Monday, December 03, 2018

December 3, 2018 - The Recreation Floor

Yesterday and today Claire and I have had the opportunity to explore a part of Memorial Sloan-Kettering we hadn’t encountered during my earlier hospitalizations: the Recreation Floor. It’s not an entire floor of the hospital: just a part of the 15th floor, with a rather nice view of Manhattan skyscrapers.

My first couple of days here have all been about getting mobile again after my neck-dissection surgery - a more scary description than “lymph node removal surgery,” which is the kinder and gentler term I’ve been using. Dr. Boyle stopped by today and explained that he took out more than 50 lymph nodes - I’d only heard about 4 or 5 nodes lighting up on the PET Scan, but I figure the removal of the others was prophylactic. He said the pathologist will have a look at the nodes he removed and will let us know what’s going on with them. That will inform our future discussions about possible further therapy, be it radiation or chemo, or good old watch-and-wait.

The fact that the surgery site has continued to drain fluid into the plastic tube - that feeds a little cup nestled in the chest pocket of my hospital gown - is what’s kept me from going home today as predicted. Everyone’s optimistic that the flow will slow down by tomorrow, so the tube can be removed. I’m more than ready to go home. We’ll see.

That means I’m (1) mobile and (2) not receiving much in the way of active medical treatment, which has made me a good candidate for the Recreation Floor. Claire and I have hung out there twice now. Yesterday there was a group of five earnest Juilliard students putting on a little concert/dance performance, and today there was a guy tickling the ivories on the baby-grand piano (movie themes, jazz standards and the like), who I’m pretty sure was self-appointed but who was mighty good.

There’s a cruise-director sort of person who’s in charge of the Recreation Floor, who sets people up for art projects (decorating tote bags and Japanese lanterns), explains how the coffee machine works and lets everyone know which programmed diversions are coming up next. But most people just hang out, enjoying the cityscape view, reading their email or playing board games.

There are two types of people on the Recreation Floor: those solemnly padding around in hospital gowns (some dragging IV poles behind them), and others in street clothes - undoubtedly friends and family either accompanying their loved ones or taking a break from visiting them. None of us patients looked especially hale or hearty, but we didn’t much care. It just felt good to be out of our rooms.

The Recreation Floor is a gentle reminder of the fact that cancer is something you live with. Amidst all the high-tech medical wizardry around here, it’s nice to know there’s a place for painting Japanese lanterns and watching a talented ballet student demonstrate her grace and balance.

It’s about life. Which is the point of it all, isn’t it?

Saturday, December 01, 2018

December 1, 2018 - Recovering

Surgery is over: and successfully, according to Dr.Boyle. It took about three hours. Recovery is under way.

None of the unfavorable side effects have taken place. My voice is unaffected.

I don’t know whether it’s because surgery to the side of the neck is more difficult than surgery (thyroidectomy) to the front of the neck, or whether it’s because I’m five years older, but I’m finding this recovery slower going than before. I think it’s a little of both. I’m making progress, though.

One difference is that I do have a drain implanted - a plastic tube sticking out of one side of my incision. This was expected. Nurses stop in several times a day to empty the little plastic cup attached to it. Obviously, there’s no going home until the drain is out, but at this point I wouldn’t have the energy to do for myself at home, so it’s  just as well.

The care here at Memorial Sloan-Kettering is first rate. All the staff are very attentive.

I do very much appreciate all the prayers and expressions of support.

Thursday, November 29, 2018

November 29, 2018 — Back to the Operating Room

It’s been more than a year since I’ve posted to this blog — which is a good thing. I haven’t had a lot of medical news to report. But now, that situation has changed.

Looking back at my past entries, I see that, on August 9, 2017, my endocrinologist Dr. Stephanie Fish was talking with me about the slowly-growing lymph nodes in my neck. She said at that time that they were big enough to remove surgically, but that I could also wait on the surgery if I preferred.

I chose to wait. She told me I’d probably need surgery within 2-5 years, depending on what happened to the thyroglobulin numbers.

Well, it’s not even two years yet, and the thyroglobulin numbers have climbed at a faster-than-expected rate. In subsequent visits with Dr. Fish and my surgeon, Dr. Jay Boyle, I got the unmistakable impression that — based on those rising numbers, as well as measurements of my lymph nodes taken by ultrasound scan — my doctors were ratcheting up their pro-surgery lobbying efforts.

Part of my hesitation has had to do with non-cancer-related realities of my life. After 27 years serving one congregation, I’m now in the first year of a new pastorate, and loving it (I started on February 1, 2018 as Pastor of the Lamington Presbyterian Church in Bedminster, New Jersey). I’ve been feeling hesitant to break the momentum of this critical first year, and as long as my doctors were at all open to a watchful-waiting approach, I’ve been content to coast along.

