Monday, July 30, 2007

July 30, 2007 - Speak Up!

There was a fine article in yesterday’s New York Times: "Cancer Patients, Lost in a Maze of Uneven Care," by Denise Grady. It highlights the sad fact that, for all the technological wonders we have available to us in this country for treating cancer, the actual delivery of those treatments often leaves much to be desired.

Cancer is a complex disease. Almost always, successful treatment requires not just one doctor, but a team. It also requires patients to become well-informed about their condition, and to participate, along with their physicians, in making treatment decisions. It’s not that the patients know more about medicine than the doctors (we don’t). It’s that, in many cases, there is no clear-cut treatment protocol. Like the scarecrow in the Wizard of Oz – who, when Dorothy asked him which way to the Emerald City, replied by saying, “Some folks go this way, some folks go that way, but other folks go both ways” – sometimes doctors actually say to patients, “I have several different treatments I could recommend, all of which show some track record of success – which one would you prefer?” When we hear such a question from our oncologist, we’ve got to be able to supply an answer. That’s why it’s so important to educate ourselves about the disease.

For patients to be active participants in treatment decisions is sometimes more than a matter of personal preference. It can make the difference between life and death. The Times article tells the story of Karen Pasqualetto of Seattle, who – in her thirties – developed colon cancer. By the time it was diagnosed, her disease had progressed to stage 4, and had spread to her liver.

Karen’s first doctor said her liver cancer was inoperable. There was nothing he could do for her, other than palliative chemotherapy treatments. He told her she had six months to live. Not taking no for an answer, Karen found a new oncologist, who was willing to give her aggressive chemotherapy. It helped. But this doctor, too, considered her a poor risk for surgery. Still refusing to take no for an answer, Karen located a physician at Johns Hopkins Hospital in Baltimore who was an expert on risky liver surgeries. She went to him, and learned that – while he agreed she was not a good candidate for surgery – he thought she was good enough. (Karen had stacked the deck a bit, by – in a blatant bid for sympathy – holding her infant daughter on her lap as she spoke with the surgeon.) After a very involved operation, she was able to return home and live – at least for now – a relatively normal life. Her cancer will likely recur, but already she’s outlived the original life-expectancy predictions.

Karen’s original medical insurance company was only willing to pay for the palliative chemo. If her husband had not moved to a new job – as a mid-level executive with Starbucks – that offered better medical coverage, Karen’s surgery would not have been covered. In that scenario, unless she would have been able to tap friends and family to pay for her care, she would be dead today.

Karen’s care, the Times article says, cost over $400,000. Her original insurer refused to pay it. Because her husband moved to a new job, and because his employer’s medical insurance didn’t exclude Karen’s case as a pre-existing condition, she was able to survive.

Reflecting on the members of a cancer support group she attends, Karen said, “It was amazing to me the different experiences people were having based on what they could afford or who their provider was. I was able to say, ‘If the provider won’t pay, my family will. I don’t care, I’m going for a second opinion.’ ” But, she also knew that not every patient could make such a statement.

Is it worth $400,000 to give a young mother a few more months, even a few more years, to help raise her child? It’s an agonizing question. How can one even put a price cap on something like that? The sad truth is, insurance companies do it every day. It’s all part of the game. In countries with universal health care, it can still be problematic. In those places, it’s the government making the call, not private companies – although, in those systems, at least the playing field is more level, from one patient to another. It’s less of a maze (to use the Times writer’s metaphor).

For us patients, speaking up for ourselves is part of the game too. The proverb’s right: the squeaky wheel gets the oil. Sometimes, something else is also true: it’s the squeaky wheel that survives.

Friday, July 27, 2007

July 27, 2007 - Harry Potter and the Christian Faith

Yesterday, I went for my PET scan and accompanying CT scans. I've written previously of what these tests are like, and these were no different – so, I see no need to repeat myself. I'll be eagerly awaiting the radiologist's report interpreting these images, which will suggest whether or not the cancer has advanced further since my last scans, just over three months ago. There's not much more to say than that: once again, it's a waiting game. I'm getting quite used to that, by now.

What I'd prefer to write about, instead, is the book I've just finished reading, in the wee hours of this morning. Along with millions of other people, I've been reading J.K. Rowling's Harry Potter and the Deathly Hallows, the seventh and final volume in this series that has been such a publishing phenomenon. (Don't worry, if you haven't read it yet: I have no intention of communicating "spoiler" plot details.)

I've always been impressed by this series of children's books, that adults have read just as eagerly. The first volumes attracted some undeserved flak from Christian fundamentalists, who feared that the magical premise of the stories – all the talk about wizards and spells and flying around on brooms – could somehow be spiritually dangerous to young readers. It's the same sort of misguided thinking that leads some Christian conservatives to forbid their children from trick-or-treating on Halloween (or, at least, to steer them away from wearing ghostly bedsheets or pointy witches' hats). There are some people who seem to believe more strongly in the devil's power than in the very Lord whose victory, scripture tells us, results in Satan being chained and cast into a bottomless pit (Revelation 20:1-3).

Fortunately, most of the malicious whisperings about the Harry Potter books being un-Christian have died down – because anyone who actually reads them quickly realizes there's a deep morality at their very core: one that's certainly compatible with Christian faith, even if it may not speak explicitly in Christian terms).

I was pleased to no end to realize, upon reading this seventh and final volume, that it's a departure from the others. What's different is that the Christian symbolism of the earlier books – which had been, at best, extremely subtle – now becomes very obvious indeed. I can't say too much more than that without giving away plot details, but I will predict that the Harry Potter books will henceforth be considered to be as much classics of Christian literature as C.S. Lewis' Narnia books now are.

In most of her press interviews, J.K. Rowling has adroitly dodged the topic of her personal religious beliefs. In at least one interview, however, she's admitted to being a member of the Church of Scotland. That means she's not only a Christian, but – are you ready for this? – a Presbyterian! This latest volume contains two Bible verses, both of them found on tombstones of important members of the wizarding community who have died in years past: "Where your treasure is, there will your heart be also" and "The last enemy that shall be destroyed is death." These are, of course, Matthew 6:21 and 1 Corinthians 15:26. Rowling doesn't cite chapter and verse, nor does she identify these words as coming from the Bible, but their placement in the story line is about as unmistakable as a neon sign.

