Saturday, December 31, 2005
As 2005 closes with a diagnosis of rectal cancer, 2006 approaches with the prospect of chemoradiotherapy, surgery and more chemotherapy. All treatments are important, but surgery is clearly the most invasive and possibly curative of the three. I turn my attention to the intention of my surgical oncologist to use a technique called TME or total mesorectal excision. My academic training as an historian sometimes affects how I conduct research into important issues in my life. Here is what I’ve found about surgical techniques for rectal cancer. (Much of what follows comes directly from the article The Role of Total Mesorectal Excision in the Management of Rectal Cancer, published in 2002.)
Ernest Miles first described abdominoperineal resection in 1908 (abdominoperineal resection is a surgical procedure in which both the rectum and the anus are removed from the patient, thereby requiring a colostomy, an opening in the abdominal wall by which to connect the remaining colon and replace the anus; the patient is thereby left with a device for the remainder of his life to handle defecation). By the 1920s, this surgical method had reduced rates of recurrence of rectal cancer from almost 100% to about 30%. The practice became the gold standard for surgical treatment of rectal cancer for many years even though there were still significant recurrence rates and urinary, sexual and gastrointestinal side-effects.
By the 1950s, anterior resection (a portion of the rectum is removed and the remaining ends are joined) replaced abdominoperineal resection as the surgical standard treatment for rectal cancer. One of the distinct advantages for patients in this approach was the possibility of avoiding a colostomy. Unfortunately, there continued to be significant concern about recurrence rates.
Then, in 1982, total mesorectal excision was first described by RJ Heald and his colleagues. The TME procedure is based on complete removal of the mesorectum, the tumour and as much of the rectal tissue as necessary. The mesorectum is the rectal mesentery, a membranous fold of lymphatic vessels, lymph nodes and fatty tissue which is itself contained within a thin membrane called the mesorectal fascia containing the rectum, the mesorectum and the lymph nodes. A major goal of TME surgery is to remove the mesorectum intact. Why? Because the blood supply and lymphatic drainage for the rectum are contained in the mesorectum. If the mesorectum is removed, the chances of cancer cells spilling during surgery and remaining in the abdominal region are greatly reduced. TME has been shown to reduce rates of recurrence to as low as 4% after 5 years from the time of curative surgery.
Now, TME is considered the gold standard for surgical treatment of middle and lower-third rectal cancer in most of Europe, with many advocates in the United States and Canada. But the technique is difficult and requires great skill on the part of the surgeon conducting the 3- to 5-hour procedure. In fact, of all major surgically treated cancers, outcomes for rectal cancer treated with TME are the most dependent on the technical skills and experience of the surgical oncologist.
Monitoring Skill Level
Heald recommended an audit method for surgeons utilizing TME techniques. It is called the Quirke-based method for histopathological study of the excised specimen. Dr Phil Quirke promoted the circumferential margin involvement (CMI) of the TME specimen as a significant indicator of local recurrence of cancer. In other words, the pathologist has to examine the circumference of the specimen very carefully to determine how far from the outer edge of the specimen cancer cells are located. Generally, if there is a margin of 1 mm for the entire circumference, then it is designated as “clear”. In addition, the pathologist has to assess 12 or more lymph nodes to ensure there are no metastases of the cancer.
Standardization of both terminology and technique is progressing. As of 1999, surgical oncologists agreed to dispense with other names for the surgical technique and agreed to settle on TME. In Canada, it appears that at least some provinces are moving towards standardizing on Quirke-method histopathology techniques thereby allowing better evaluation of surgical expertise.
There continue to be problems with TME for the patient. Leakage rates from the anastomatic resection and the inability to defer defecation in lower rectal resections, especially in lower rectal resections, continue to be problematic. If nerve-sparing techniques are utilized in TME, there is mounting evidence that urinary and sexual function can be spared, but patients should be prepared psychologically for potential problems.
Laparoscopic surgical techniques for total mesorectal excisions may become more common. A study from 2001 assessed open surgery and laparoscopic-assisted surgery (far smaller incisions for the patient); in that study, it was estimated that up to 50% of patients would benefit without compromising survival and recurrence rates. Another presentation by Michelle K. Smith at the 8th World Congress of Endoscopic Surgery in which 112 consecutive patients in 3 centres in France from 1991 to 2001 were treated with laparoscopic TME suggests that laparoscopic TME may even be superior to open surgery insofar as there is improved visualization, it is easier to determine correct anatomical planes, and there is improved ability to standardize and teach the technique to other surgical oncologists.
Friday, December 30, 2005
“How far down the rabbit hole are you prepared to go?”
“It makes you think, doesn’t it? If thoughts can do that to water, imagine what our thoughts can do to us.”
Two separate scenes from a movie that is on my top ten list – What The Bleep Do We Know? (a sequel will be released in February 2006 entitled What The Bleep – Down The Rabbit Hole).
The first quote is an obvious reference to Alice in Wonderland. The second is made by Armin Shimerman, the actor best known for his portrayal of the Ferengi bartender Quark in Deep Space Nine. He is talking to the character portrayed by Marlee Matlin about an exhibit he and she are currently viewing of an experiment done by a Japanese scientist (Dr Masaru Emoto) in which the effects of thoughts and blessings on ordinary water are documented with photographs. What is so extraordinary about the exhibit and the photographs is that they clearly show how thoughts and feelings affect the physical reality of water crystals. Words are spoken or “sent” by focused intention to the frozen water which then responds by changing its “expression”. Negative thoughts or polluted water sources have a distinctly “ugly” expression compared to the beautiful expressions arising from positive thoughts or clean water sources.
The implications for cancer patients from both the movie and Dr Masaru Emoto’s experiments relate directly to my reflections over the past couple days about “arguing with oneself” and “prayer”. They relate as well to the increasingly persuasive and sophisticated science of positive psychology promoted by Dr Martin Seligman. The bottom line is fairly simple to state: there is mounting evidence that prayer, love, good intentionality, optimism, and happiness affect physical reality in ways modern, flatland science would never have imagined only a few short years ago.
Does this mean those of us afflicted with cancer can heal ourselves? Well, that’s another question entirely and I simply don’t have an answer yet. But whatever the complexity of the subject, whatever the limitations of this emerging science, whatever the hurdles we face in empowering individuals to apply some of the lessons of quantum physics to self healing…there is reason to hope, there is reason to be optimistic, there is reason to be kind and to love one another.
Thursday, December 29, 2005
Yesterday, I was blessed with two people praying for me out loud, one after a visit to our home by relatives, the other on the telephone with a friend whom I haven’t seen for a very long time. In both cases, they asked if I would mind if they prayed for me. In both cases I accepted, and in both cases I felt blessed.
So how does the perennial skeptic deal with this rationally?
Yesterday I wrote about arguing with oneself, about the process we all engage in daily of hearing voices asking questions, offering answers, making speculations, and so on. I suggested that there was no more credibility to the voices inside our head than to those we hear in dialogue with other people. I advised disputing the conclusions and assumptions of the voices within by using evidence, alternatives, implications, and usefulness of ideas. The point of arguing with oneself is to generate optimistic thoughts and emotions, something which we all know instinctively heal the spirit if not the body.
But then it occurred to me – is there any difference between arguing with oneself and prayer?
When friends and relatives pray out loud for you in your presence, there is a different tone and attitude expressed than when you are both engaged in dialogue. Extemporaneous prayers of petition express generosity and good will toward the one who is ill; that much is clearly obvious. But they also express the highest aspirations and dignity of the human spirit (OK, not always, but most of the time) for the wellbeing of another person; they do so in the guise of a personal petition to God.
But if both religion and the meaning of cancer are best understood as human creations, then prayer can be understood as a special kind of human dialogue whose purpose is to heal the sick. Not cure the illness, but heal the sickness.
We might not agree with one another about the nature of the universe, about the existence of a supernatural god, or even about the meaning of cancer. But when someone prays for you, especially out loud in your presence, the invitation is to a dialogue of healing. I can’t see anything wrong with this, as long as the individual being prayed for can separate his own worldview easily from that of the person praying for him. If the prayer is a genuine expression of a desire for healing, and if it doesn’t bludgeon the individual being prayed for with too many ill-conceived ideas, then it can be truly useful.