Besides, there’s a bit of a risk to this surgery. Although they reassure me that my cancer is slow-moving and my prognosis is good — and that there’s a strong likelihood the surgical solution will be effective — there are structures in the neck that could sustain collateral damage from the surgeon’s scalpel. The principal concern is nerves: especially one that controls the ability to lift the arm higher than the shoulder and another that controls my left vocal cord.

I figure I can live with some decreased mobility of my left arm, should that be the result. The vocal cords are a different matter: I speak for a living. Dr. Boyle tells me some permanent hoarseness of voice is a side-effect in about 25% of cases. (I’m assuming he’s talking about the general average; as a surgeon who narrowly specializes in this type of surgery, his personal average is surely better than that.)

Until about a month ago, I was hoping I could postpone the surgery until early in 2019. Considering the rhythms of parish life, there’s just not a good time for a pastor to take medical leave in the late fall — what with the annual stewardship campaign, and with Advent and Christmas following soon after.

Drs. Fish and Boyle were clearly not pleased with my foot-dragging, so several weeks ago I  reluctantly agreed to have the surgery done tomorrow, November 30, at Memorial Hospital of Memorial Sloan-Kettering Cancer Center in Manhattan — the same place where I had my thyroid removed.

What pushed me over the edge was a consultation with a third MSKCC physician, Dr. Eric Sherman, a chemotherapy specialist, that took place on October 26. (Yes, my doctors triple-teamed me; and it worked.) There’s a possibility, I learned from him, that it may be wise to follow the surgery with either some mild radiation treatments — possibly a repeat of the radioactive-iodine pill I took following my thyroidectomy — or some chemotherapy, or both. Dr. Sherman was reassuring in predicting that the chemo I may receive will be nowhere near as potent as the R-CHOP regimen I underwent in 2006 for my non-Hodgkin lymphoma. He didn’t seem to think that either of those treatments will slow me down much. So, I’ll wait and see what recommendation emerges, after the pathologist has a look-see at my tissue samples, post-surgery.

Dr. Sherman also explained a detail to me that I somehow hadn’t picked up from what my other doctors had told me. There’s a sweet spot for lymph-node removal surgery: the nodes have to be big enough to remove easily, but not so large that they become enmeshed with other structures in the neck: that would make collateral damage harder to avoid. I’m in that sweet spot now. Were I to wait much longer, the possibility of limited arm motion or vocal-cord damage would be greater.

So, here I am, on the eve of surgery: fearful of post-operative pain, and anxious about waking up with a hoarse voice that may be more than the typical result of having been intubated in the operating room. They tell me I’ll be in the hospital for at least three nights following surgery, because I’ll have a drain implanted near the incision for that period of time. I’ve never had one of those before, so I don’t know what to expect.

The problem is, I’ve had a long time to think about this, to weigh the relative risks of watchful waiting vs. surgery. Had it been an emergency, I simply wouldn’t have had time to engage in second-guessing as I have.

In 48 hours or so, I suppose I’ll know a lot more.

Wednesday, November 08, 2017

November 8, 2017 — Alcohol and Cancer

The latest cancer research news is likely to make a lot of people unhappy: drinking alcoholic beverages is now considered a definite risk factor for cancer, particularly cancers of the mouth, throat, voice box, liver and — for women — breasts. Alcohol also plays a lesser role in causing colorectal cancers.

The Cancer Prevention Committee of the American Society of Clinical Oncology (ASCO) has issued a statement of its belief “that a proactive stance by the Society to minimize excessive exposure to alcohol has important implications for cancer prevention.” Although they note that the research on which this advice is based “is still in the formative stages,” they have reached the point where they’ve started to advise people to reduce their alcohol consumption as a cancer-prevention measure.

The New York Times reports that the prevention message is not total abstinence, but rather very limited alcohol consumption: “The message is not, ‘Don’t drink.’ It’s, ‘If you want to reduce your cancer risk, drink less. And if you don’t drink, don’t start,’" said Dr. Noelle LoConte, an associate professor at the University of Wisconsin-Madison and the lead author of the ASCO statement. "‘It’s different than tobacco where we say, “Never smoke. Don’t start.” This is a little more subtle.’”

The Times quotes the researchers’ estimate that “5.5 percent of all new cancers and 5.8 percent of all cancer deaths worldwide could be attributed to alcohol.”

We’ve long been advised that a little wine — particularly red wine, with its antioxidants — is good for health generally, especially cardiovascular health. This latest statement sets up a certain conflict in the minds of those wishing to live healthy lives. Should we drink a little wine from time to time to keep our arteries clear, or should we abstain in order to avoid mouth, throat, voice box or liver cancer?

At the very least, moderation seems advisable. But habitual, heavy drinkers put themselves at significant risk.