Again, I can't reveal plot details, but the whole story is a cosmic struggle between good and evil, in which selfless love is shown to be capable of vanquishing the most soul-chilling and vicious hatred. Death, and life beyond death, are discussed at greater length than in the previous books, as is the immortality of the soul. We have already seen how, in earlier volumes, it was the selfless, sacrificial death of Harry's mother, Lily, that rendered Harry uniquely resistant to the killing curses of Voldemort, the Dark Lord. As one Christian reviewer has put it, in Harry Potter and the Deathly Hallows "Rowling begins to reveal that, like Narnia, her world has a ‘deeper magic.' Love, expressed as substitutionary sacrifice – choosing to lay down your life for your friends – has a power that Lord Voldemort, like the White Witch before him, is blind to." (Bob Smietana, "The Gospel According to J.K. Rowling," on the Christianity Today website, July 23, 2007).

Being told you have incurable cancer – even a treatable variety, such as I have – does send your thoughts winging, more frequently than others', to subjects such as death, love, courage and life eternal. Harry Potter and the Deathly Hallows is as reliable a vehicle for raising up those weighty questions as any other novel I can think of. As more and more people read it – and as we can speak freely, no longer having to worry about avoiding “spoiler” surprises – I predict this book will become a potent tool for discussing the greatest questions of this human life of ours.

Wednesday, July 25, 2007

July 25, 2007 - Again, with the Bone-Marrow Biopsy

Yeah, today it’s time to go through this lovely ritual again (see my December 15, 2005 entry for my first experience with this test). I arrive at Dr. Lerner’s office about 2:00 p.m., feeling a good bit more composed about this than I did last time. I’m a veteran, now, I say to myself. I even have the presence of mind to dress in drawstring gym shorts and a t-shirt, knowing this will make things go a little more smoothly.

They take me back to the phlebotomy room for a blood draw (absolutely routine for me, now, as many times as I’ve had this done), then into the little room they use for bone-marrow biopsies. It’s the first time I’ve been in here since my last one. There’s an examining-table in the center of the room. Laid out on a counter, off to one side, are some glass microscope slides, ready to receive the red goo the doctor will soon suck out of my pelvic bone. They don’t have the actual instruments laid out yet, though. That’s probably a good thing.

After taking my blood pressure and temperature, the nurse instructs me to pull my pants halfway down my buttocks, and lay on my left side on the examining-table, looking away from the counter with the slides laid out on it. (Forget about dignity with this procedure.) She covers me with some surgical paper coverings. Dr. Lerner, who had stuck his head in to greet me a few minutes earlier, comes in now, and says it’s time to get started.

The first order of business is to numb the area up, with some injections of novocaine (or something similar). These injections are the most acutely painful part of the experience (ironic that the pain-killer causes so much pain – but, then, I wouldn’t want to imagine what this would feel like without the local anesthetic). It’s a sharp, burning pain, repeated each time he sticks me with the needle. Waiting a few moments, he does it again – though I don’t feel much this time, because the first dose has started to take effect.

From my last experience, I remember what I felt during the actual harvesting of the marrow could better be described as pressure than actual pain. This time, it’s not quite so benign. When he’s ready to go in, Dr. Lerner suggests I may want to take some deep breaths: in through my nose, out through my mouth. (Let me tell you, whenever a doctor tells you to breathe like this, what’s coming your way is not good.)

I fix my eyes on a nearby, random object – the adjustment knob on the back of a desk chair – and try my best to zone out, going someplace far away. I do feel actual pain, this time – a sharp sort of pain that seems to be coming from my tailbone, rather than from the hip (where the doctor is actually working). This happens as Dr. Lerner inserts a syringe into my bone, to “draw out some fluid.”

Next, it’s time for the actual biopsy. Thanks to the local anesthetic, I don’t feel anything when the instrument goes through the skin, but I do feel him twisting something rapidly behind me – rather like the motion you’d use to turn a corkscrew – and then I feel a sort of pop. This, I’d imagine, is the biopsy instrument punching its small hole in the pelvic bone. Next, Dr. Lerner says I may feel a sort of pulling, as he removes the sample. I don’t actually experience that, though I do feel the same sharp pain in my tailbone I felt when he stuck the needle in.

Moments later, it's all over. “We got a nice, big piece,” he informs me, with a tone of satisfaction. (“We didn’t get it, you did,” I think to myself, “but thanks, anyway, for including me as a partner in the project.”) While he works on setting up the microscope sides, the nurse cleans me up and puts a dressing on the wound. She then instructs me to turn over and lay on my back.

This I remember from the last time. I have a few minutes, looking up at the ceiling while Dr. Lerner is filling out some paperwork, to bring him up to speed on the latest appointments – the delay of my PET/CT scan till tomorrow, and the fact that I’m now scheduled to visit Dr. Portlock at Memorial Sloan-Kettering on August 7. He suggests I make my next appointment with him for August 8, the very next day, so we can discuss treatment options.

Dr. Lerner says goodbye, then, and turns to leave the room. “Thank you for everything you’re doing to help me,” I blurt out, before he goes (it just occurred to me that maybe I haven’t said “thank you” often enough). That may sound like a strange thing to say to someone who’s just poked a hole in your bone, but I really mean it. As uncomfortable as the procedure was, it certainly wasn’t terrible. I’ve heard enough stories from fellow cancer patients about absolutely agonizing bone-marrow biopsies – and enough good things, from the nurses, about Dr. Lerner’s skill at the procedure – to know he’s kept my pain to a minimum.

A few more minutes of looking up at the ceiling, and the nurse tells me I can sit up and dangle my legs off the table. She brings me a small can of orange juice (rather like being a blood donor, I think to myself). Then, after asking me a couple times if I feel dizzy (I don’t – well, not much, anyway), she says I can go home.