There are still some sticking points that I need to work on here. If prayer by another person who believes in a supernatural God is useful to the sick person, can a non-theistic sick person’s prayer for himself be useful? I suppose it can – in the same way that disputation with oneself can be useful in the healing process, I suppose prayer consciously directed towards the highest aspirations and dignity of the human spirit can be just as useful in healing oneself. But I need to think about this. Perhaps I need to pray about it too.
Wednesday, December 28, 2005
Ken Wilber uses the phrase “condemned to meaning.” By this, he means simply that we have no choice; when cancer is diagnosed, we will look to the medical experts to treat the illness, but to our culture to provide the scripts by which we attach meaning to the sickness which has invaded our life. Like his wife Treya did when she was diagnosed with breast cancer, I find myself alternating, sometimes at the speed of light, between the various scripts provided by Christian, New Age, Medical, Psychological, Gnostic, Existential, Magical, Buddhist, and Scientific approaches to the meaning of cancer (see yesterday’s blog for more about the idea of scripts).
If you’ve glanced through the brief summaries of these different approaches, you will probably find, like me, that not a single one is sufficient, although it is safe to say that some resonate more than others. Perhaps you find that it’s something like combination chemotherapy; if you mix a few together you can find a cocktail that is more appealing than any of the single approaches. For me, that mix would probably be a blend of scientific, medical, existential, and Buddhist approaches.
The point is simple: the meaning of cancer is a human creation, something which necessarily involves both the individual and the community in dialogue. This conversation between the personal and the communal is a non-stop process even when the voices we hear are not spoken aloud but inaudibly spoken in our minds as we think about cancer.
“What did I do to deserve this?”
“You were a shit disturber, weren’t you? That’s why you’ve got colorectal cancer now.”
“If I think positively, will that extend my life?”
“Only if you’re an idiot who thinks wishing for things will make it so.”
“If cancer has no meaning, can’t I just make it up? If it works for me, what difference would it make for anyone else?”
“Yeah, stupid. You have a family, right? Don’t you have an obligation to at least come up with a meaning that works for them too?”
We all have these conversations with ourselves, sometimes endlessly so. If somebody else were to offer questions or opinions to us, we would feel justified in disputing their assumptions or their logic. But sometimes when the voice arises within, we feel that it must be true, it must be our authentic self. The truth is, the nonsense we use in our internal dialogues is often just as nonsensical as what we hear other people saying.
Martin Seligman, in his book Authentic Happiness, offers advice on how to argue with yourself. What I find fascinating about his advice is that he recommends we do whatever is necessary to find an optimistic meaning. In the context of coping with cancer, this means that we need to develop facility in recognizing when our internal voices are offering pessimistic interpretations. Then, once recognized, we need to learn to dispute those voices. We do so through four approaches: evidence, alternatives, implications, and usefulness.
Evidence means that often the best way to dispute the pessimistic view of cancer which is voiced internally is to show that it is factually incorrect. For example, even thought Stage III rectal cancer prognosis statistics state that 55-60% will survive after five years from diagnosis, a pessimistic view suggests that means I have a 40-45% chance of dying in the next few years. Evidence suggests that the statistics are skewed. Most involve all age groups, not guys in the early 50s with an otherwise good state of health and no prior hospitalization, with an absolutely top-notch medical team using the most current surgical, systemic, and radiation therapy approach. The evidence clearly suggests that my Stage III rectal cancer has better survival prognosis.
Alternatives means that there are other ways to talk about and look at the circumstances facing us than the often most pessimistic view we take. If we focus on the elements that are changeable (I can exercise and eat well and develop my enduring happiness levels), specific (yes, the tumour has penetrated through the rectal wall, but all the distant organs look normal), and nonpersonal (this cancer isn’t about me failing in some way; it’s just an unfortunate series of events; and, after all, we’ve caught it before any evidence of metastasis), then those alternatives become life-enhancing and productive.
Implications means that even if the evidence is stacked against you, even if reality looks grim, we can still decatastrophize. What are the implications of Stage III rectal cancer? Well, we simply choose those that are life-affirming and ignore the worst-case scenario.
Usefulness means that sometimes the only smart thing to do is evaluate whether holding a belief about your prognosis is destructive or not. Whether it is accurate or not may matter far less than how it helps you. No, the world may not be fair, but the smart person will not think about that. If you concentrate instead on what you can do to make things better, things will be better.
Tuesday, December 27, 2005
If you’ve ever programmed a computer or been responsible for updating databases, you’ll understand all about scripts. One variety of script is the SQL script (structured query language) in which a series of instructions are carried out against tables, views, fields, indices, and relations.
Today, for instance, I spent my time sequestered in a concrete bunker we call the data centre running update scripts against our ERP (enterprise resource planning) database in Oracle. The longest of these scripts ran for about 2 hours. Its purpose in life is to ensure that the entire database is modified so that it will accept new data generated by the Delphi 7 software application which powers our ERP system. When the users of our ERP system come back January 2nd, they will find new features and functions available to them provided by both software and database modifications both of which are generated by scripts.
Scripts can be easily corrupted. Misspell one word or move one line into the wrong location and the entire database or application can collapse into a heap of meaningless bits and bytes.
Cancer is something like that. At the biochemical level of our existence (in fact, all life), DNA scripts can become corrupted, thereby shattering the patterns which sustain life. Medical science has made great strides in treating cancer through blunt force methods like chemotherapy, radiation therapy and surgery. But it hasn’t helped as much in explaining how these script errors are introduced into DNA in the first place or in preventing such errors. In that regard, it is still very much like computer programming and database engineering – any attempt to fix errors in scripting can easily backfire, generating other unacceptable problems.
Cancer as an illness is all about scientific knowledge; it’s like software as the product of database engineering and programming constructs. Cancer as a sickness, however, is about the cultural meaning we assign to the experience of having cancer. In this regard, it is like software experienced by users who see only the forms, reports and menus. For them, the meaning of a software application is provided by their job description and the keystrokes or mouse clicks in the application which help them do their job. The less the user knows about the underlying programming and database constructs, the more the meaning of that application becomes the product of their own scripts, the meaning they assign to the experience of the software.
Cancer as a sickness is vastly more important to the patient than cancer as an illness. In fact, cancer as a sickness is much more significant to everyone, medical practitioner and patient alike, than cancer as an illness. There are still scripts for cancer as sickness (cultural meaning), just as there are scripts for cancer as illness (DNA). We may have options available to us in the scripts we run as we try to determine the meaning of cancer, just as the meaning of a software application varies according to the job description of the user. But, I would argue, we have to be very vigilant about the scripts we choose to run in providing meaning for the sickness of cancer.
What are some of the scripts available to us (what follows derives from Ken Wilber’s Grace and Grit, p46-7)?
- Christian: cancer is a punishment from God for some sort of sin
- New Age: cancer is a lesson; you have given yourself cancer and now need to learn something about mistakes you have made in the past
- Medical: cancer is a biophysical disorder; psychological and behavioural approaches are ineffectual
- Psychological: cancer is repressed emotion, perhaps even a death wish
- Gnostic: cancer is an illusion; when you awaken from the illusion, the cancer will be gone
- Existential: cancer has no meaning; whatever meaning I give it is the only meaning that matters
- Magical: cancer is retribution for bad thoughts and feelings about other people
- Buddhist: cancer is an inescapable part of the manifest world; only in enlightenment is it possible to transcend the impermanence of all manifest existence
- Scientific: cancer is the effect of either a single or a cluster of causes; some causes are determined, others occur by chance; either way, there is no meaning, only chance or necessity
Coping with cancer is mainly about running scripts to discover the meaning of the sickness. If it was just about treating the illness of cancer…well, then my blog entries would be far fewer in number. As it is, I am a script runner, trying to learn what I can about the illness and doing what I can to create meaning about the sickness.
Sunday, December 25, 2005
It’s Christmas. And yet the first thought of the day is not Christmas cheer, stockings, turkey, or presents…it is CANCER!