Wednesday, August 09, 2017

August 9, 2017 — On the Back Burner

I’m overdue posting my latest news, but I’ve been away on vacation, then was occupied with re-entry tasks after returning.

On July 31st Claire and I drove two and a half hours down to Albany from our Adirondacks camp in Jay, boarded a train in Albany and headed into Manhattan. Our destination was Memorial Sloan-Kettering, where I had a long-standing appointment with my endocrinologist, Dr. Stephanie Fish.

Once our vacation plans had fallen into place, I’d tried to postpone the appointment so we wouldn’t have to travel so far. But when I learned that Dr. Fish’s next open appointment slot was in February — you heard it right, FEBRUARY — I cooked up our elaborate travel plan.

I’d had ultrasound testing at the time of my appointment with Dr. Boyle in June, and had gone to the new MSKCC satellite facility in Middletown, NJ for a blood draw just before we left for the North Country. So, this appointment was to hear Dr. Fish’s recommendation on whether or not surgery is called for, to remove the suspicious nodules in my thyroid bed and the lymph nodes on the left side of my neck that have yielded a positive biopsy for thyroid cancer.

Turns out, the answer is neither yes nor no, but “not yet.”

Dr. Fish observed that my thyroglobulin had gone from 1.0 ng/mL in June of 2016 to 5.7 in January, 2017. My latest July 21 blood work had it at 5.2, slightly lower. My June 5 ultrasounds showed no significant growth of the lymph nodes in my neck. The suspicious nodules in my thyroid bed are unchanged in size (these are the ones that could not be successfully biopsied with a needle because they’re too deep). Both my surgeon, Dr. Jay Boyle, and Dr. Fish concur that it's acceptable to continue the watch-and-wait.

Dr. Fish said they’d be willing to proceed with the lymph-node and nodule-removal surgery now if that’s something I want, but I told her I’m content to wait on that. She said she had been expecting — based on the January results — a steady climb in the thyroglobulin level, indicating rapidly advancing disease, but it does seem to have stalled for now.

I asked her what I could expect as far as how long the watch-and-wait strategy will continue, and she predicted I’ll probably need surgery within 2-5 years, depending on what happens to the thyroglobulin numbers. She said her greatest concern is the nodules, because - if they are indeed cancerous - they’re located in a place where, if they did start to grow, they could invade other structures in my neck, such as the larynx and esophagus. The lymph nodes on my neck, on the other hand, are close to the surface and would be less likely to impact other structures.

This whole experience is sort of like being stalked by a vicious sloth. We can see him coming, but there’s no particular hurry to get out of the way.

Bottom line: watch-and-wait continues. Surgery is on the back burner. Follow-up blood work and ultrasounds are scheduled for 6 months from now.

If I wasn’t such a veteran at receiving this sort of news,  I’d probably be consumed by anxiety. But I’ve been living with cancer for so long now, it’s not a new thought. Just more of the same.

After a dinner out with my sister-in-law Ramona in Manhattan, Claire and I bade each other farewell for the next week. I boarded an Amtrak train back to Albany, and she a NJ Transit train to our home on the Jersey Shore (she’d run out of vacation days and had to get back to work). I spent the next week getting our house ready for putting it out for rental on AirBnB: a new experiment for us.

Wednesday, July 12, 2017

July 12, 2017 — A Living Drug

A hopeful news bulletin today from the New York Times:

“A Food and Drug Administration panel opened a new era in medicine on Wednesday, unanimously recommending that the agency approve the first treatment that genetically alters a patient’s own cells to fight leukemia, transforming them into what scientists call ‘a living drug’ that powerfully bolsters the immune system to shut down the disease.

If the F.D.A. accepts the recommendation, which is likely, the treatment will be the first gene therapy to reach the market. Others are expected...”

This particular treatment focuses on an uncommon form of childhood leukemia, and is earmarked for the 15% of patients who don’t respond to other treatments. Here’s how it works:

“The treatment requires removing millions of a patient’s T-cells — a type of white blood cell — and genetically engineering them to kill cancer cells. The technique employs a disabled form of H.I.V., the virus that causes AIDS, to carry new genetic material into the T-cells to reprogram them. The process turbocharges the T-cells to attack B-cells, a normal part of the immune system that turn malignant in leukemia. The T-cells home in on a protein called CD-19 that is found on the surface of most B-cells.

The altered T-cells — called chimeric antigen receptor cells — are then dripped back into the patient’s veins, where they multiply and start fighting the cancer. Dr. Carl H. June, a leader of the University of Pennsylvania team that developed the treatment, calls the turbocharged cells ‘serial killers.’ A single one can destroy up to 100,000 cancer cells.”

It's fascinating to me that the new treatment uses a stripped-down form of the HIV virus as a pack-mule to carry the re-engineered genetic material back into the patient's cells. There's a kind of poetic justice in using one killer to fight another.