I take it easy the rest of the day – sitting on the couch and reading the new Harry Potter book. Every time I get up, I feel a dull pain in my right hip, like a pulled muscle. This, too, shall pass.

Dr. Lerner told me the lab-test results will be available around the middle of next week. If I don’t hear from someone in his office by Friday, he suggested, I should give them a call.

Tuesday, July 24, 2007

July 24, 2007 - Providence

Yesterday, I was supposed to have a PET/CT fusion scan and an accompany- ing CT scan. That didn’t happen, because the PET/CT fusion scanner broke down. Atlantic Medical Imaging called yesterday morning to tell me not to bother to come in. Of course, I’d already drunk half a bottle of the chalky contrast fluid the night before, as instructed.

Oh, well. I’ll just have to repeat the procedure on Wednesday night, for my rescheduled Thursday scan. Through a fortunate error, they gave me an extra bottle of the lovely stuff, so at least I don’t have to make an extra trip to their facility to pick up another.

I wonder what medical-imaging companies do when their high-tech machinery breaks down? Call the repair service, I guess. Does the dispatcher tell them, “Make sure somebody’s there tomorrow, sometime between 8 am and 4 pm?” I have visions of some guy showing up in a panel truck, wearing a toolbelt over his greasy, low-riding jeans, saying, “OK, show me where ya got dis here PET scanner...”

Today, I’ve been reading an excellent article, “Security Check,” from the July 10 issue of The Christian Century. It was recommended to me by Carol, a friend and ministry colleague. It’s an excerpt from an upcoming book by Scott Bader-Saye of the Unversity of Scranton, Following Jesus in a Culture of Fear (Brazos Press).

Bader-Saye tells the story of an acquaintance of his, a cancer patient named Steve, who received a letter from a well-meaning, but theologically clueless friend. This woman knew – she just knew – God would heal Steve, if he would only believe.

The letter didn’t bring a whole lot of comfort, because Steve was astute enough to realize the implication: if he did not receive a gift of miraculous healing, it would be his fault, because he did not have enough faith.

Steve was offended enough by the letter to venture a reply, even though – because of his weakened condition – he had to call on his brother to write down his words:

“I share your faith in the almighty power of God to heal and sustain us. There may be times, though, when God's greatest miracle is not the miracle of physical healing, but the miracle of giving us strength in the face of suffering. Paul wrote in 2 Corinthians 12 that he prayed God would remove a thorn in the flesh, but God answered simply, "My grace is sufficient for thee: for my strength is made perfect in weakness . . . for when I am weak, then am I strong." Also, Jesus prayed in the garden that he might not suffer, but it was God's will, and he faced that suffering with a perfect faith.

As I read the Bible, God's promise is to remove all our suffering in the next life, though not necessarily in this one. In this world, we will sometimes weep, suffer and die. But in the New Jerusalem, ‘God shall wipe away all tears from their eyes; and there shall be no more death, neither sorrow, nor crying, neither shall there be any more pain, for the former things are passed away’ (Revelation 2:14).

I sincerely hope that if my cancer continues to grow, no one will see it as a failure of my faith in God, but that perhaps people can see me as faithful even if I die while I am still young. I do not claim to understand God's will, but I do know that I am in God's hands, whether in life or in death.”

Commenting on the woman’s letter, Bader-Saye speaks of the theological doctrine of providence, which many people take to be synonymous with a promise of protection. It’s not:

“She mistook God's promise to provide for a guarantee to protect, and once she had done that, she could only lay the blame for Steve's cancer at his own feet. Once she had ruled out the possibility that the cancer could result from chance or misfortune (and her understanding of providence left no room for contingency), she assumed that someone had to be blamed for the illness. This perverse theological form of adding insult to injury results from misunderstanding the connection between providence and security. Providence does not guarantee protection; rather, it assures us of God's provision (making a way for us to go on) and redemption (restoring what is lost along the way).”

I like that. I’ve never taken providence to mean protection, myself, but Bader-Saye reminds me anew that God promises to provision us for the journey, however difficult it may be. As the most beloved of Psalms reassures us:

“Even though I walk through the darkest valley,
I fear no evil;
for you are with me;
your rod and your staff –
they comfort me.”
(Psalm 23:4)

God doesn’t spare us the arduous journey – but God does hand us a rucksack, filled with provisions for it (if only we are willing to accept the gift). And, at journey’s end, we are welcomed with a feast that redeems the suffering:

“You prepare a table before me
in the presence of my enemies;
you anoint my head with oil;
my cup overflows.”

The only thing my cup’s overflowing with, these days, is radioactive contrast fluid, but no matter. There will be other cups, and more meaningful libations.

Sunday, July 22, 2007

July 22, 2007 - "Undefeated" Video

This short, inspirational video was created by a cancer survivor, Melanie Briggs, during her time of treatment for locally advanced breast cancer. It expresses her thoughts about being not a cancer victim, but a cancer survivor.

Click on the picture to activate it:

Saturday, July 21, 2007

July 21, 2007 - Trusting the River

This evening, I come across a rather good metaphor for living with cancer. It comes from an obituary in the Boston Globe, for Lynne Dahlborg, a woman whose cancer blog I've been following. It was written by a Globe correspondent by the name of J.M. Lawrence:

"On her 59th birthday last year, Lynne Dahlborg went tubing with her children down the rocky course of the Virgin River near Utah's Zion National Park.

Doctors had told her a few weeks earlier that she had a rare terminal cancer and removed her gallbladder.

Writing about that river ride in a blog, Ms. Dahlborg said she found herself exhausted and terrified, with no exit. Her daughter loved the three-hour adventure, but Ms. Dahlborg was in agony until she stopped fighting the flow, she wrote.

‘Like life, the river kept going, and my surrender was part of living and healing and knowing that I could survive even the sharpest rocks and deepest drops,' Ms. Dahlborg wrote, using the river as a metaphor for her cancer and strong faith that God would heal her spirit."