Last night, my wife, my eldest son and I (my youngest son decided church wasn’t where he wanted to be) went to our local Anglican church for the Christmas Eve eucharist. We went mainly because it is something we traditionally do; I went chiefly because I didn’t want to be the humbug who said “No”, but also because I wanted to see my friends in the choir, especially one person who told us at Thursday’s choir practice that they have found something in her breast that requires a biopsy as soon as possible. I spoke to her, a nurse in the choir, and my naturopath before taking my seat in the congregation alongside my family and all the others ready to sing the carols we all love.
But the word hangs in the air – CANCER – my cancer is already diagnosed and ready for battle. Her diagnosis, we hope, will be different; the surgeon and pathologist will discover it is nothing more than a benign growth. That would definitely be the best way to end 2005.
Last night, as another part of our home-grown tradition, we read one of our many Christmas books. It is a tradition which owes its origins to my wife’s family. Her father would read The Littlest Angel every year. If you’ve never read this story, it is well worth the effort of finding a copy. The most memorable reading for me, as I gradually wormed my way into their family over the years of dating and then being married to their daughter, was the Christmas of 1988. Father was in his hospital bed and we were gathered around him. He couldn’t read the story, so I agreed to do the reading on his behalf. The story speaks of all the good things of our life, the beauty of nature, the gifts of creation, the wonder of childhood. The words caught in my throat a couple times, but I managed to get through it all. Father died a week before my youngest son was born.
Last night, the atmosphere was more cheerful, buoyed by gratitude and thanksgiving that we have one another and our traditions to keep us warm. We read A Wish for Wings That Work, each person taking turns reading a couple pages and showing the fantastic illustrations to everyone gathered by our Christmas tree. Like The Littlest Angel, the lesson was simple: we are at our best when we take our strengths and use them in the service of other people instead of wishing for things that can never be. I love these simple lessons. To me personally, they are so much more relevant than a recitation of the Nicene Creed.
Today, we will revel in each other’s company, receiving and making calls to relatives, maybe watching some of our new DVDs or listening to our new CDs; I will watch Kobe Bryant and Shaquille O’Neal square off as the Lakers fight the Heat and maybe even catch some of the San Antonio/Detroit game. My wife tells me that I will definitely be helping with meals ;>)
But behind everything, there is that word again – cancer. It will not cancel Christmas for us. It will simply tug at our sleeves throughout the day, reminding us that nothing can be taken for granted. Maybe that is the strange gift this word brings to us today.
Saturday, December 24, 2005
My youngest son and I experienced the crazed, frenetic pace of last-minute Christmas shoppers in their cars today, some of them driving without any consideration at all for pedestrians or other drivers. We, too, were out doing some stocking-stuffer shopping before the crowds were too thick and cursing the rude and ridiculous alike as we struggled simply to get in and out of mall parking lots. But then, in an almost Dickensian moment, a kind of Scrooge-gets-Christmas episode, we experienced first-hand something which Catherine Ryan Hyde called Pay It Forward.
We had promised to buy tins of Tim Horton’s decaffeinated coffee and hot chocolate. The line-up of cars was one of the longest we’d ever seen. But there was one driver who had obviously made a mistake and not found the end of the line. He was waiting patiently but probably hopelessly for someone to let him into the line-up. On a whim, I motioned for him to cut in before us. Then, when we finally got to the window to pay for our tins, the clerk told us that the gentleman in the car ahead of us had already paid for our order simply because he appreciated us letting him into the line.
A little while later, while getting breakfast in another drive-through, we decided to “Pay It Forward” for the person in the car behind us in the line-up. We didn’t see if the driver was as pleasantly surprised as we had been. In both cases, what we experienced was rather mundane, simple examples of actions which were “beyond ego”, a kind of affirmation not of the triteness of Christmas spirit, but of something more akin to “hey, we’re all in this together.” It was, however, a transitory moment.
Later, as the day progressed, I fell back into a funk that was totally dependent on ego. Yesterday, as we spoke with the radiation oncologist, I asked about possible side-effects of radiation on sexual function. The answer I received was that, although the radiation might not have much effect, the surgery would probably do long-term damage to sexual function by damaging nerves. Last night and again throughout most of this day before Christmas, I wallowed in self-pity with ego-driven thoughts of myself, the “guy who might never have another erection.”
There really isn’t anything wrong with grieving loss of sexual function…nothing at all. But when the ego pushes aside truly transcendent moments which come from a place beyond ego, then we need to do something about that. Ego is good. Ego is fine…in its place. Cancer is bad. Cancer sucks. But neither ego nor cancer is the real point of the journey, after all. Pay It Forward moments remind us that not only are we all in this thing together, but that the tragedy of cancer is, in its own way, an opportunity to move beyond ego. I hope I can remember this lesson.
Friday, December 23, 2005
I coached his son and my son in basketball two years ago. As soon as the radiation oncologist walked into the consultation room to join my wife and me, we both recognized each other but couldn’t quite recall the connection until a little later when my wife broke the ice and asked about a few possibilities. We settled on basketball almost immediately. It feels good to know that my radiation oncologist has a personal connection with my family, even though it’s somewhat tenuous.
Today, as you may have figured out by now, we went to the Grand River Regional Cancer Centre where we reviewed how the radiation therapy would be conducted. I’ll go back to the centre in the first week of January for a simulation session in which we use a CT scan reserved just for the radiation oncology team. During that session, we will discover exactly how I will be positioned for a course of 28 fractions of radiation therapy. Permanent tattoos in the form of small, bluish dots will “mark the spot” to guide subsequent radiation therapists as they set me up for the daily, Monday-to-Friday sessions beginning January 9th for a little over 5 weeks. After that, I will have about a 6-week break to recover, followed by surgery.
We talked about side effects, the purpose of the therapy (reduce the tumour for excision and to make possible a low anterior resection), how I might feel, and how the chemotherapy side effects might interact with the radiation therapy side effects. To make it short and sweet, there may be about 3 weeks in which the side effects of radiotherapy will grow increasingly worse, followed by another 3 weeks after the treatments have stopped when I will gradually feel better. That will be followed by a 2-week period that we’re calling the “honeymoon” when I shouldn’t feel too bad at all – then, it’s surgery.
There will be some damage to the skin in the pelvis, some possible inflammation of the bladder and prostate, and probably a fair amount of fatigue. It may even be that I won’t be able to work for a few weeks prior to surgery.
Before the consultation, I went to medical imaging for some chest X-rays. After the consultation, we met with a volunteer to get enrolled in an orientation session called “Feeling Your Best During Cancer Therapy” for next Friday about coping with chemotherapy.
We also picked up an Outpatient Oncology parking permit and got our instructions and activation key for the online My CARE Source. Back at home, after activating my site, I was pleased to see a discussion board, web links, a place to store questions, as well as a my health area where I could document all of the following:
- My Conditions
- My Treatment
- My Side Effects and Self Monitoring
- My Appointments
- My Medications
- My Care Team
- My Diary
- My Profile
- My Community Resources
- My Education
I am really impressed with what I’ve seen of the GRRCC and its team members. And they’re all working for me!
Thursday, December 22, 2005
Concentrating on the objective realities, the physical “stuff” of cancer and cancer treatment comes naturally to me. I crave information as a first line of defence in coping with cancer.
Why is this true for me? I don’t know. It could be a gender tendency as one of my friends proposed. Guys don’t want to talk the cancer out, as some women seem to do, they want to dig it out and the sooner the better. “Get me a knife and some bandages and I’ll be fine” seems to be the stereotype for male approaches to coping with cancer. But you can’t make the incision until you have the precise information you need to take action.
It may be because of the nature of the work I do. Information and technology and management of problems – well, cancer’s just another problem to be managed through good information and judicious use of technology – maybe.
Or it may be because I’m not a member of Alcoholics Anonymous and don’t say the Serenity Prayer every week at meetings.
It could be because I don’t believe in God…or to be more precise…I don’t believe in theistic Christianity. I have no problems intellectually with non-theistic interpretations of any major world religion. But the key here is “non-theistic”. You can’t pray to a God who doesn’t exist! And you certainly can’t find comfort in a basket load of Bible verses whose underlying assumption is that some divine personality is overseeing and possibly intervening in human life, even to the cellular level that is the turf of cancer.
On the other hand, I understand why people pray for me and I greatly appreciate the sentiments and generosity that implies. It’s just not for me personally. I’m not praying about my cancer. I’m not asking God to make everything better or even to give me the grace to cope with whatever comes my way. Others can do that on my behalf if they want. But it makes no sense for me to pretend that I believe in a God who intervenes.