Although the article refers to this treatment as a “drug,” it stretches the usual definition of the word. It’s part drug, part treatment protocol.

Whatever it is, I’m glad to see it’s ready for prime time. It can’t be long before other, similar treatments for a variety of cancers will follow.

Monday, June 05, 2017

June 5, 2017 — Keep Waiting, Keep Watching

I've just returned from Memorial Sloan-Kettering's satellite facility in Basking Ridge, New Jersey. I had a routine ultrasound followed by a consultation with my surgeon, Dr. Jay Boyle. Routine, yes, but - since I'd had a biopsy of a lymph node on the left side of my neck several months ago that revealed recurrent papillary thyroid cancer - I knew this would be a discussion about treatment options. They're also pretty certain that several small nodules that have been detected in my thyroid bed (where the thyroid used to be) are also cancerous, but those are too inaccessible for a needle biopsy.

I also knew that, because Dr. Boyle saw no need to move my appointment up after news of the biopsy results came in, this is a relatively slow-moving situation.

Bottom line is, we decided to continue watchful waiting for now. I'd told the nurse that was my preference, based on what I knew, and she told Dr. Boyle of my wishes before he came into the room. He's agreeable with that. He said that, as far as he's concerned, we could go either way. He did say that, if we decided on surgery, he'd recommend removing a whole lot of lymph nodes as well as the nodules in the thyroid bed, because it's not easy to keep going back in there and remove a lymph node here, a lymph node there. With each new surgery, there's more potential for damage to the tissues of the neck area. He said that, based on the location of the nodules, surgery would present about a 10% chance of permanent damage to the nerve that controls the vocal cords. I speak for a living, so permanent hoarseness and weakness of voice is not something I'd consider lightly.

I asked him where in the body thyroid cancer usually metastasizes to, and he said the lungs and the bones are the most common. In either of those cases, though, he said it's usually treatable with either further radioactive iodine treatments or beam radiation.

The ultrasound showed no change in the size of the thyroid-bed nodules, nor of the couple of abnormal lymph nodes they've been watching, but it did show a new, very small lymph node in the same area that also looks abnormal. The doctor said he could only barely feel any of those lymph nodes as he palpated my neck.

The other doctor who's involved with this decision is my MSKCC endocrinologist, Dr. Stephanie Fish. Dr. Boyle tried unsuccessfully to get Dr. Fish on the phone to find out why, exactly, she'd ordered the biopsy - because he said that, in his experience, when a doctor orders a lymph node biopsy, it's generally because surgery is a likely outcome (if it turns out there's a malignancy, of course). When I reminded him of my non-Hodgkin lymphoma history, he said that could explain it - there would be a need to determine which of my two kinds of cancer was causing the swelling in the lymph nodes. Different cancer, different treatment protocol. (We now know, of course, it’s the thyroid cancer that’s recurred, not the lymphoma.)

I see Dr. Fish on July 31st. They drew blood today that will provide her with thyroglobulin numbers and other crucial information she needs, prior to that appointment.

It's kind of nerve-wracking to wait all that time, and a little frustrating that the two doctors weren't on the same page prior to my arrival today. Dr. Boyle said he will talk to her, though, and I'm sure he'll call if there's any change.

I'm OK with this outcome. I'd rather not face another surgery at this time, if if can be avoided. With years of watchful waiting for my NHL behind me, I'm comfortable with the "don't shoot till you see the whites of their eyes" approach. Sure, I'll continue to live with uncertainty, but what else is new?

Today's appointment confirms for me how important it is to be go into such meetings well-informed, and to speak up about my own preferences as a patient. Some treatment decisions are less than clear-cut, clinically speaking, which leaves significant room for patient preference to be taken into consideration.

Next appointment with Dr. Boyle is in 6 months. As I've said, I see Dr. Fish in just under 2 months.

Monday, May 22, 2017

May 22, 2017 — Enough with the Battle, Already

I’ve written before about the many reasons why the familiar military imagery as applied to cancer survivors — her “courageous battle with cancer” — is not the most sensitive choice of words. I’ve seldom seen this topic explored so eloquently nor so concisely as in an article in the most recent issue of The Presbyterian Outlook.

The author is Ashley-Anne Masters, and the article is “Cancer Doesn’t Discriminate Between the Sinners and the Saints” (Presbyterian Outlook issue of May 29, 2017, pp. 48-49). She’s Interim Manager for Spiritual Care and the Heartlight Program at Lurie Children’s Hospital of Chicago:

“One side effect of cancer treatment that's as gross as nausea is the battle imagery. I can't stand hearing that someone who died from cancer ‘lost her battle.’ Anyone who ever endured cancer invading his or her body is anything but a ‘loser.’ The battle imagery is dangerous and painful. It implies that when someone dies of cancer, he died because he didn't fight hard enough. It implies that if someone chooses palliative treatment in the face of terminal diagnosis, she is giving up or not fighting.