I felt touched, a week or so ago, when I visited Lynne's blog and found an entry written by her partner, the Rev. Patty Kogut, announcing her death. These blogs allow us to journey with people we've never met, through some pretty rich and challenging human experiences. When one of us falls, there's a sadness – not as distinct as the sadness of someone we've known through face-to-face contacts, but a sadness all the same.

I do so appreciate Lynne's image of the white-water tubing trip. The cancer journey includes some wild rides, and also significant periods of calm, placid water. I think Lynne was right in pointing out that the only way to make the journey is to cease resisting our little craft's tossings and turnings, and trust the river to carry us along.

Friday, July 20, 2007

July 20, 2007 - Relapse

This afternoon, as Claire and I sit in one of Dr. William Lerner's examining rooms, he hands me a prescription for another PET/CT scan. At the bottom, he's written: "DX: Lymphoma in relapse for restaging."

Yes, that's right. I've relapsed.

There's some good news, in the midst of the bad. The pathologist's analysis of my core-needle biopsy sample has revealed only small lymphoma cells. The lab-coated geniuses peering through microscopes found no trace of the larger, aggressive cells that were present at the time of my initial diagnosis.

Dr. Lerner says this doesn't surprise him. Other patients he's had in the past, with the same "diffuse mixed large and small cell" grading, have been treated successfully for the aggressive component of their disease. The indolent, small cells, on the other hand, are always much harder to defeat – in fact, indolent lymphoma is considered "incurable, but treatable."

I ask Dr. Lerner if patients like me, with the "diffuse mixed large and small cell" diagnosis, can in fact be considered to have two different types of lymphoma. He agrees that, yes, that's an accurate way to describe it. So far, the R-CHOP chemotherapy regimen seems to have wiped out my large, aggressive lymphoma cells (please emphasize the "so far," because it will still be some time before we can venture to use the word "cure," referring to those aggressive cells). As for the small, indolent cells, they're likely to keep bugging me for some time to come.

Dr. Lerner conducts a physical examination, spending a great deal of time touching and probing my neck and armpits with his fingers (these are parts of the body where lymph nodes are close to the surface). I ask him if he can feel the same swollen nodes under my jaw and at the base of the neck he felt the last time I was in his office. He says he can't – but, this comes as no great surprise to him. Cancerous lymph nodes swell up, but sometimes they also inexplicably diminish in size.

Locating the tiny scar from the biopsy needle at the base of my neck, he probes that area. He says he can't feel the deep-down, swollen node from which the biopsy sample was taken (but then again, neither could the surgeon, Dr. Gornish, as I lay on the operating table several weeks ago).

So, what's ahead? The first order of business is another PET/CT scan. I'm due for one, anyway – more than three months having elapsed since my last one – so there shouldn't be a problem getting the insurance company to fund it. Second, I'll return to his office for another bone marrow biopsy – I'm due for one of those, too. Third, I'll take those scan results, along with the biopsy slides and pathologist's report, up to Dr. Carol Portlock at Memorial Sloan-Kettering Cancer Center in New York. (She's the lymphoma specialist I've been conferring with, for second opinions.)

As for treatment, Dr. Lerner says there are a number of different directions we could go – and, since this is a slow-moving cancer, we can take our time to consult with other specialists and make up our minds. With this kind of cancer, he admits, treatment decisions "are not black and white." Put a hundred lymphoma specialists in a room, he predicts, ask them what they would do, and they'll come up with a range of recommendations. Here are the possibilities:

• (1) Watchful waitingIt's a slow-growing lymphoma, and I have no symptoms right now, so one approach would be to just wait and see what develops (this approach is more commonly used with older patients, rather than younger ones like me, but it could still be appropriate if the next scans continue to reveal only a few problematic lymph nodes, and if I continue to have no symptoms).

• (2) Aggressive chemotherapyThis would be treatment with a second-line chemotherapy regimen, with the usual grisly side effects. It would almost certainly wipe out all discernible traces of lymphoma – although it's debatable whether it would be more effective, in the long run, than the other options.

• (3) Stem-cell transplantThis is a form of second-line chemo, but the drugs are so toxic, they would take down my entire immune system. The doctors would harvest stem cells from blood ahead of time, freeze them, and use them to rebuild my immune system after the treatments are finished. The stem cells would come either from one of my brothers (allogeneic transplant) , or from my own blood (autologous transplant) . Stem cells from a sibling donor are more likely to wipe out the cancer, because there's zero chance any free-floating cancer cells could slip through the sieve – although they offer their own set of challenges.

• (4) Treatment with Rituxan aloneMy R-CHOP treatment was a combination of Rituxan and the four-drug CHOP chemo cocktail. The next time around, I could be treated with Rituxan infusions alone. The side effects of Rituxan are pretty much limited to some uncomfortable reactions during the infusion itself – there's no hair loss, no nausea, no mouth sores, none of the other miserable side effects people associate with chemo.

I ask Dr. Lerner about the radioimmunotherapy drugs, Bexxar and Zevalin. He says that, yes, one of those would also be an option:

• (5) Bexxar or ZevalinBoth these drugs are Rituxan with an added kick: a tiny fragment of radioactive material that piggybacks on each molecule of the medication. The Rituxan does its thing, targeting the CD-20 protein on the surface of the lymphoma cells and sending out its microscopic smart bombs to attack those cells: but, then, the little radioactive hitchhikers deliver their own payload as well, making it a one-two punch. Dr. Lerner's office is not set up to administer Bexxar or Zevalin, but he sometimes refers patients to Jersey Shore Medical Center, which is licensed to deliver these treatments. Bexxar and Zevalin are new drugs, he cautions, and it's still not clear what their long-term effects are. There's some chance the radioactivity could cause long-term damage to my bone marrow – and, since, at age 50, I'm looking ahead to many years of living with lymphoma, this is something he advises I weigh carefully.

