Craig Sager was courageous by any definition of that word.  He was a husband, a father, and like me, a victim of acute myeloid leukemia (AML).  I was receiving my first, and hopefully only, stem cell transplant at M.D. Anderson Cancer Center in Houston at the same time Craig was receiving his second of three transplants.  I never met Craig.  I knew his room was around the corner from mine because I saw the signs on his door reminding nurses and hospital staff to respect his privacy and to refrain from talking to the press about his condition.

AML is a vicious disease.  The immature cells in your bone marrow somehow become mutated and never mature.  They look like large purple blobs under a microscope.  As they multiply they completely squeeze out other cells in your bone marrow preventing them from maturing into white blood cells, red blood cells, and platelets.  In a short period of time you lose all of your immunity to bacteria, viruses, and fungi.  Left untreated, you quickly die from pneumonia or sepsis.  The 5-year survival rate for AML patients is about 26%.

There are three risk categories of AML based upon the type of mutation involved.  Those categories are called Favorable, Intermediate, and Poor.  If you happen to be in the Favorable category, your disease can be treated with chemotherapy alone and your odds of living without the disease for five years are pretty good.  If you are in the Intermediate or Poor risk categories, your chances of living five years with chemotherapy alone are very slim.  Only a stem cell transplant can substantially increase your odds of survival.

My AML risk category is somewhere between Intermediate and Poor.  I assume that Craig’s AML was also in one of those two categories.  The gold standard in stem cell transplants is to receive compatible stem cells from a sibling who is a “full match” to you.  A “full match” comes from the 6 HLA antigens, (Human Leukocyte Antigens.)  Only about 30% of patients have a sibling who is a full match.  The other 70% of patients must resort to a donor registry or a relative who is a half match.  I was fortunate enough to have a brother whose stem cells were a “full match”. Craig fell in the category of patients who had to rely on a “half match” donor who happened to be one of his sons.  With the advent of better anti-rejection drugs, the results of a half match transplant are almost as good as a full  match.  However, the risks of Graft vs. Host Disease (GvHD) are greater.   Your donor’s T-cells  mistake your skin, eyes, liver, intestines, and lungs as foreign invaders and attack them.  In my case, I developed itchy skin rashes, a serious cough, elevated liver enzymes, irritated eyes, and fingernails that split and became very rough.  Fortunately, increased daily doses of the anti-rejection drug Tacrolimus have decreased my symptoms of GvHD.  Based on his appearance during televised events, Craig appeared to be suffering from GvHD after each of his transplants.

A stem call transplant can lengthen your life if you have AML but it can also be a brutal experience.  In order to make room for donor stem cells, it’s necessary to first kill off the existing cells in your bone marrow.  In the past, doctors used full-body radiation to kill your bone marrow.  These days, the doctors at M.D. Anderson use “ablative chemotherapy” consisting of IV busulfan combined with fludarabine.  Busulfan is a derivative of World War I mustard gas and is very toxic to bone marrow.  Fludarabine suppresses the immune system.  The side effects of ablative chemotherapy are miserable.  Busulfan causes nausea, vomiting, diarrhea, mouth sores, throat pain, abdominal pain and darkening of the skin.  In addition, the tissues in your throat, mouth, and tongue become swollen, it becomes very painful to swallow, and your mouth generates a tremendous amount of saliva which has to be suctioned to prevent you from choking.  It was the most miserable experience I have ever had.

Most people only ever receive one transplant.  A small minority might receive two. Unfortunately for Craig, his AML relapsed after the first and second transplants which is an all-too common occurrence.   It is very rare that any patient willingly undergoes three transplants in a bid for survival.  Craig Sager was one of those rare patients with the courage to undergo three transplants. Tragically, the third transplant did not succeed and he died yesterday.

Craig’s courage and will to fight for life was inspiring to all who met him or watched him on television.  His attitude is best summed up by the remarks he made recently while being honored at the ESPY award show: “Whatever I might have imagined a terminal diagnosis would do to my spirit, it summoned quite the opposite — the greatest appreciation for life itself. So I will never give up, and I will never give in.”