Randall Russell was diagnosed with cancer when his son Tyler was 1 month old.
The mass on the left side of Russell's neck had been growing larger for some time, but he ignored it. The lump didn't bother him. Besides, he'd already mapped out his life with his fiancee, Kimberlee Patrick, and their new baby.
"It was going to be perfect," he said.
Cancer simply wasn't part of the plan.
But then Russell started waking up at night, drenched in sweat, running a 104-degree fever.
"I couldn't work anymore," said Russell, who delivered water for Appalachian Springs. "I pushed it off for so long."
In 2016, he went to the emergency room at Bon Secours St. Francis Hospital in West Ashley. A body scan revealed that his spleen, liver and other organs were enlarged. A follow-up phone call on a Friday night confirmed his worst fear.
"The only place I'd ever heard 'cancer' before was on the TV," Russell said. "I just started bawling."
The hospital referred him to an oncologist, who diagnosed Russell with a rare and aggressive form of cancer called peripheral T-cell lymphoma. He was 29 years old.
"When he first came to see me, he basically had a softball growing out of his neck," said Dr. David Ellison, with Charleston Oncology. "There was no question. This was a real problem."
The field of cancer research has evolved in such stunning ways in the 21st century that some diseases considered almost always fatal even 10 years ago are now treated without surgery or chemotherapy. Since the early 1990s, cancer death rates among men and women in the United States have fallen by more than 25 percent. Many patients diagnosed with advanced disease have good reason to hope that they will live for many years.
Even so, some cancers remain persistently difficult to cure. Russell's lymphoma, for example, required him to undergo three different chemotherapy regimens before he was considered in remission.
Then, in 2017, doctors transplanted stem cells from Russell's own bone marrow in a bid to cure his disease for good. But the transplant didn't work.
On Oct. 23, he received another stem cell transplant — this time with cells from his brother's bone marrow.
His doctors called it a "salvage" procedure.
"Other things haven't worked," Ellison said. "You have no other option."
The history of stem cell transplantation dates back decades. Early research into the procedure was conducted by the Department of Defense as a way to explore treatment options for patients who had been exposed to the radiation of an atomic bomb blast, said Dr. Michelle Hudspeth, medical director of the bone marrow transplant program at the Medical University of South Carolina.
"Bone marrow transplant" and "stem cell transplant" are often used interchangeably, she explained, because stems cells are found in the bone marrow.
Here's how it works: After stems cells are harvested from the patient's bloodstream or the bone marrow, the cancer patient receives very high doses of chemotherapy — much higher levels than the body could tolerate normally. The stem cells, which are capable of producing many different types of cells, are then infused back into the body to restore the bone marrow function and create a new immune system, including red blood cells, white bloods cells and platelets.
When donated stem cells are required, those cells are collected after the chemotherapy is administered so that the cells can be infused on the same day without the need for them to be frozen.
The procedure takes time. And patients are very vulnerable to disease and infection after transplant.
Susan Frickman, a nurse practitioner who has helped care for Russell in the hospital, compared his immune system after the transplant to a newborn baby's. One of his doctors said it was, in fact, more fragile than an infant.
"His white blood cell count is zero — literally zero," Frickman said earlier this month. And it's still too soon to know if it will work, she said. "There's no guarantee. He could still die of this aggressive lymphoma."
In the late-1980s, the national bone marrow registry program, called "Be the Match," was established as a way to connect patients who need a bone marrow transplant with a donor. Today, the registry includes 20 million people who have signed up to donate their bone marrow if they're matched with a patient in need.
But recent advancements in the procedure have made it easier for many patients to find a donor within their own family. Stem cell transplants used to require an exact match, based on precise tissue typing. Now, patients can receive donated stem cells from someone considered a "half-match," such as a sibling. This is particularly good news for black patients like Russell, who are underrepresented on the national registry.
MUSC is the only bone marrow transplant program in the state that offers the procedure to patients who need stem cells from an unrelated donor, such as a donor from the registry. And MUSC's Hollings Cancer Center easily completes more stem cell transplants than any other program in the state — 136 during the 2019 fiscal year.
Meanwhile, the procedure has become more feasible for smaller hospitals and medical practices to offer, too.
Charleston Oncology completes about 30 stem cell transplants a year at Roper Hospital's Mott Bone Marrow Transplant and Cellular Therapy Program.
Dr. George Geils, Charleston Oncology's medical director of bone marrow and cell therapy transplant, said his practice only offers stem cell transplants using a patient's own cells or using cells from a related donor. Charleston Oncology chooses not to participate in the donor registry.
His practice treats thousands of cancer patients a year, Geils said, and a very small percentage of them will ever need a stem cell transplant. The procedure can be lengthy, painful, risky and expensive. Some patients spend weeks, even longer, inside the hospital. Complications from the procedure, which Geils estimated can cost $500,000 or more, can be deadly.
"The problem that remains — and it has been true since the beginning of transplantation — (patients) are more likely to die of relapse than any other complications," Geils said.
Lowcountry Hematology and Oncology, a separate local group, doesn't offer the procedure for many of these reasons. It refers all cancer patients who need a stem cell transplant to MUSC or to hospitals outside the state.
MUSC and other academic medical centers typically offer patients a chance to enroll in clinical trials to advance the understanding of stem cell transplant, said Dr. Daud Nawabi of Lowcountry Hematology and Oncology. And transplant doctors at larger teaching hospitals tend to sub-specialize in certain diseases. Nawabi and his partners believe this level of expertise benefits their patients.
"We’re better now than we were 20 or 30 years ago," he said, but "transplant is an area that is still evolving."
When Russell proposed to his girlfriend at Applebee's in 2013, life was looking pretty good. He'd recently started a new water delivery route and was making more money. A few years later, they found out they were expecting a baby.
"I was so happy," he said. "We were going to start a family."
Tyler was born in 2016 and not long after, Russell received his cancer diagnosis. He became too sick to work. They moved out of their apartment and into Kimberlee's mother's home in North Charleston. At one point, Russell lost his health insurance. Wedding plans were postponed.
He beat the cancer, but then it came back.
Now he's fighting for his life. The stem cells he received from his brother are slowly building his immune system back to full strength. If the transplant works, that process will take months. He will need to receive all the same vaccinations that infants and children receive.
"It's so hard. It's so hard," Russell said earlier this month, wiping away tears during his hospital stay on Roper's fifth floor. "I feel secluded. I'm the youngest one. You can't leave the floor. You can't go anywhere. It's like being in prison."
His doctors declined to discuss his long-term prognosis.
Russell was discharged from Roper a few days before Thanksgiving, but will be required to return to the hospital several times a week to receive outpatient treatment.
"He's at risk for readmission at any point with complications," said Frickman, the nurse practitioner.
There was one bright spot during his 40-day hospital stay. Frickman and some of the other staff organized a wedding for Russell and Kimberlee on the inpatient oncology floor. They were married in a small ceremony Nov. 4 and now share a last name.
A Go Fund Me campaign was recently established to raise money for the family. They talked about taking Tyler on a Disney Cruise for their honeymoon.
"I want to do something special," Russell said. "All I wanted was one love. And I got it."