I mention the recent article in the New York Times, about the relative slowness of the oncology world to adopt Bexxar and Zevalin (see my June 23 and July 14 blog entries). Dr. Lerner says he isn't entirely happy with the article – he suspects the Times editorial staff has it in for the medical profession, and particularly for the pharmaceutical companies – but the facts about the drugs presented in the article are essentially accurate. He says he especially resents the implication that doctors are influenced by financial considerations when it comes to choosing the most effective treatment to recommend. (For the record, Dr. Lerner impresses me as a person of principle, who would not be easily swayed by such inducements.)

I also mention that, the first time I conferred with Dr. Portlock at Memorial Sloan-Kettering, she suggested I consider a clinical trial for a new cancer vaccine protocol. This clinical trial was limited to newly-diagnosed indolent lymphoma patients – so, once the MSKCC pathologist found aggressive as well as indolent cells in my tissue sample, that deal was off. Although vaccine treatments are not yet generally available, should Dr. Portlock be aware of another clinical trial for which I'd qualify, that would give me yet another treatment option:

• (6) Vaccine therapyCancer "vaccines" are quite different from any other kind of vaccine. They're not so much a means of preventing disease, as a way of treating it. If I were to qualify for vaccine therapy, a sample of my malignant cells would be harvested through another biopsy, and sent off to a laboratory. In the lab, a custom vaccine would be cultured from the malignant cells, which would then be injected back into my body at regular intervals, over a period of time. (The clinical trial I was briefly looking at made use of monthly injections over a two-year period.) The vaccine would essentially teach my own immune system how to fight off the cancer.

I feel particularly fortunate in having five, and possibly six, treatment options from which to choose. I ask Dr. Lerner if he would care to rank them in some sort of numerical order, but he says he's not able to do so. There are so many factors involved in the decision – and, besides, I ought to wait and see what the next set of scans reveals, and also hear what Dr. Portlock recommends.

He's just laying out all the possible options, at this point. This is an indolent lymphoma, so we have time.

I feel even more confidence in Dr. Lerner than I did before. He takes the time to explain things, and he seems naturally inclined to take a collaborative approach – not only with professional colleagues like Dr. Portlock, but also with his patients. He doesn't seem to let his ego get in the way: when there are multiple options to be weighed, he's not afraid to admit the complexity of the situation.

Stopping at the scheduling desk on the way out, I book a bone-marrow biopsy for Wednesday of next week. Later, after my return home, I get a call from one of Dr. Lerner's staff, saying that Atlantic Medical Imaging can squeeze me in for a PET/CT scan on Monday morning. A subsequent call from Atlantic confirms that my insurance company readily approved it, so we're good to go.

And how am I doing, in the midst of all this? I'm doing OK. From the time those swollen lymph nodes showed up on my last PET/CT scan back in March, the signs have been pointing to a relapse – so, it's no surprise. I've had plenty of time to get used to the possibility, and there's a certain comfort in finally emerging out of the fog of uncertainty. The fact that there are no aggressive cells in the tissue sample is good news, indeed – probably the best news I could have expected.

More and more, the phrase "living with cancer" seems to be my mantra. It's time to embark on the next stage of that journey.

Wednesday, July 18, 2007

July 18, 2007 - Looking for the Rock

Today, Claire and I are in Plymouth, Massachusetts. She’s attending a professional conference: a four-day certification program for bereavement facilitators. It’s connected with a recent change in her responsibilities at Meridian Hospice. Henceforth, Claire’s duties will be focused in the area of bereavement: ministering not so much to patients and their families before death, as to the families afterwards.

I’m on vacation, so I’m tagging along as a spouse – an unaccustomed role for me. Most times in the past, I’ve been the conference participant and Claire the supernumerary. That means I’ve had plenty of time to stroll the streets of this picturesque New England coastal town – made famous, of course, by the religious dissenters known as the Pilgrims, who chose it as their first North American settlement.

This burg is of particular interest to me, because (along with tens of thousands of others) I’m a descendant of two of the Mayflower passengers: John Howland and Elizabeth Tilley. Howland – manservant to the expedition leader, John Carver – had a memorable mishap during the voyage: he fell overboard during a storm. The crew fished him back aboard with a boat hook. That means I can tell people – truthfully – that I have an ancestor who fell off the Mayflower.

I find Howland Street, and get Claire to snap a photo of me in front of the street sign. Later on, I notice a garbage truck, with the words “Howland Disposal Company” painted on the side. It’s good to know that business is picking up, for my seventeenth cousins – or whatever kin they are to me, so many generations later. Tomorrow, after Claire's conference is over, we’ll visit the Jabez Howland House, which is restored and open to tourists. Named for one of John and Elizabeth’s sons, who built it, it’s the house where John died, and where Elizabeth lived as a widow for the remainder of her life.

For centuries, the chief objective of tourist treks to Plymouth has been the ordinary-looking boulder known as Plymouth Rock. According to lore, this rock was the first place English settlers stepped ashore as they disembarked from the Mayflower, back in 1620. This claim is historically doubtful: as the Pilgrims landed at this bleak-looking spot – hundreds of miles north of their Virginia destination, with winter coming on – surely the last thing they had on their minds was keeping track of which boulder had received the first European footfall.

But, no matter. Underneath a majestic, neoclassical portico – embedded in a meticulously-raked plot of sand, reminiscent of a Zen garden – Plymouth Rock is an impressive-enough national shrine. It’s been so for hundreds of years. Over time, this nondescript hunk of New England granite has been carted around, jostled, dropped, engraved with the year “1620,” broken in two and cemented back together – not to mention chipped down considerably in size, by chisel-wielding souvenir-hunters.

Gazing down at the rock, coddled in its neoclassical nest like some dinosaur egg, I get the distinct sense that this is a shrine to permanence. Why else would a culture go to the trouble of building an ornate stone roof, just to protect another stone? The portico is just as much a part of the shrine as the rock itself. “Looky here,” it screams out, to passersby who might otherwise miss this one boulder, so similar to all the others. “This is an object of veneration. Regard it and wonder.”

The town of Plymouth is chock-a-block with other shrines to permanence, poor relations of the celebrated rock. I don’t think I’ve ever seen so many boulders with bronze plaques bolted onto them. They’re everywhere. So are greenish bronze statues of various Pilgrim fathers and mothers, and street signs bearing their names. It’s a town built on memories.