Spirit, on yet another hand, is something else entirely – ultimate concern, the god beyond God, “God as a verb” – these all have a great deal of potential both intellectually and emotionally for me.
This attitude of mine is, I have discovered, not a common response or coping mechanism when the diagnosis of cancer has been made. Over 90% of adults believe in God and over 70% say religion is a very important influence in their lives. For some, a diagnosis of cancer is the occasion for the discovery of faith in the God of the Bible. I do not quibble with those for whom such thoughts are comforting. But for me it is not so, nor would I ever hope that I would change in the face of serious illness or death. As Carl Sagan put it in an essay in March 1996 before he succumbed to bone marrow disease:
"Many of them have asked me how it is possible to face death without the certainty of an afterlife. I can only say that it hasn't been a problem. With reservations about 'feeble souls,' I share the view of a hero of mine, Albert Einstein: 'I cannot conceive of a god who rewards and punishes his creatures or has a will of the kind that we experience in ourselves. Neither can I--nor would I want to--conceive of an individual that survives his physical death. Let feeble souls, from fear or absurd egotism, cherish such thoughts. I am satisfied with the mystery of the eternity of life and a glimpse of the marvelous structure of the existing world, together with the devoted striving to comprehend a portion, be it ever so tiny, of the Reason that manifests itself in nature.'"
“Feeble souls” isn’t how I would put it, no matter how great a man I think Albert Einstein. But Einstein, Sagan, and people like Treya Wilber are the model for how I wish to approach life, illness, and death. If you want to know what I mean, then take a couple days and read Ken Wilber’s tribute to his wife Grace and Grit: Spirituality and Healing in the Life and Death of Treya Killam Wilber.
Wednesday, December 21, 2005
My eldest son joined me again today for another trip to Grand River Hospital. This time, instead of medical imaging, we had our very first trip to the Grand River Regional Cancer Centre. The GRRCC was able to find a cancelled appointment for Wednesday the 21st and get me in to see the Medical Director of Systemic Therapy a full month before the date offered me yesterday. This was very good news for me.
The consultation and physical examination was straight forward and went as expected…almost. I had to revise my expectations for the duration of neoadjuvant treatment. In addition, I hadn’t fully realized in my research thus far that I would also be getting adjuvant chemotherapy. Preoperative chemotherapy will be delivered 24 hours a day by ambulatory infusion pump for a full five weeks and will involve low-dose 5-Fluorouracil (5-FU). Postoperative therapy will begin about 4 or 5 weeks after surgery and will likely involve a “cocktail” of drugs – either FOLFIRI (folinic acid, 5-FU, and irinotecan) or possibly FOLFOX (folinic acid, 5-FU, and oxaliplatin). For both preoperative and postoperative chemotherapy, I will have a catheter in a vein with a pump connected. Each week, I will have a nurse replenish the medicine.
There are, as you might expect, a number of precautions and possible side-effects with which I may have to deal. The most important of these, and possibly life-threatening, is a fever of 38.3 Celsius (101 Fahrenheit) at any time or 38.0 Celsius (100.4) for more than one hour. A fever may indicate a severe depletion of white blood cells.
Other side effects are what one might expect, the most feared of which for me personally is general fatigue. The GRRCC has a short seminar planned to explain the chemotherapy treatment, side effects, and how to deal with fatigue which I will attend early in the New Year. My hope is that I can manage general fatigue well enough to get substantial work done in my role as IT Manager. Although I don’t like admitting this, some of my self-esteem derives from how well I perform my job functions, a major part of which is my mental agility and energy levels.
I really do appreciate and am grateful for the progress being made on treating my cancer. But now that I am so close to actual initiation of chemoradiotherapy, the impact is becoming less theoretical and more real. Today was, emotionally, one of highs and lows – highs because of getting this appointment, our annual company Christmas party at King Crab Oyster Bar & Grill (which was absolutely fantastic, by the way!), going to see a Vinyl Café Christmas with Stuart MacLean at the Center in the Square with my family, and lows because of the realization of what I and my family are going to be going through very, very soon.
Tuesday, December 20, 2005
Apart from barely being able to walk down the stairs or to bend down to pick something up off the floor, it was a very good day. But even those aches and pains felt good. They were the telltale symptoms of a good physical workout, the result of barbell and stability ball squats, indicators that the core training exercises from yesterday were already paying dividends.
But what set this day apart for me was simply that cancer wasn’t always on my mind. Knowing approximately what the staging is for my cancer, what kind of treatment I can expect, having appointments scheduled to meet with the radiation oncologist and medical oncologist – that was enough to relieve my mind sufficiently to turn to other matters with more enthusiasm than I’ve been able to muster over the past three weeks.
Friends and some family members have also been incredibly generous. Our children’s god parents and cousin came to visit yesterday and to demonstrate their love and concern for the entire family. College friends, online buddies from around the globe, fellow choristers and parishioners, my sister’s husband – they have all been very supportive and generous in their offers of assistance.
But what really makes a good day great is the people closest to me, my wife and my sons. Throughout the past three weeks, they have made the uncertainty tolerable. Good days and bad days only make sense with them in the centre of everything. Between the four of us (not to mention our cat and dog), we have created something that transcends good news, bad news, and no news at all.
Monday, December 19, 2005
Wait times are on the political agenda these days. The Ontario government has a Wait Time Strategy to reduce wait times for key medical services. Cancer surgery and diagnostic scans (MRI and CT) are two of the five services being targeted by the provincial government (the others are cardiac procedures, cataract surgery, and joint replacement). Unfortunately, it won’t be until December 2006 that the Wait Times Information System will be available in 50 Ontario hospitals.
In my case, I am not disappointed with the wait times for diagnostic scans at the Grand River Hospital (from the time of my first meeting with the surgical oncologist to the time of the CT scan was 10 days, 14 days to wait for the MRI). But, if the wait times listed on the Grand River Regional Cancer Centre’s site for chemotherapy and radiation therapy are reasonably accurate (they use the median time from a referral to the centre to the first treatment), then I will have to wait 5 weeks from December 14th (the day after the tumour board made its decision about the treatment protocol to be followed for my case) until treatment starts. That would be January 18th. Then, surgery would be exactly 12 weeks later on April 12th.
Comparison of wait times among the province’s regional cancer centres is done using data forwarded from each centre to Cancer Care Ontario. The GRRCC hasn’t yet posted its cancer surgery wait times on its own site, although there is a link on Cancer Care Ontario’s site where you can select Wait Times in Your Area which then takes you to the waittimes.net site where you can search for wait times by the category of cancer and location of hospital. That search engine told me that the median wait time for gastroenterological cancer surgery at Grand River Hospital was a median of 18 days, an average of 26 days, and 90% completed within 61 days. The times are calculated from the patient’s decision to proceed with surgery to the time when surgery is complete.
Rectal cancer that is treated preoperatively with chemotherapy and radiation therapy automatically pushes the surgery out by 12 weeks, so the comparisons for me for surgical wait times don’t compare readily with the standard wait times.
The problem is more subjective anyway, no matter what the statistics and figures indicate. I was told 5 days ago that there was confirmation on the pathology report of carcinoma and that the tumour board had agreed on the treatment protocol recommended by my surgeon. I called the GRRCC today to talk to the clinical director of supportive care. She was attuned to the problem of waiting for newly diagnosed cancer patients and quite sympathetic. Although she couldn’t tell me when I would be meeting with my medical team, she promised I would receive a call tomorrow to clarify next steps.
That’s all I can really expect, I guess. If I have to wait for chemotherapy and radiation therapy, then I’ll simply have to grin and bear it. But I can use the time to research, to work on my physical training program which I started today (I can barely walk!), and even try to enjoy the Christmas season. I may even put off my diet until Christmas is over.
The other major news today included getting copies of the pathology report and the text copies of the CT scan and MRI reports. Until I meet with my medical team at GRRCC, I should be careful interpreting the technical terminology of those reports, but from what I am reading, it appears there is no evidence of metastatis to distant organs, but possible lymph node involvement in two small nodes in the mesorectum (“two small presacral adenopathies”). The tumour itself is about 6 cm long and about 1.3 cm in thickness, which means the tumour has penetrated through the rectal wall. The MRI indicated “some spiculation and irregularity on the outer surface on the rectum”. The pathology report confirms the diagnosis: “invasive colonic adenocarcinoma arising within an adenomatous polyp.”