It's also an unpleasant side effect for those living with cancer or thriving in remission. We celebrate and are grateful, yet battle imagery can add to a patient's symptoms of survival guilt. It does not mean he isn't (or wasn't) in the fight of his life during treatments. It does not mean she doesn't fear recurrence at annual scans. It does not mean they aren't strong and brave. But saying they ‘won the battle’ when they, too, have lost friends, colleagues and family members to cancer implies that they are somehow superior to the people they miss. Let's assist in savoring their celebrations and milestones. Let's not taint their gratitude and gumption with a prescription for guilt.”

Another reason, of course, why the battle imagery misses the mark — one that Ashley-Anne doesn’t mention, and in fact gets a little bit wrong — is that cancer is actually not an invasive disease, in the same way a bacterial infection is invasive. We don’t “catch” cancer. Cancer cells are manufactured by our very own bodies as a result of genetic mutations. While there’s sometimes an external cause that can be identified — as asbestos exposure is a leading cause of mesothelioma — it’s not the carcinogen that makes people sick, but their own body’s response to the carcinogen.

In cancer, certain cells of our body — for reasons that are often inexplicable — turn against other cells of our body: surrounding, quarantining and devouring them. That’s the true battle of cancer: not patient vs. disease, but cell vs. cell. The patient is the battlefield, not the steadfast soldier.

Visualizing ourselves “battling” cancer means we’re doing battle with our own bodies, and that’s hardly a helpful way of looking at it.

Friday, March 24, 2017

March 24, 2017 - Moving That Fear Threshold

Today, in the online Cure newsletter, I came across an article by a cancer survivor named Barbara Carlos, who’s noticed a change in the role fear plays in her life, since undergoing cancer treatment:

“I am not sure exactly how or when it started, but somewhere in the midst of chemo, I noticed a change. Things that used to make me crazy no longer bothered me. Other things that I had thought so unimportant that they had been left perking away on the back burner for years suddenly came to a full boil. It was confusing....I kept chugging along, constantly juggling priorities and re-prioritizing them. After a while, I noticed a change in my attitude. I was no longer afraid of the little things in life. I didn’t care if I wore the wrong clothes or said something stupid in a meeting. After my last chemo, I spent a week in the hospital with neutropenia and had another two weeks of bed rest at home. I didn’t physically feel up to doing anything that required more exertion than breathing, but my brain clicked away as I lay there. By the time I started radiation, the transformation was complete. I had become fearless. In spite of the nasty burns on my chest and the pain they generated, radiation was a piece of cake compared to chemo. I had made it through chemo and I was going to make it through radiation just fine. I had faced off the Emperor of All Maladies and won the battle. I felt empowered beyond words and completely confident that I was going to win the war.”

It’s similar to the experience I’ve had, over the 10+ years of my journey with cancer. And, I know from conversations I’ve had with other survivors, that it’s true for many other people as well.

“Whatever doesn’t kill you makes you stronger,” goes the old adage. It’s especially true of cancer.

One of the things we learn as cancer survivors is that our fear threshold is moveable. What moves it is the experience of facing our fears, not running from them. When we face a hitherto unimaginable challenge and move right on through it, we’re strengthened to face other challenges that may lie ahead.

We’re not free of fear as we do so. Fear can’t be so easily banished by positive thinking, nor even by prayer. Most of us don’t pray away our fears: we pray through them.

Often, folks are inclined to match up the word “courageous” with “cancer patient,” but those of us who’ve been through it know it’s not any virtue inherent in ourselves that helps us make this transition. It’s one of those Higher Power things, as our friends in AA would say. When we’re flat on our back on an operating-room gurney, and the anesthesiologist is about to open the valve on the IV line that will send us off into unconsciousness, there’s nothing we can do in that moment to influence the outcome. We’ve got to turn it all over. We have no other choice.

Those of us who are conversant in traditional religious language turn it over to God. Others may go the Higher Power route. But whatever language best captures our experience, there are times when we can sense that fear threshold moving. And the good news is, once it moves forward, it rarely moves back again.

Thursday, February 09, 2017

February 9, 2017 — Confirming What We Already Knew

Three days ago I made the trip to Memorial Sloan-Kettering in Manhattan for a repeat of the biopsy that didn’t work out so well. That was actually two biopsies: one of some lymph nodes in the left side of my neck that have become enlarged, and the other of some small nodules that have developed in my thyroid bed (the area where the thyroid used to be).