Plymouth Rock – one of America’s earliest tourist destinations – is a monument not so much to the real, historical Pilgrims, as to a patriotic young nation’s hallowed, misty-eyed memory of its forebears. In a nearby museum are dozens of artifacts – everything from a portable writing desk to an old, woolen stocking – reputed to have belonged to Mayflower passengers. Nowadays, the museum’s placards candidly admit that most of these attributions are bogus. Yes, most of these artifacts were donated or loaned to the museum by descendants of the original families. Yet, these people were as eager as we to possess their own, personal icon of permanence. Consciously or unconsciously, they invented a Mayflower provenance for many well-worn items that were not quite old enough to qualify. (William Bradford may be dead and gone, but his woolen stocking belongs to the ages.)

Compared to the weathered boulders of this world, human life is fleeting. As the old gospel hymn puts it, paraphrasing Psalm 90:

“Some glad morning when this life is over,
I’ll fly away.
To a home on God’s celestial shore,
I’ll fly away.

I’ll fly away, O Glory,
I’ll fly away.
When I die, Hallelujah, bye and bye,
I’ll fly away.”

In a recent blog entry, cancer patient Leroy Sievers ruminates about what memories his survivors will cherish about his life, once his disease claims him:

“When we’re gone, how fast will we disappear? How long before time erases any trace that we were ever here? ‘Dust to dust’ is not just a figure of speech, after all. We’ll live on for a while in the memories of those we’ve touched. But over time, these, too, will fade along with our pictures.

I’m not talking about fame. It’s of dubious value now, and certainly not worth much after we die. Who, besides a few contestants on Jeopardy, can name the builders of the pyramids? The Seven Wonders of the World have all but disappeared, to be replaced recently by a new list that just doesn’t seem to fire the imagination the way the old one did. The bottom line – it really doesn’t matter what anyone says after we’re gone. It would be nice if everyone said good things. But we won’t be here to hear them....

So what matters is not what we leave behind. What matters is what we do now. Do we touch the lives of others? Do we make a difference? Do we earn our place for the brief time that we are here? I think all we can hope for, all we should strive for, is a day well lived. And then another, and another. What better legacy could there be?”

Cancer or no cancer, that’s the only rock we’re likely to find.

Saturday, July 14, 2007

July 14, 2007 - How Long Have I Got?

“So, Doc, how long have I got?” That’s the question that often follows hard upon the dread announcement, “You have cancer.” With lymphoma – as an article in today’s New York Times makes clear – that all depends on what type of malignant cells you’ve got (Alex Berenson, “A Disease Affecting White Blood Cells, the Body’s Infection Fighters”).

It’s a companion piece to a news article about the radioimmunotherapy drugs Bexxar and Zevalin, and why doctors have been slow to prescribe them (an issue I dealt with in the June 23rd installment of my blog – “A Smart Bomb that Could Be in My Future”).

The Times article deals with the “Doc, How long have I got?” question rather bluntly:

“Doctors divide the disease’s many varieties into two broad categories: aggressive, and indolent, or slow-growing. Aggressive lymphoma can be cured in 65 percent to 75 percent of the cases. If it is not cured, patients usually die within two years.

Indolent lymphoma, which includes the follicular type, cannot be cured. But it typically responds to chemotherapy and can be put into remission for years in most patients. Eventually, though, it comes back, and each time it becomes more aggressive. Typically, patients survive about 10 years after their initial diagnosis, although the course of the disease varies widely.”

So, what type do I now have, aggressive or indolent? That’s the big question. Back in December, 2005, my grading – according to the Memorial Sloan-Kettering pathologist, who differed from the local pathologist – was that I have “B type, diffuse mixed large and small cell.” This actually demonstrates characteristics of both grades (large-cell lymphoma is aggressive, small-cell is indolent). For treatment purposes, “diffuse mixed large and small cell” is categorized as an aggressive lymphoma.

About a year ago (see blog entry for June 9, 2006 – “Cancer Conference”), I had the chance to ask one of the speakers at a cancer conference – a researcher from the University of Pennsylvania Hospital, Dr. Martin Carroll – about the “diffuse mixed large and small cell” grading. I wanted to know whether it in fact belongs to both categories, or whether it’s simply aggressive. He confirmed that it does demonstrate characteristics of both varieties. Does that mean, then, that I have the worst of both worlds, I asked?

You could say that, Dr. Carroll admitted.

If that’s so, then I wonder how the New York Times’ quick answer to the “How long have I got?” question can be applied to my particular case? Let’s see. With the aggressive component of my disease, I have a 65 percent to 75 percent chance of being cured completely. If I’m in the unlucky 25 to 35 percent, though, I’m likely to be gone within two years of diagnosis – which means that (since I was diagnosed a year ago last December), in the worst-case scenario, time’s wingèd chariot is rumbling rapidly onward on in my direction.

Yet, I have (or, at least, had) both types of lymphoma – indolent as well as aggressive. That means the prospect of a permanent cure is unlikely. Even if I’m in the lucky 65 to 75 percent whose aggressive cancer does get cured, I still have to worry about those pesky, indolent cells of mine – the ones that make for a chronic, incurable condition, whose symptoms can be managed pretty well but never turned back completely. The presence of those small, indolent cells would suggest that the answer to the “How long have I got?” question is “10 years, on the average.” (Of course, “average” could mean considerably more than 10.)

The good news is, I was diagnosed early, without having experienced much in the way of symptoms. I’m also on the younger side of the typical lymphoma patient’s profile – both factors which are in my favor. Furthermore, the field of lymphoma research is developing so rapidly that, even within that 10-year window, a whole new drug could be on the market by then – meaning that all bets are off.

Then, there’s the matter of those enlarged lymph nodes – three of them, at least (one of which was biopsied last week). If lymphoma turns out to be the cause (and not some benign, but long-lasting infection), then what type of malignancy is it – indolent, aggressive, or both?

