the hospital emergency room. After being hospitalized for a week under the care of her family physician, Dr. David Mysko, in consultation with a medical oncologist, Dr. Phillip Chatham, a bone marrow test was ordered. The test showed that Carol was in the first stages of multiple myeloma, a relatively rare cancer with a historically poor rate of cure.

About 16,000 Americans are diagnosed with multiple myeloma each year. With this aggressive disease, cancerous blood plasma cells reproduce in bone marrow. Malignant tumors form, crowding out healthy cells. And, because bone marrow exists throughout the human body, multiple tumors can develop at multiple sites.

From that point, Carol says, life for herself and her husband, Patrick, became a roller coaster ride. “Within 2 weeks I was being treated with Aredia, steroids and Thalidomide to stop reproduction of fast-growing cancer cells.” After 7 months of medication and care, Carol was referred to City of Hope, a nearby NCI-designated Comprehensive Cancer Center. There, Carol was seen by Dr. Leslie Popplewell, Division of Hematology & Hematopoietic Cell Transplantation, and the hospital’s Chair of Radiation Oncology, Dr. Jeffrey Wong.

“City of Hope is a major bone marrow transplant center,” Dr. Wong says. “And high dose therapy and bone marrow transplantation are often considered in cases like Carol’s.”

“Bone marrow transplantation often combines radiation therapy delivered to the entire body—total body irradiation—with chemotherapy,” says Dr. Wong. “Standard radiation therapy can be an effective way of purging the body of cancer cells, but it also can affect normal cells and non-target organs. This can cause inflammation of the lungs and irritation of the liver. And side effects such as nausea, sore mouth and throat, vomiting and diarrhea are common.”

Carol’s situation seemed grim. But she was about to find a silver lining.

Carol was eligible for a cutting-edge clinical trial directed by Dr. Wong and colleague George Somlo, MD. The purpose of the trial was to study treatment of multiple myeloma with the TomoTherapy® Hi·Art® treatment system.

Carol began a multi-step process in which stem cells from her body were collected and stored. Then, to purge her body of cancer cells, the bone marrow where they were reproducing was treated by chemotherapy, followed by targeted radiation therapy. Radiation was directed primarily to the bone and bone marrow using the TomoTherapy Hi·Art treatment system. Finally, Carol’s stem cells were reintroduced and, if all went well, her marrow would begin to produce healthy cells.

The TomoTherapy® Hi·Art® treatment system.

With traditional approaches to total body marrow irradiation, the same dose of radiation is delivered to the rest of the body as to the bone marrow—often with a single, large beam directed from only 1 to 4 angles. In contrast, the Hi·Art treatment system uses thousands of tiny “beamlets” directed from all 360 degrees, in a spiral pattern, around the patient.

Each TomoTherapy beamlet delivers one small part of the total radiation dose, allowing doctors to deliver therapy to where it is needed most, with much less radiation going to normal organs. In addition, built-in 3D imaging capabilities let clinicians see where they are about to treat, further increasing the system’s precision.

Carol called it “a little like Star Wars.” Dr. Wong calls it “exciting.”

“With the TomoTherapy system, radiation is primarily targeted to bone and bone marrow while significantly reducing radiation delivered to healthy organs,” Dr. Wong says.

Each day for 5 days Carol received total bone marrow irradiation using the TomoTherapy Hi·Art treatment system.

“My body was supported by a cast,” Carol recalls. “In I went. It wasn’t painful. [The staff] did everything to make me comfortable, even putting a baby monitor inside the machine so we could easily speak to each other.”

Carol found her own, unique way of coping with the treatments. “There I was, lying on my back, absolutely still,” Carol says. “I pretended I was bobsledding. I sang old Peter, Paul, and Mary songs….It was my own approach to TomoTherapy!”

Although Dr. Wong’s goal was to eradicate cancerous cells in Carol’s bone marrow, his team carefully monitored all effects of the TomoTherapy radiation treatment.

“We knew TomoTherapy could deliver radiation in ways not possible with previous technology,” Dr. Wong says. “Standard total body marrow irradiation is often a life-saving procedure.” However, serious side effects are common. One question addressed by the clinical trial was, would the reduction in radiation doses to healthy organs using targeted bone marrow irradiation also reduce side effects?

Carol relaxing in her yard with a friend.

“I didn’t have the side effects you hear about,” Carol says. “No mouth sores, almost no nausea. A little itchy dry skin.”

Carol was the first patient at City of Hope to receive total marrow irradiation using the TomoTherapy Hi·Art treatment system.

“We expected the usual side effects of standard total body radiation,” Dr. Wong says. “The day her treatment was completed, we were aware of her side effects—or lack of. One of the doctors asked, ‘Are you sure you’ve given her enough?’

“But, in a few days, her blood counts dropped as expected. We had purged the bone marrow successfully.”

One and one-half years later, Dr. Wong is treating the 19th participant in this clinical trial. Repeated experience is demonstrating how multiple myeloma patients respond to TomoTherapy treatments.

With standard radiation therapy, tumors and surrounding tissues can receive 100% of the dose of radiation. Healthy organs can receive unwanted radiation exposure.

“With TomoTherapy, we’re seeing normal organs receiving less than 65% of the total radiation. Sometimes that’s as low as 15%,” Dr. Wong explained.

“That’s the beauty of this technology,” Dr. Wong said. “Our projections were that lower radiation doses to healthy tissue would result in fewer and less-intense side effects. So far, patients’ experiences correlate with projections. Although more experience is needed, the initial results are encouraging. This has the potential to make a big difference for patients with many types of blood cancers.”

After Carol’s treatments were completed, her bone marrow stem cells were reintroduced and maintenance drug therapy continued.

“A year and a half into this, I’m in remission,” Carol says.

“Of course, we don’t know the final outcome….I have to pace myself. But, before, when my life was filled with activity, I didn’t necessarily take time. Time to connect. To interact at a different level.”

Carol has become involved with on-line support networks for multiple myeloma patients and their families. She’s also contributed with her firefighter son, Chad, to a cancer support network for firefighters. “Recently I’ve told firefighters in other states and total strangers in England and Korea about TomoTherapy,” she says.

Family, church and friends are Carol’s priorities. Her family took a “dream trip” to Moloka’i, a beautiful, less developed Hawaiian island. They have plans for more travel.

With her eyes on the future, Carol plans the summer garden.

“I’m not afraid,” Carol says. “I take care of myself. I’m cautious. But I’m going to live life now. I’m going for it!”

Recently, Carol was reminded of the silver lining TomoTherapy treatments brought to her cancer experience.

“My daughter, Kelly, and I saw a billboard. It read ‘TomoTherapy—Cancer’s Newest Enemy.’ I thought, this is great! People need to know about TomoTherapy. They need to know they have a choice.”