I evidently misunderstood what the nurse told me in an earlier phone conversation. Turns out, the lymph-node biopsy was successful after all, yielding enough tissue for analysis. The problem was with the nodes-in-the-thyroid-bed biopsy. This is the one they wanted me to come in to repeat, this time to Manhattan rather than to Basking Ridge.

That didn’t happen, though. The interventional radiologist in New York did an ultrasound of my neck, and after looking at the results she concluded it was too difficult, even risky, to biopsy the nodules. They’re located very deep inside the neck, and they’re surrounded by so many blood vessels that there would be the risk of internal bleeding that could be hard to control. Her largest needle is barely long enough to reach that spot, she explained, and the longer the needle, the harder it is to control its tip precisely. She promised I’d be hearing soon about the results of the lymph node biopsy, once the other doctors have had a chance to confer.

Yesterday, I got a phone call from my endocrinologist, Dr. Stephanie Fish, who ordered the biopsies. She confirmed that there is papillary thyroid cancer in the lymph nodes, the same type that had showed up in nodules on my thyroid gland five years ago.

This is further confirmation of what we already knew — or had at least surmised. Dr. Jay Boyle, the surgeon who removed my thyroid, told me back in July that the nodules were almost certainly a recurrence of thyroid cancer.

But there’s still no particular hurry to do anything about it. The protocol continues to be “watch and wait.” Dr. Fish told me that Dr. Boyle sees no reason to move up the date of my next scheduled appointment with him, which is in June.

I’m OK with this. It’s taken me some years as a cancer survivor to wrap my mind around the concept, but “watch and wait” is not a matter of ignoring the issue. In certain circumstances, it’s a treatment modality in itself.

To paraphrase ol’John Milton, they also heal who only stand and wait.

Thursday, February 02, 2017

February 2, 2017 - Again with the Needle

Late this afternoon, I was a the gym when my mobile phone rang. Caller ID said only "New York City." Realizing it wasn't a local emergency call involving a church member, and not wanting to step off the elliptical trainer, I let it go to voicemail.

When my 30 minutes on the elliptical were ended, I listened to the message. It was from Memorial Sloan-Kettering. Please call back because one of the nurses has a message for you from Dr. Fish.

OK, this is it, I said to myself. My biopsy results.

I called back, and was eventually connected to the right nurse. Yes, she did have my biopsy results: just not the results I expected.

The tissue samples from the lymph nodes were not diagnostic. (In other words, inconclusive.) Dr. Fish wants you to come in - to the main hospital in New York this time - and repeat the biopsy.

That was surprising to me because the needle-wielding doctor at the MSKCC Basking Ridge facility had seemed so confident she'd gotten a good sample.

Someone's going to phone me tomorrow to set up the appointment.

I'd call the news "a kick in the pants" were it not for the fact that getting another needle in the neck sounds worse.

Oh, well. Cancerland is full of surprises.

Tuesday, January 31, 2017

January 31, 2017 — Under the Needle

I haven’t posted anything here since last summer, because not much has been happening. Which is, of course, a good thing.

Yesterday, though, I went up to Memorial Sloan-Kettering in New York for a routine consultation with my endocrinologist, Dr. Fish. I’d had an ultrasound of the neck a week before, which told her that the lymph nodes on the left side of my neck that had been slightly swollen last summer are significantly larger now. That, coupled with a spike in certain chemical markers in my blood, indicates that thyroid cancer has very likely taken up residence in those lymph nodes, and is growing.

She recommended a needle biopsy of the lymph nodes, to confirm what we’re dealing with. (I asked her if it could be a return of the non-Hodgkin lymphoma, but she said she doesn’t think it likely. The blood test is pointing to thyroid cancer as the culprit.)

It was all very laid-back. Thyroid cancer is typically slow-moving, so there’s no particular rush about these things. For that reason, I was a little surprised a few minutes later when the doctor’s scheduler, seeking a date for the biopsy, asked, “How about tomorrow?”

I initially said no, that’s a little too soon, but when I learned the next opening she had was more than a month away, I took a quick survey of my calendar and said, “Why not? Let’s go with tomorrow.” I suppose there must have been a cancellation or something.

Which brings me to today. This morning I drove up to the Memorial Sloan-Kettering satellite facility in Basking Ridge, New Jersey for my ultrasound-guided needle biopsy.

Dr. Fish had clued me in to the fact that this would be done while I was awake, without anesthesia. “They’ll give you a little lidocaine,” she told me, “to numb the skin. But it’s a very tiny needle, so you’re not likely to feel any pain.”

Well, when I got there, the diagnostic radiologist who would be conducting the biopsy said there would be no lidocaine, because the biopsy needle is actually smaller than the needle they use to inject the lidocaine. The act of numbing the skin would be more painful than the biopsy itself.

I asked her if they had any lidocaine spray around, but she said no, they didn’t. That surprised me a little, but I figured, hey, they do this all the time, it will be fine.