If it’s more on the aggressive side, that could suggest that I fall into the unlucky 25 to 35 percent, and that it’s time to call out the Special Forces (second-line chemo, radioimmunotherapy or stem-cell transplant). If, as the local pathologist thought – back in December of 2005, before the Memorial Sloan-Kettering expert weighed in – the grading turns out to be indolent, then it’s a matter of just whacking the cancer mole back down again, and waiting for the next recurrence.

As for the CHOP chemo treatment I’ve already received (along with the gentler Rituxan), the Times article is blunt about its side-effects: “While effective, it is highly toxic and can damage the heart, so it can only be given a limited number of times.”

As for stem-cell transplants, that treatment is no bed of roses: “When drug treatments have failed, stem-cell transplants are another option. But they are extremely expensive and carry a risk of mortality of 3 percent to 30 percent, depending on whether doctors are using a patient’s own stem cells or transplanting cells from another patient.”

Bottom line? The answer to the “How long have I got?” question is not at all easy to come up with, in my case. There has always been some uncertainty about the grading of my cancer – an uncertainty that may continue, if this most recent needle biopsy turns out to be (like the last one) not such a good sample. Yet, even if the “diffuse mixed large and small cell” verdict does continue to be in place after my most recent test results come in, it’s maddeningly complex, in and of itself (having characteristics of both aggressive and indolent).

Most doctors shy away from giving a clear answer to “How long have I got?” anyway – any answer can be a self-fulfilling prophecy. So, I continue to live with ambiguity, “delicious” or otherwise.

Today's Claire's birthday, and I've got a party to plan. That's enough of ambiguity, for now.

Thursday, July 12, 2007

July 12, 2007 - Biopsy Results Delayed

Yesterday I got a call from Dr. Lerner’s office, letting me know the biopsy results will take longer than anticipated to come in. (That comes as no surprise to me: I suspected all along that receiving the pathology report in three days was probably a stretch.)

Bottom line? My appointment with Dr. Lerner has been rescheduled for next Friday, July 20th. I suppose I may get a phone call a few days earlier – or, he may just wait till I’m there in the office to tell me what the report says.

This is turning out to be a summer of making it up as I go along. It’s hard to do any sort of planning – for vacation, taking Ania to college, or anything else – when the earth keeps moving under my feet. It’s a new experience for me to live day by day, rather than by the calendar.

Gilda Radner found this out, as she learned how to live with cancer:

“I wanted a perfect ending. Now I've learned, the hard way, that some poems don't rhyme, and some stories don’t have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what's going to happen next. Delicious Ambiguity.”

(Thanks to Rob Pollock for the quotation. I found it on today's installment of his blog.)

My recovery from the needle biopsy has been rapid. I removed the bandage after 24 hours, as instructed. The area at the base of my right neck, where the needle went in, is still a little swollen and tender, but there are no ill effects.

That’s the latest news, such as it is. Stay tuned for further bulletins.

Tuesday, July 10, 2007

July 10, 2007 - Have BiPAP, Will Travel

Today, Claire and I drive over to Ocean Medical Center, for the needle biopsy of my superclavicular lymph node (medical jargon for "above the collarbone"). I've been through this procedure once before, for the January, 2006 needle biopsy of the bulky tumor in my abdomen, that confirmed the lymphoma diagnosis and helped chart my whole course of treatment. Once again, Dr. David Feng will conduct the procedure.

Dr. Feng is an "interventional radiologist." That, as I understand it, is a relatively new medical specialty. Basically, an interventional radiologist is a doctor who sticks something into your body, while gazing at images on a screen that are provided by some form of radiological scanner (like an ultrasound or CT scanner). Sometimes the procedure is done for diagnostic purposes (as with me, today). Other times, its purpose is to deliver some form of treatment (such as placing a stent, or performing the "radio frequency ablation" treatment that zaps lung or liver cancer, through a needle inserted directly into the tumor).

As we drive over there, I try not to think about the fact that I'm voluntarily walking into a place where somebody is waiting to stick a needle into my neck.

Ocean Medical Center's Interventional Radiology Suite opened a couple of years ago, to great fanfare. It's a specialized operating room, that contains not only an operating table, but also an array of radiological scanning equipment.

Anesthesia is mostly by sedation, rather than general anesthesia. When the nurse in the same-day surgery staging area asks me about prior difficulties with anesthesia, and I relate my tale of waking up on the operating table twice (during my previous needle biopsy, and during the surgery to implant my port), she explains that I won't be dealing with an anesthesiologist today. Dr. Feng, she says, is his own anesthesiologist – and, I won't see him until I actually go into the operating room.

O.K, I think to myself. I'll go with the flow on this one. Today, I've brought not only my BiPAP mask with me, but the whole BiPAP machine. (It's a lesson learned from experience.) When it comes time for them to roll my gurney down to the surgical suite, the shoulder bag with the BiPAP in it is sitting on top of my legs. I have to be vigilant in hanging onto it. At least one nurse mistakes it for my personal belongings, and tries to whisk it away into a storage locker.

When I get to the operating room, two nurses there introduce themselves, and immediately ask about the black shoulder bag sitting on top of my legs. I explain that it contains my BiPAP machine, that I use it every night for obstructive sleep apnea, and that I'd like to use it during the needle biopsy, if that's O.K. with Dr. Feng. Fortunately, they don't seem fazed by this, at all – although they do grumble a bit that no one from same-day surgery warned them I'd be bringing such a machine with me.

It turns out I'm going to undergo this procedure without even shifting onto the operating table. I'll stay right on the gurney. (Sort of like drive-thru surgery, I think to myself.) There's no convenient place to put the BiPAP machine, so I just shift my legs to one side of the gurney, and the nurse places it on the other side. I put the mask on, myself (I'm a lot more familiar with it than she is), and she hooks up the tubing and plugs the electrical cord into an extension cord she pulls down from the ceiling. I explain that, once the mask is on, I won't be able to talk without first taking it off (the positive airflow of the BiPAP into my nose creates a sort of vacuum effect that keeps my mouth closed: which is precisely why the thing is so effective in preventing apnea – the dropping-down of the soft palate and its side-effect, snoring).