Saturday, December 17, 2005
“I’m constantly hearing you have to be positive. But you can’t ‘pretty up’ this disease. You have to face it, deal with it, and you have to think about it.
When I’m faced with depression, sleeplessness, anxiety, the last thing I need is a pep talk, Intellectually I know that feeling positive is good for your mental health and yes, I will get there. But for now, I need a place where I can allow myself to feel miserable, and down, and depressed, a place where I’m not protecting those around me from cancer. A place to deal with the tough issues that come with cancer.”
-Rosa McDonald, breast cancer patient (p.17 - The Emotional Facts of Life with Cancer: A Guide to Counselling and Support for Patient, Families and Friends)
I hear you, Rosa!
Well meaning people tell me to “put my brain into neutral”, “let God be in control”, “don’t think about the ‘what ifs’”, “have a manager’s state of mind”, “repeat healing scriptures twice each day aloud”, “don’t tell people anything about your cancer who don’t need to know what’s going on”, “forget the technical information research”, and the grand daddy of them all – “just live one day at a time”. On the other side of the hill, a fellow cancer survivor suggested we go out to one of his favourite haunts, drink a few mugs of beer, get into a fight, and flirt with the women on “ladies night”.
I appreciate all these people. I really do. Some of them are among the most important people in my life and always will be. They’re all trying (in both senses of the word) to be supportive and demonstrate their concern for my wellbeing. But they’re missing something terribly important that I think I need to express. And sometimes I feel like I need to shout it from the rooftops:
“I hate this f…ing cancer! I hate what it’s done to my life, to my plans, to my self esteem, to my hopes and dreams, to my sense of control. I feel betrayed. I need to understand what’s going on, why it’s happening, what to expect next…”
OK. I’ve said it. And I realize that if it wasn’t cancer it would be something else. But it is cancer!
As I read through the material the Colorectal Cancer Association of Canada so graciously sent to me recently, I came across a wonderful booklet entitled The Emotional Facts of Life with Cancer: A Guide to Counselling and Support for Patient, Families and Friends. It is a publication of the Canadian Association of Psychosocial Oncology whose first edition was released in February 2003. An online version of the booklet is available at http://capo.ca/eng/docs/bookletREVISED.pdf.
It seems these people get it. Every cancer patient (I don’t think I should call myself a cancer survivor yet until I’ve paid my dues with treatment) is unique and the way they deal with cancer will be unique. Counsellors who get this use an approach specifically tailored to the unique needs of cancer patients - the technical term for this kind of counselling is psychosocial oncology. They recognize the informational, psychological, social, practical and financial, and spiritual needs and try not to confuse categories too often.
Like hope and concern, there is a flip side to this business of emotional needs; namely, that of caregivers, family and friends – the very people whose attempts to provide support to patients may backfire on them. Perhaps I can be bold enough to suggest to those who love me and are reading my journal:
“Take care of yourself too. I do love you, even when you say things I don’t appreciate or aren’t useful in a specific situation. You are entitled to your feelings and beliefs, to your own sense of loss and helplessness, to your own need for care and concern. I might not be able to help, but there are professionals who can. Just remember that.”
Friday, December 16, 2005
She is really an incredible person. The executive assistant for my surgical oncologist has been very supportive and helpful, responding quickly to all my questions and concerns. Perhaps the most useful asset she brings to the surgeon’s medical practice is the rapport she seems to establish so readily with troublesome patients like me. Although she is attempting to help me deal with my experience of the dragging of time, I'm not sure anyone can affect such a subjective feeling.
I am finding this period between diagnosis and confirmation of the treatment plan and the beginning of chemoradiotherapy hard to handle. The waiting period really is minimal; it just seems to drag. That’s the nature of rectal cancer diagnosis and treatment according to stories I’ve read. It seems like time isn't the classical 4th dimension any more. For some, time blurs. For others, time is like a movie that's paused and then starts up again with no recollection of what went on in the interim. For me, it simply drags when I can't get the information I think I need when I want it.
Work is therapeutic. Everyday activities help. These things distract me and help me deny that anything has changed...at least for a few moments.
It feels good to make progress with information technology problems and challenges, to meet with colleagues to review projects and plans, to joke with acquaintances about Christmas shopping and the foibles of leaders in our national election campaign, to play euchre at lunch, to sing with the choir, to drive our sons to school and basketball tournaments, to walk with my wife in the evenings with the crunch of snow beneath our feet, to relax and watch the Toronto Raptors lose a few more games, to munch on chocolates and ju jubes in the shape of Santa Claus…these everyday things truly help...momentarily.
But…my experience of time and my interests have been transformed. Thinking three months down the road towards surgery takes a supreme effort. Subjects that would have elicited my ready attention before have just faded into a muted background. I could care less about politics these days. International affairs - it barely registers on the radar. Even technical issues pertinent to my work have been sidelined. I know this will change. I just don’t know when.
When I can pick up a novel again instead of a book on colorectal cancer in the evening, I’ll know time is returning to normal.
Thursday, December 15, 2005
Is it possible to get through a day without more questions?
What is the preoperative staging assigned to my case? What TNM (tumour/node/metastasis) classification has the tumour board given me (see below)? What’s my activation key for My CARE Source, the Grand River Regional Cancer Centre’s online resource for managing my treatment plan? What is the significance of clinical complete and clinical partial responders to neoadjuvant chemoradiation for rectal cancer? And what exactly is the difference between clinical responders and pathologic responders? Perhaps even more importantly, is there any point to the patient looking for and expecting answers to these kinds of questions?
TNM Staging System
- T1: Tumor invades submucosa.
- T2: Tumor invades muscularis propria.
- T3: Tumor invades through the muscularis propria into the subserosa, or into the perirectal tissues.
- T4: Tumor directly invades other organs or structures, and/or perforates.
- N0: No regional lymph node metastasis.
- N1: Metastasis in 1 to 3 regional lymph nodes.
- N2: Metastasis in 4 or more regional lymph nodes.
- M0: No distant metastasis.
- M1: Distant metastasis present.
- Stage 1 - T1 N0 M0; T2 N0 M0
- Stage 2 - T3 N0 M0; T4 N0 M0
- Stage 3 - any T, N1-2, M0
- Stage 4 - any T, any N, M1
I feel like I’m being tossed around, not by anybody in particular, but mainly by what I should or should not do in participating in my own treatment.
In my profession, one thing that is very clear is that there is no lack of questions to ask. There are literally dozens of tasks that can be done each and every day related to managing information technology, usually organized according to the questions being asked. The trick is not in having a lot of questions; the trick is in asking the right questions at the right time with the right goal in mind. Success is more about assessing priorities and clarifying objectives than in having immediate answers to those pressing questions.
But now I feel like I’m a novice all over again. I have no idea what the right questions are or even what my focus should be.
Question: Is this normal?
Question: Would it make more sense for me to leave the technical questions to the experts and concentrate on my emotional health and general wellbeing? Or is it silly to try to distinguish between the two?
Final question for today: Is it time to put my brain into neutral yet again?
Wednesday, December 14, 2005
“The tumour board met last night to review your case. They have concurred with the diagnosis and treatment being recommended. Your name has been forwarded to the Grand River Regional Cancer Centre and you will be registered with them. Either the medical oncologist or the radiation oncologist will call me soon with the date and time for your next consultation. When you meet, the oncologist will discuss the chemoradiotherapy schedule with you and review the reports and images that helped the board make its decision last night. If you have any questions at all, please don’t hesitate to call.”
As it turned out, I was digging in my winter clothing trying to retrieve my cell phone and missed the call. I called back right away and discovered that the second set of biopsies was unequivocal. I do have carcinoma, as expected. But I qualify for the treatment protocol recommended by my surgical oncologist and can expect to get started right away with radiation therapy and low-dose chemotherapy to shrink the tumour.