I’ll say it ended up being not exactly fine, but tolerable. The doctor was right, the needle is very small. I’m so used to blood-test needles by now that I barely feel them going into my arm any more, and that was true of this needle as well, penetrating the left side of my neck. I did feel a distinct pressure from the needle as it advanced deeper below the skin, though. That pressure, bordering on pain, was uncomfortable, but the lidocaine wouldn’t have done much about that in any event.

Three punctures later, it was all over. I was lying on my side during that part of it, so the doctor told me I could watch it on the ultrasound screen if I wanted. I decided to do so. It was odd, watching the tip of the needle penetrate my lymph node, move up and down a few times, then come back out again.

Mission accomplished with the lymph nodes. Then, it was on to step two. Dr. Fish had also ordered a biopsy of the abnormal nodules that have appeared in my thyroid bed (where the thyroid used to be). Those are pretty stable, not having grown since last summer, but she figured that, while I was on the table, they ought to go ahead take a look at them as well.

This involved me lying on my back with my head stretched over a pillow positioned under the back of my neck. The target nodule was considerably smaller and a good deal deeper than the lymph nodes.

Same deal: very tiny needle, no anesthetic, but this one was aimed just below the base of my neck, smack dab in the center. This was a different sort of experience. Again, the surface puncture was barely noticeable, but the digging around deep inside crossed the boundary from pressure into pain. The doctor could tell I was in pain, and decided to stop after just one sample. She said she was reasonably sure she didn’t get enough tissue from the tiny nodule for a good result, but she didn’t want to proceed any further because I was clearly uncomfortable. The nodules weren’t the main target for today, she explained: the lymph nodes were.

I was grateful. If it had been strongly necessary, medically speaking, I would have been willing to tough it out. But I was just as glad when she decided to call a halt.

Results should be in within two or three days. It will be up to Dr. Jay Boyle, my thyroid surgeon, to communicate the results and begin the conversation about next steps.

Surgery will almost certainly be in my future — he told me that last summer — but the big question will be, when? The pathology results will tell us how aggressive my particular variety of cancer is.

It could be pretty soon, or it could be a matter of more watchful waiting.

The question will also be, what? Just an excision of the close-to-the-surface lymph nodes (fairly easy), or a removal of the nodules in the thyroid bed as well, with the risk of possible damage to the vocal cords?

Watch this space.

Sunday, July 10, 2016

July 10, 2016 — Living Beyond

Last December, I wrote a blog entry acknowledging the tenth anniversary of my first cancer diagnosis. I dared to hope it could be a sort of capstone for this meandering project. Maybe I was finally out of the woods. Maybe ten years meant I was “cancer-free.”                                    
Recent events have proven otherwise. My December annual visit to Dr. Stephanie Fish, my endocrinologist at Memorial Sloan-Kettering, turned up some abnormalities in an ultrasound of my neck. Several tiny nodules had appeared in my thyroid bed — the area where the thyroid gland had once been — that looked worrisome.  Dr. Fish reassured me that it was too early to tell if this was significant, but arranged for me to come back for another ultrasound in six months.

I’ve now had that follow-up test. Dr. Fish informed me there are unmistakable “signs of disease” in the thyroid bed, as well as some swelling of nearby lymph nodes. The usual treatment for recurrent thyroid cancer, she explained, is further surgery. Because I already had a routine follow-up scheduled with Dr. Jay Boyle — my thyroid surgeon — she told me I should ask him what treatment options he recommends.

Last week, Claire and I drove up to the Memorial Sloan-Kettering satellite clinic in Basking Ridge, New Jersey to see Dr. Boyle. He confirmed everything Dr. Fish had told me. The thyroid cancer is back. The truth is, it probably never left me. He’d warned me back then that it’s difficult to surgically remove every microscopic bit of thyroid tissue. That’s the reason for the radioactive iodine treatment I’d had at the time: it’s a precautionary cleanup of the whole area. But it’s not always 100% effective.

As for the lymph-node involvement, he told me that was visible even at the time of my surgery, but is of no greater concern than the newly-appeared nodules.

Well, what’s ahead? A biopsy?

The nodules are too small to biopsy.

A further radioactive iodine treatment?

Not likely. That’s a one-time approach, much less effective on the second go-round.

What about further surgery?

The nodules, he explained, are still very tiny and are therefore hard to remove surgically. They’re also located in an inconvenient place, close to the nerve that controls my vocal cords. If I opt for surgery, there’s a 10% chance of permanent hoarseness as a side-effect. Dr. Boyle knows as well as I do that I make my living with my voice.           

As for the lymph nodes on the left side of my neck, they’re closer to the skin and therefore easier to remove, but that would require a large incision that would do damage to delicate neck tissue. Such an incision would make further surgery in that area — should it ever be required, down the road — problematic.

