June 7, 2007 - Whack-a-Mole

How long have I had this cancer, anyway?

That’s a question that’s been on my mind, lately – not only as I’ve thought back to my initial diagnosis, but especially now, in this awkward, transitional time of wondering whether or not I’m having a recurrence.

Dr. Vance Esler, a hematologist-oncologist from Texas, has a helpful perspective on this question in the June 5 edition of his blog. Dr. Esler points out, in vivid terms, just how many malignant cells – and just how much time – is typically involved in a burgeoning case of cancer.

Cancer cells multiply exponentially. Cancer begins with just one malignant cell, then that one splits, then both of those split – and on and on, until there are tens of thousands, then millions and, eventually, billions. It’s not until those mutating cells hit astronomically high numbers that they surface on our most sophisticated cancer-screening tests.

In Dr. Esler’s words,

“Advancing technology is helping us to detect smaller and smaller cancers, but as a general rule, the smallest mass that we can currently detect within internal organs is about 1 cubic centimeter (.06 cubic inches) – about the size of a small marble. This equates to about 1 gram of tissue, or .04 ounces!

This is a little tumor – small enough that a woman could easily miss feeling it in her breast (for example), but large enough to probably be detectable by a mammogram. Everyone feels good when we detect cancers this small – until you realize that a tumor this size consists of approximately 1 billion cancer cells!”

How do all those cancer cells accumulate? They do it by doubling, as each cancer cell splits, creating two new cells. To get to that small-marble size, Dr. Esler estimates, a tumor may well have gone through 30 doublings: a process that – depending on the type of cancer – could take 5 years or more. With some cancers, the oncologist’s response is “Come right in for surgery.” Other times, it’s “Let’s try watchful waiting.”

I don’t know how long it takes lymphoma cells to grow, but if that five-year figure is at all accurate, my cancer could have taken a very long time indeed to reveal itself. When my largish abdominal tumor – between the size of a baseball and a grapefruit – first showed up on an ultrasound in the fall of 2005, it could have been growing inside me since well before the turn of the millennium.

That also means that, in May 2006, as Dr. Lerner declared there was no longer any sign of cancer on the PET scan, there could still have been renegade cancer cells hiding out in small clusters, in various parts of my body. (Or then again, maybe not – the results of my upcoming June 25 lymph-node biopsy will have something to say about that.)

“Chemotherapy,” writes Dr. Esler, “generally kills dividing cells. If most of the cells are resting, then they are not susceptible to chemotherapy agents which only attack dividing cells. So with repeated cycles, we simply hope that we will catch enough cells dividing each time to expect a reasonable kill.”

It’s like a giant game of Whack-a-Mole – that arcade game that keeps young children, especially boys, gleefully occupied for many minutes. The goal is to pound those little mechanical moles with a foam-rubber maul, as they poke their heads out of various holes. Even using the most sophisticated chemical and radiological agents, the oncologists are just hoping to pound enough of the pesky cancer critters that none of them will stick their heads up again for a while.

T.S. Eliot has a famous line about “measuring out our lives in coffee-spoons.” We go about our daily activities – thinking about tomorrow, and maybe next week or next month – but cancer has a much longer time frame. Cancer measures out its life in backhoe-buckets. We cancer survivors put so much stock in pronouncements like “one year cancer-free,” or “five years cancer-free,” but – especially in the time frame of some the slower-moving cancers – such intervals don’t mean a whole lot.

The hard truth is, lots of cancer survivors are walking around saying, “My cancer is gone,” when, on the microscopic level, it’s not. Years (or even decades) later, after the doubling process has done its work, and cancer rears its ugly head on a scan, they commiserate, saying, “My cancer came back” – when, in fact, it never left. It just went underground. “Cure” is an elusive concept, when the terrain investigators have to scour is so unimaginably vast.

In one of the Indiana Jones movies, the swashbuckling archaeologist fights his way into the inner sanctum of an ancient middle-eastern church, where a wizened old knight is guarding the Holy Grail (the cup used by Jesus at the Last Supper). This pious Crusader has survived, all those centuries, because he’s been imbibing regularly from the Grail. His time frame is no longer the same as that of ordinary mortals. He’s been wetting his whistle with tincture of eternity.

Maybe the ancient knight is a model for long-term cancer patients. He’s sort of like the old yogi who’s learned through meditation to slow down his breathing and heart rate, entering a state resembling suspended animation. In living with cancer, it’s not the quick, frenetic whack-a-mole response that makes the difference. Slow and steady wins the cancer race.