This time I was prepared; in fact, I was downright cheery. Yes, I have a cancerous tumour in the rectum, but we have a good plan in place, an excellent medical team, fantastic medical resources, a loving family, dear friends, supportive acquaintances and colleagues, a good medical leave benefit package, a fitness trainer and a core training fitness program ready to go, and a determination to remain optimistic and enthusiastic about my small part in this fight.
There are so many people helping me right now. Books, movies, web sites, programs – friends and family are making recommendations and getting involved. They’re in my corner and ready to cheer me on. One friend from my college years wrote today to tell me of her fight against a Stage IV cancer diagnosis from several years ago. She is now cancer free. Her message was simple and dramatic - nobody can say for sure what will happen or fail to happen. But when you are surrounded with hope and when you are kind to other people, you can participate in your own healing. In addition, she and her family are praying for me and I know she will be there if I need a word of encouragement.
I will be training both physically and emotionally during the next three months as I prepare for surgery. We worked on the physical training program today at Popeye’s Gym. I’m excited about working out and being monitored closely as to my physical progress.
But how does one train the emotions? Well, apparently it’s not just a matter of willpower, of fighting negative thoughts and ruminations, of trying to be cheerful all the time, or even of avoiding stressful situations and people. You can actually build your enduring level of happiness through a scientifically tested regimen and clinically tested set of practices.
Two days ago, I mentioned Martin Seligman’s Learned Optimism. Yesterday, I discovered, purchased and downloaded an e-book edition of one of his more recent books about a movement he has pioneered called Positive Psychology. The book is entitled Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. This book has an interesting equation: H = S + C + V which translates into Happiness (enduring level of happiness) = set range + circumstances of your life + factors under your voluntary control. What this clearly implies is that even though I might not readily change my set range of emotions and can probably do little to change the circumstances in my life, I can modify factors under my control and thereby increase my enduring level of happiness. If happiness heals, then I can train myself in emotional healing.
Now, if we can just get the washing machine fixed ;>)
Tuesday, December 13, 2005
I watched the first episode of the new Canadian television series Terminal City last night. My wife wasn’t sure I should watch it, but I did. It is a ten-part series dealing with one family’s confrontation with cancer. In that episode, Katie Sampson discovers she has breast cancer. The next day she takes her daughter with her to the clinic where her biopsy is performed.
Ironically, my eldest son came with me today as I ventured to Grand River Hospital for my MRI, presumably a major piece of the puzzle considered by the tumour board which meets to review my treatment options this evening. The board will have in hand the CT scan, the images from the MRI, as well as the biopsy results from last week and all the other colonoscopy and sigmoidoscopy reports. But I won’t be there. In fact, it may be next week before I meet again with the surgical oncologist to hear what the board has determined is the best way to address my rectal cancer. While I wait, they deliberate.
The MRI itself was painless. There was an intravenous, as there was for the CT scan, and there were problems yet again finding a good vein in my arm, but the procedure was straight forward. The procedure was forty minutes of keeping very still and listening to what I call a “magnetic symphony”. Even with ear plugs and a face cloth across my forehead and eyes, the sensation of the magnetic resonances, each with a distinctive tonality and rhythm, was enough to keep me in a kind of limbo state, close to sleep, but still aware. I was a little concerned that I might move my body as the images in that near-sleep state kept floating through consciousness.
Again, like the CT scan, we stopped about half-way through the procedure for a contrast injection to illuminate the vascular system in the pelvic region. The only awkward thing from the patient perspective about the whole procedure was the length of time required. But from the little I have learned about the technology, the time required is well compensated. The MRI images can be highly tuned to answer precise questions that the medical team has regarding an injury or condition.
Now, I have a few questions that need to be answered too!
Monday, December 12, 2005
A few days ago I wrote that hope and concern were flip sides of the same coin. Another way to imagine this is to think of a spectrum with markers demarcating more or less optimistic outcomes. As I await medical imaging results and the pathology report, it is the continuum or spectrum of outcomes that drives my anxiety and my hope.
At the pessimistic end of the spectrum is the possibility that the images will reveal a tumour which has broken through the bowel walls completely, has invaded numerous lymph nodes and possibly even metastasised to the liver or lungs. The biopsies would show clear carcinoma.
At the optimistic end of the spectrum is the possibility that the images will show a large tumour that has not broken through the bowel wall, but is long and relatively shallow. The biopsies would show a tubulovillous adenoma with low-grade dysplasia like the previous biopsy. The CT scan and MRI would show no indication of lymph node involvement and no hint of metastases to any other organs.
In between, we get middling results. Perhaps the biopsies show no carcinoma, but the images show penetration of the bowel wall. Perhaps the biopsies give evidence of cancer, but the tumour is shallow with no lymph node involvement. Perhaps there is only some evidence of enlarged lymph nodes but no marks on the liver. And so on…
As I read Paul Tillich’s The Courage To Be today, I discovered that these kind of scenario-building fantasies reflect the natural inclination to relieve anxiety by turning it into fear of a particular object. In other words, generic anxiety and dread are eased by thinking of specific situations that I fear but for which I can generate a measure of courage or fortitude. By focusing on concrete objects or situations fear and bravery becomes possible. Far, far worse is unspecified, inarticulate dread. And, I suppose, it might also be reasonable to assume that unspecified, unrealistic hope is unhelpful since it betrays denial and unwillingness to face truth.
But I’m not so sure about generic optimism. Martin Seligman’s book Learned Optimism has a chapter devoted to health and the effect of learned helplessness. In case after case, he demonstrates that a “fighting spirit”, a sense of general optimism, a sense of control and participation in one’s own treatment leads to better results. Where there is a delicate balance, optimism he says can make the difference between life and death.
One thing about all this is virtually certain. It is far better to live one’s life with hope and optimism than to wallow in despair and dread.
Sunday, December 11, 2005
A friend wrote to me recently telling me about life-changing events in his own life. His survival and triumph was characterized by courage. Although he didn’t say it, the implication was that both he and I have resources which sometime are hidden from consciousness but that are available to us when circumstances deal us a blow.
As I read his note, it occurred to me that the concept of courage was something I hadn’t considered for a very long time. In fact, in the not-too-distant past, I have joked with my family saying, “I sure hope I never get a serious disease because I’m a wimp. I don’t think I could deal very well with life-threatening illness or a serious accident.” Never did I think then that I would face a diagnosis of colorectal cancer. Now, strangely, I am looking for and perhaps finding those hidden resources.
As I reconsider courage, my memory is bringing back material I have read many years ago. Today, for instance, being sure that somewhere in my library were books about courage that I need to reread, I searched for and found two oldies but goodies. The first is Paul Tillich’s The Courage To Be, published in 1952, the year before I was born. The second is another theologically oriented book by a major contemplative of the 20th century, Thomas Merton. The book is a collection of letters and is titled The Courage For Truth: Letters to Writers (published in 1993).
This week is about waiting. I’m waiting for an MRI. Then I will be waiting for the consultation I expect with my surgical oncologist to review the results of the biopsies from last week, the CT scan and the MRI.
There are a number of directions I could take in handling the waiting. There is distraction. For instance, I can simply go to work and do what is necessary. I’ll do that for sure. Then there is research. But I’ve already read so much that there are diminishing returns until I have further preoperative staging information available to me that nobody can provide except the oncologist. It might be smarter to take this week to reconsider what these great men of faith and thought have to say about courage.
Let’s see where that takes me.
Friday, December 09, 2005
“We are so lucky here. When we say you’re going to be scanned with the ‘old’ 16-slice CT scan, you’re really being scanned with a machine that’s less than a year old. In fact, we are one of the very few facilities in Ontario that has two CT scanners, a 16-slice and a 64-slice – both are less than one year old. Our waiting times have gone down dramatically. We can now process 56 patients a day.”
She was a very pleasant, personable woman who told me exactly what to expect. Thank goodness, because when the injected solution started streaming through my veins, it was only a couple seconds before I could feel the taste in my mouth, followed closely by an oddly familiar warm sensation in my groin. I’m glad she warned me about that one!
This evening, I’ve been sticking very close to the washroom because of the barium solution used to help highlight the organs in the abdominal scan. The frequency and urgency of trips surprised me. Nobody warned me about this part of the procedure.