Better to postpone surgery, he advised. Thyroid cancer is typically slow-moving. At 59 years of age, I just may outlive it. If I do reach the point where surgery is indicated, it would be just as effective then as it would be now.

The treatment Dr. Boyle recommends is one that’s become familiar to me as a non-Hodgkin lymphoma survivor: watchful waiting. Dr. Fish has already ordered a follow-up ultrasound for six months from now. Dr. Boyle thinks that’s an appropriate precautionary step, but he doesn’t expect to see a big change.

A short while after our visit to Dr. Boyle, I had a conversation with a friend who’s a breast cancer survivor. She’s had a long series of surgeries and treatments. She, too, is not in any immediate danger, but her scans have revealed some recurrent disease.

My friend told me she’s stopped updating friends and family about every detail of her situation, because it’s hard for others to grasp what watchful waiting really means. “We’ll always have cancer,” she told me, frankly. “People who haven’t lived through it have a hard time understanding that. They don’t understand that the most aggressive treatment isn’t always the best choice.”

My situation exactly.

Recently I read a little article in Cure magazine by Mike Verano, a psychotherapist and cancer survivor. It’s called "Moving On After Cancer." Mike’s point is that few people are ever able to move on after cancer, to attain the much-heralded “closure.” Most cancers are simply not that sort of disease.

Mike has this to say:

“Thirty-plus years into the practice of psychotherapy, I’ve learned that telling someone that their recovery depends on ‘moving on’ is akin to telling a depressed person to just ‘be happy.’ My approach these days is to talk about living with rather than living without, allowing over forcing and, most importantly, realizing that life moves on in wellness and illness, joy and suffering, pleasure and pain. I firmly believe that illness does not halt this process; it does not put the brakes on existence. Feeling stuck comes from a trick of the mind that sees suffering, of any kind, as an unnecessary detour and waste of time.

Once we allow our lives to unfold with cancer as part of our experience, we awaken to the literal meaning of the word survive which is ‘to live beyond.’ This is the wisdom of being told that we become survivors on the day we receive our diagnosis. Thus, the need to discover the way ahead, to put psychological, emotional and spiritual distance between ourselves and the illness is already being met. Therefore, the work is often a matter of staying out of our own way as we move through this process.”

Survival as “living beyond”: I like that insight. It sounds positively theological. Jesus Christ says he has come that we “may have life, and have it abundantly.” It’s so very easy for us to ascribe to cancer the power to make this God-given life less abundant than it already is. Cancer has no such power.

We watch. We wait. We live. We love. We have cancer.

We live beyond.

Wednesday, December 02, 2015

December 2, 2015 — Ten-Year Cancerversary

Ten years ago today, Claire and I were sitting in the office of my oncologist, Dr. William Lerner, feeling stunned by the news of my diagnosis with non-Hodgkin lymphoma. It was too much information to take in all at once. As happens with many who receive a cancer diagnosis, it rocked my world. I can remember sitting there and nodding my head as the doctor went into various details of my grading and staging and what to expect, but only retained about half of it. Thank goodness I had taken some notes to which I could refer later.

During the months that followed, I had surgery to implant a chemo port that would stay in my body for 7 or 8 years. I had six rounds of R-CHOP chemo, spaced at three weeks apart. I lost my hair, and dealt with all the weakness and queasiness that go along with a powerful chemo regimen.

I learned much about the love and support that come from family, friends and church during a season of serious illness. I ran up against the limits of my energy on numerous occasions, and learned how to step back and let others do things for me — never an easy thing for someone in a helping profession.

I had a subsequent diagnosis of thyroid cancer a few years ago, which led to the surgical removal of my thyroid gland followed by radioactive iodine treatment. There has been no recurrence, though I still see the thyroid surgeon, Dr. Jay Boyle, once a year for follow-up, as well as my endocrinologist, Dr. Stephanie Fish, who monitors my Synthroid dose. The thyroid cancer may or may not have been aggravated by radiation from the numerous CT and PET scans I’ve had, to look out for lymphoma recurrences (my doctors say it’s unlikely that the radiation from the scans contributed to the thyroid problem, but I do know the thyroid gland is the body’s canary in the coal mine with respect to radiation exposure — bottom line is I’ll probably never know for sure).

Because the type of lymphoma I have is an indolent form — one that can float beneath the diagnostic radar for years, and when it does recur is considered incurable but treatable — I’ll never be able to take comfort in being declared  cancer-free. But that’s OK. Life is good, I’m feeling fine and I’ve come to appreciate all the lessons this experience has taught me.

I’ve grown in faith, hope and love and am glad this blog has been a helpful resource to many others who are walking a similar road. From the bottom of my heart, thank you to all who have offered me support over the years.