Even though I will have to wait for the CT scan and MRI results, as well as the pathology results from the biopsy on Wednesday, I am feeling grateful today that we have such incredible medical resources in the Waterloo region. Today, because everything is so close by, I could go to work until noon, drive myself to the hospital for the medical imaging, then go back to work for another couple hours. When preoperative radiation treatment starts, it will be the same routine. If I had to drive to Hamilton, London, or Toronto, the effect on my work and home life would be far more intrusive.
Another comforting thought this evening came from the second episode of Carl Sagan’s Cosmos DVD series. As he spoke of natural selection and accidental mutations, it occurred to me that cancer is just another piece of evidence of the way evolution works. Random mutation of DNA and the cells in which the strands of life are contained is almost always maladaptive. In other words, cancer as an abnormal growth of cells can be thought of as par for the evolutionary course. The dance of death is the price we pay for the variety and richness of life.
Now, that thought in itself is not particularly comforting to somebody facing a diagnosis of rectal cancer. But what is comforting is the realization of the necessity of death and the awesome way in which life prevails. Our medical technology, our science, and our will to live – these are just some of the ways in way humanity improves the odds of natural selection dramatically. If I beat cancer, then it will be because evolution has taken another step beyond maladaptive mutation of cells. That step is really a leap, a kind of variation in the dance of death in which life carries on longer than one might expect.
Yes, we are so lucky here.
Thursday, December 08, 2005
I deal with high tech everyday. In fact, my job title is IT Manager. Information technology is the game I play, and I think I’m pretty good at it. But this technology – the CT scan – leaves me almost breathless in the range of information it can potentially provide.
The body passes through a donut-shaped apparatus while lying on a moving table. A series of x-ray photographs are timed to be taken from many angles, and then the information from those images is collated and presented as if the body was sliced through the middle at the point exactly where you want to look. For abdominal images, it’s one of the very best ways to preoperatively stage colorectal cancers. The physician or radiologist can look at the image and confirm the presence of a tumour, measure its size, determine how much involvement the tumour has with other abdominal tissues, and even locate the best sites for preoperative radiation treatment for rectal cancer.
Tomorrow I have my first-ever CT scan, perhaps one of the most important photographs of me ever taken. I doubt it will be my good side…how, after all, does the abdomen say “Cheese”?
Still, I find myself anxious once again this week prior to yet another trip to the hospital. This is an image that I desperately want to reveal a tumour and only a tumour. No metastases, please! No lymph node involvement, please! No penetration of the tumour into surrounding tissues, please! Please, let it be just an ordinary image of a not-so-ordinary tumour spanning the rectum and rectosigmoid.
They say it’s good to be hopeful. Sometimes, though, I find it difficult to determine the difference between hope and concern. Wishing for a good outcome and worrying about a poor outcome seem to me to be just flip sides of the same coin, a currency about as loonie as the Canadian dollar.
What is it they say? If wishes were dollars…”
Wednesday, December 07, 2005
It’s like having your own personal National Geographic special!
That’s what Robin Williams is supposed to have said when he watched the video screen for his colonoscopy. I can’t say if the story is apocryphal or not, but now I know what he means. Today, I was admitted to the day surgery department of St. Mary’s Hospital in Kitchener where I had both a flexible and rigid sigmoidoscopy. This time I was given a choice, so I opted not to be sedated but to watch the events unfold on the video screen, including the excising of two biopsy specimens.
The objective of the sigmoidoscopy was twofold: first, to measure the distance from the anal verge to the distal point of the tumour (11 cm); second, to obtain another biopsy to confirm carcinoma, something which the first biopsy sample was unable to do. Now that the surgical oncologist has the measurements confirmed, I am an eligible candidate for preoperative (neoadjuvant) chemoradiotherapy treatments before surgery to remove the tumour.
Friday, I have a CT scan and then next Tuesday I have an MRI. Both of these are to help determine whether there is any lymph node involvement as well as get a better estimate of the size of the tumour and whether or not it has penetrated through the rectal wall into the abdomen. The chemoradiotherapy will then attempt to shrink the tumour. Surgery will use the total mesorectal excision technique to remove completely the mesorectum surrounding the part of the rectum to be excised. I won’t know for sure about whether or not a colostomy will be required until the time of the actual surgery, although the TME technique offers not only hope for a lower recurrence rate of cancer in the bowel but a greater chance to preserve sphincter control, nerve preservation and sexual function. TME is not as widespread in North America as it is in Europe. Brigham and Women’s Hospital has an archived webcast of a total mesorectal excision.
So, I guess my journey is really just beginning – a journey and a fight against rectal cancer. I trust Dr. C. Everett Koop, former U.S. Surgeon General, was right when he said, “The best prescription is knowledge.” All I really know now is the diagnosis and the treatment protocol. But this National Geographic special has really just begun.
Tuesday, December 06, 2005
Anxiety is systemic.
It’s an interesting idea. And not just academically interesting – interesting in a theoretical, dispassionate sense of the word. It’s interesting in the sense of timely and appropriate to the circumstances.
At work, we have a consultant who has been involved with our company for about a year now. I have met with this consultant three or four times discussing leadership and team building. In one of those meetings, she recommended I read a book by Jeffrey Miller entitled The Anxious Organization: Why Smart Companies Do Dumb Things. I ordered the book and it finally arrived yesterday.
As I become fatigued with constantly reading about colorectal cancer, the arrival of this book provided a welcome diversion. Ironically, though, the thesis of the book seems entirely pertinent to the situation in which my family and I find ourselves – we’re anxious - anxious about my health, anxious about our finances, anxious about how each of us in the immediate family is coping, anxious about our dear friends whose father just died early in the morning…anxious.
Systemic implies something that affects the entire organism or organization. Even a single person's anxiety can be considered systemic in the context of the entire organization. In that sense, anxiety is contagious or infectious. But the author’s contention is that this pattern of contagion can be interrupted. In other words, one person, making what appears to be a minor change, can affect the entire organization, for good or ill, whether that organization is a corporation or a family. If one person in the family is overly anxious, the entire family's level of anxiety increases, and as it does, it becomes increasingly dysfunctional.
I can see that first-hand in my family’s response to the diagnosis of cancer. Tonight, for instance, as I prepare for the next biopsy and sigmoidoscopy tomorrow, I’m feeling anxious, irritable, and less likely to be a positive influence on our family.
But here’s the really cool thing about what Miller has to say about the feelings of anxiety. They are not the real me! Miller says, “We discover our true selves when we make calm, clear, and conscious choices.” That’s not to deny feelings, just to put them in their proper place.
Miller argues that thinking carefully is one of the best ways to overcome the automatic pilot of anxiety and the evolutionary dead-ends into which anxiety-driven reactions lead us. Anxiety is still important, but the automatic responses and reactions coming from our "lizard" brain, and even the "mammalian" emotional brain, do not represent the best of our evolutionary heritage. The real me responds to anxiety with recognition of the causes of anxiety, with acknowledgement of the fight, freeze, or flee response mechanism, and with gentle appreciation for the complexity and authenticity of emotional responses.
Although it is easy for us to discount the reptilian brain's meagre list of reactions, it is far harder for us to recognize the limitations of the mammalian brain's massively complex emotional responses. But that is precisely what we have to do; for once we recognize that so many of our emotional responses are habitual and based on childhood or adulescent behaviour patterns (the way we always respond), we find that we have other resources. We have choices.
It is the next step, where we marshall the resources of our neo-cortex, where we analyze, synthesize, and carefully discover what we really think, where we recall what our true principles are - it is then that we are in tune with our real nature. This is not to deny what people of faith refer to as God. It is not to toss aside prayer, contemplation, meditation, or even active listening to other people. It is simply to say that the best of me is all of me - but the command centre is the thinking brain.
Monday, December 05, 2005
In the past few days, I’ve had conversations with many friends and acquaintances. Some are quite interested in learning more about how colorectal cancer is diagnosed. Most are amazed and somewhat dismayed to learn just how pervasive a problem colorectal cancer is in Canada.
When we get past the initial discomfort people have with talking about bowels and symptoms, I find that almost everyone is willing to spend a few minutes learning about risk factors and signs and symptoms. But not everyone! So, for those who would rather read about it than talk about it, here are symptoms and signs (note, however, that these same signs and symptoms can and often do mean something else entirely):
- Change in bowel habits such as loose stools, constipation, uncomfortable bowel movements, thin stools, a feeling of incompletely emptying the bowels
- Abdominal discomfort, including gas, pain, bloating, cramping and fullness
- Bleeding (bright red or dark)
- Weight loss
- Iron deficiency
Although I think it is important for people to realize what the signs and symptoms are, the bottom line is that we can’t wait for symptoms. Screening before symptoms arise, especially the colonoscopy, is what will make a difference in preventing unnecessary death from colorectal cancer. I just have to hope that family, friends, and acquaintances will learn from my experience and take screening seriously.
Sunday, December 04, 2005
The International Agency for Research on Cancer (IARC) has indicated that bowel cancer kills half a million people worldwide each year. In Canada, we are told that 8,400 will die in 2005 from colorectal cancer and 19,600 will be newly diagnosed. I am one of those 19,600 people. I sincerely hope I will never be one of the 8,400 in any year! But the Canadian figures clearly show that Canada has one of the highest rates of colorectal cancer in the world.
What is most depressing about these statistics is that Canada has no population-based programs designed to screen for colorectal cancer. It’s not that nobody cares. It’s simply that we don’t have government sponsored health care policies in place designed to prevent unnecessary and premature death from colorectal cancer.
In my view, one of the major weaknesses of health care policy in Canada is that it is a provincial responsibility. Now that we are engaged in another federal election campaign, the one health care initiative from the governing Liberals designed to reduce wait times for medical procedures on a nation-wide basis will now be put aside until after January 23rd, 2006. I think that initiative is incredibly important, not just to reduce wait times, but to step up national awareness that some things are too important to be left to provincial governments.
Screening for colorectal cancer could be another federal initiative. Why not? Death from colorectal cancer is an unmitigated national tragedy that is almost completely avoidable, but the provincial governments have shown no leadership on this issue at all.
The Colorectal Cancer Association of Canada has recently started its first advocacy campaign. The goal is to lobby provincial members of parliament to talk to their respective Ministers of Health requesting progress towards a population-based screening program. Here is an example of a template used for email for MPPs in Ontario:
I am writing as a constituent to ask for your support for a properly funded screening program for colorectal cancer in Ontario.
The incidence of colorectal cancer in Canada is among the highest in the world. In 2005, approximately 19,600 Canadians will be diagnosed with colorectal cancer, and about 8,400 will die of the disease. It is the second leading cause of death from cancer in this country.
If detected at an early stage, colorectal cancer can be treated effectively with a high chance of cure. We need to screen for this disease to have any hope of early detection.
In December, 2002, the National Committee on Colorectal Cancer screening announced its findings on colorectal cancer screening and recommended that screening be offered to a target population of adults aged 50 to 74 years of age, and that individuals be screened at least every two years.
While the experts tell us that screening is necessary and justified, we do not have a population-based colorectal cancer screening program in place in Ontario.
I am asking you to write to the Minister of Health in support of colorectal screening in this province. We need colorectal cancer screening.
Please consider sending an email to your provincial member of parliament. Please also consider speaking directly to those requesting your vote in the federal election campaign to request a national initiative to save lives.
Saturday, December 03, 2005
I hope there aren’t a lot of sleepless nights.
This morning, my wife and I did a few typical weekend errands and then stopped to have a speciality coffee at Starbucks. Maybe it was the lack of sleep. Maybe it was having time just to be alone with her. Maybe it is the nature of facing cancer up-front-and-personal. Or maybe my body knows I need the catharsis. But when I found myself trying to explain why reading Psalm 19 in unison at the healing liturgy on Wednesday morning left me close to tears, I felt the tears welling up again.
We got in the car, drove on, and yet the tears continued unabated.
Psalm 19: 1-6
The heavens declare the glory of God; the skies proclaim the work of his hands. Day after day they pour forth speech; night after night they display knowledge. There is no speech or language where their voice is not heard. Their voice goes out into all the earth, their words to the ends of the world. In the heavens he has pitched a tent for the sun, which is like a bridegroom coming forth from his pavilion, like a champion rejoicing to run his course. It rises at one end of the heavens and makes its circuit to the other; nothing is hidden from its heat.
Gradually, I tried to explain that it isn’t the traditional Christian theology that affects me. It is what Paul Tillich would call “ultimate concern”. Being in the healing liturgy and speaking the psalm revealed something to me - as I face mortality and try to clarify values, two elements keep surfacing.
One is family and friends. Over the past week or so, family members and friends have expressed heartfelt sympathy and compassion. Their love has touched me deeply.
The other is the universe itself, what Carl Sagan would call the Cosmos. Moments of astonishment and awe occur with regularity whenever I contemplate the beauty, grandeur, and immensity of the “created” order. God is only my symbolic name for that ultimate reality.
I tried to explain that it wasn’t tears of sorrow that I was wiping from my eyes. Sure, there is something of a sense of potential loss. But far more significantly, my tears were what Tillich would say were a response to “a pervasive sense of joy.”
So, my wife and I made a change to our errand list, drove to the public library and found the first five episodes of Sagan’s Cosmos on DVD. I’ve started viewing the DVDs. It was a very good choice! If I can’t sleep tonight, I will know exactly what to do.
Friday, December 02, 2005
“…he is a pleasant, otherwise healthy looking well nourished man.”
Hmmm, how appearances can deceive. The operative report from my gastroenterologist gives some clinical descriptions and then launches into a travelogue of the gastrointestinal tract viewed through the Olympus video colonoscope. Here’s the part that’s most pertinent:
“In the rectosigmoid between 16 to 17 cm to about 10 cm there was a large mass noted that extended over a distance of about 6 to 7 cm and involved about ½ of the circumference of the colonic lumen. It was a friable mass with areas of ulceration in the center. The distal end of the tumor seemed to be about 10 cm from the anal opening.”
“…This young man’s colonoscopy unfortunately shows a large rectosigmoid mass. He is quite a young man to have cancer at an early age.”
I think so too!
On the other hand, the first pathology report says “the biopsies show superficial fragments coming from a tubulovillous adenoma with low grade dysplasia. No invasive carcinoma is identified. However, the biopsies are superficial and sampling bias cannot be excluded.”
So, no cancer yet, but not necessarily no cancer!
Some things are becoming clearer to me now just 10 days from my colonoscopy.
- I will probably be treated for rectal cancer.
- I will probably have a special kind of MRI geared toward preoperative staging of the cancer.
- I will probably be enrolled in a clinical trial of a chemoradiotherapy protocol aimed at reducing the size of the mass in order to facilitate surgery and improve quality of life for me subsequent to surgery.
- I will probably not have full staging information for about 3 to 3.5 months from now until after the surgery is done and the postoperative pathology report is complete.
- I am (tongue in cheek) “young, healthy looking, pleasant” and spoiling for a fight with this damned cancer!
- If I qualify, I would seriously consider any clinical trials associated with preoperative chemoradiation for rectal cancer.
And now for something completely different…
If you enjoy the comedy routines of Bowser & Blue during the holiday season, you might enjoy the lyrics to their Working Where the Sun Don’t Shine in praise of the colorectal surgeon:
"Working Where The Sun Don't Shine" (The Colorectal Surgeon's Song)
We praise the colorectal surgeon
Misunderstood and much maligned
Slaving away in the heart of darkness
Working where the sun don't shine
Respect the colorectal surgeon
It's a calling few would crave
Lift up your hands and join us
Let's all do the finger wave
When it comes to spreading joy
There are many techniques
Some spread joy to the world
And others just spread cheeks
Some may think the cardiologist
Is their best friend
But the colorectal surgeon knows...
He'll get you in the end!
Why be a colorectal surgeon?
It's one of those mysterious things.
Is it because in that profession
There are always openings?
When I first met a colorectal surgeon
He did not quite understand;
I said, "Hey nice to meet you
But do you mind? We don't shake hands."
He sailed right through medical school
Because he was a whiz
Oh but he never thought of psychology
Though he read passages.
A doctor he wanted to be
For golf he loved to play,
But this is not quite what he meant...
By eighteen holes a day!
Praise the colorectal surgeon
Misunderstood and much maligned
Slaving away in the heart of darkness
Working where the sun don't shine!