So far, all my dealings have been with the two nurses. I haven't seen Dr. Feng at all, and – with me looking straight up at the ceiling with the BiPAP mask on – I realize the chances of my having any meaningful conversation with him, pre-surgery, are not good.

The nurses shave the area at the base of my neck (I've got body hair there), then apply antiseptic solution. They explain that I'll first get some novocaine injections around the target area, and that I'll feel some pain and burning from that. I do, but it's not severe. Around now, I become aware that Dr. Feng is in the room. Because of my flat-on-my-back perspective (and because the nurses have directed me to turn my head to the left, away from the right side where they'll be working), I never do see him. I hear his voice, though – as he squeezes some ultrasound goo on the base of my neck, explaining that he's first going to take a look at the enlarged lymph node.

The next thing I hear is the nurse, explaining that she's going to start the sedation. Patients generally respond one of three ways, she tells me: they sleep, they get "very mellow," or they get very chatty. She doesn't think I'm the sort that would fit into the third category, she says. (Brilliant deduction, Sherlock; I couldn't say anything with the BiPAP mask on, even if I wanted to.)

As it turns out, my response is somewhere between sleeping and "very mellow." I feel no pain throughout the procedure, although I am aware of a repeated clicking sound – which, I realize, at the time, is probably Dr. Feng, doing whatever snipping-out of tissue he does, using the hollow biopsy needle. It seems like no time at all before I hear Dr. Feng's voice saying, "We're all done." One of the nurses explains that a pathologist has been on hand, and has confirmed that the biopsy produced a large-enough sample for analysis.

I have no recollection of the trip back to the same-day surgery staging area – other than deciding to use the BiPAP there for a while as well, to take a little snooze. I awake a while later, with Claire sitting by my side, and it's not long before the someone feeds me some lunch, and the nurse tells me I can get dressed and head home.

I see Dr. Lerner on Friday, and should learn of the results then.

Monday, July 09, 2007

July 9, 2007 - Just Get Me to the O.R. on Time

This morning I awaken in our Adirondacks house in Jay, New York, on this last morning of a brief stay. It's the day when I'm scheduled to drive back home. I've just had another nightmare, prior to surgery. (This sort of thing is getting to be a habit with me.)

My surgical procedure tomorrow, at Ocean Medical Center's interventional radiology suite, is going to be an ultrasound-guided needle biopsy: Dr. David Feng, presiding. He's the same doc who did my core-needle biopsy, at the time of my initial diagnosis.

Events unfold rather differently, in my dream. For some reason, my surgery is going to be at the University of Iowa Hospitals – the place where our son, Benjamin, had a couple of minor eye operations, years ago, when he was very young (we were living in Iowa, then). Accompanying me to the hospital is my brother, Dave. In place of Dr. Feng, conducting my needle biopsy will be Dr. Aron Gornish (the same doctor who was scheduled to do the excisional biopsy, but called it off at the last minute).

The hospital complex is huge: corridor after corridor to wander through. It feels as big as the Pentagon. Eventually, we find Dr. Gornish, and he brings me back into the operating room, to show me what to expect. He holds out a mask, that closely resembles my BiPAP mask in shape – although it's constructed of sinister-looking dark metal and rubber, rather than clear plastic. It looks like something Darth Vader would wear. This is for you to wear during the operation, he explains: it will take care of your apnea problem and also deliver your anesthesia.

I also meet the members of the operating-room team. They're not ready for me yet, so they suggest we go away for a while and come back later. Go get something to eat, they suggest.

Dave and I do that. Somewhere along the line, I've changed into a hospital gown and slippers. He and I climb into a rental car – me, still in my hospital gown – and drive into the town. The town has morphed into Chestertown, Maryland, Claire's and my college town (home of Washington College, our alma mater).

We grab a quick bite to eat, someplace, then rush back, because my anxiety level is rising. There are traffic and parking delays, but eventually we do make it back, in the nick of time. It's then that we become utterly and completely lost, in the hospital complex's maze of corridors. Nothing looks familiar. We keep walking and walking, as the minutes tick by (I'm still in the hospital gown). The time of my reporting for the surgery comes and goes, but still Dave and I are no nearer to figuring out where we are, and where the operating room is.

Along the way, I vaguely wonder whether I should have had something to eat, after all. Wasn't I supposed to abstain from eating and drinking, beginning the night before the procedure? It was the operating-room team who suggested we go get something to eat – could they have goofed up? Or, did I just hear them wrong?

I hear my name being paged by a tinny, nasal voice, over the hospital p.a. system: "Mr. Wilton, Mr. Wilton, please report to the Operating Room." We walk faster, but seem to be no closer to our destination than we were before. It occurs to me that I ought to just pick up a phone and tell them we're on our way, but we figure finding a phone would waste too much time.

We pass by a huge, imposing- looking meeting room, that vaguely resembles the General Assembly of the United Nations – lots of wood paneling and hundreds of seats. Through large windows, we can see all the doctors from the hospital streaming in there, for some kind of important meeting. I wonder if Dr. Gornish is in there with the others. That would mean we're too late.

Finally we make it to the correct wing of the hospital, where I run into a member of the operating-room team, still clad in green scrubs. We've been looking and looking for you, he says. Dr. Gornish has gone for the day, so you've missed the operation. Don't worry about it, though. Come back tomorrow. We'll try to squeeze you in.

With that, I wake up. Good thing, too – I’m glad to be out from under that dream.

Wednesday, July 04, 2007

July 4, 2007 - Baseball and Cancer

Surfing the net this Fourth of July morning, I find something worth sharing on the site of fellow cancer blogger, Tom Clarke (his July 3rd entry). After confessing his love for a couple of baseball teams, the Kansas City Royals and the Chicago Cubs (both of whom have had their ups and downs in recent years), Tom throws in this little gem:

What are, then, the parallels between cancer and baseball?

1. There are always greedy people willing to put their financial self interests above the good of the whole no matter how much money they have, like certain doctors and pharmaceutical companies.

2. Hope Springs Eternal.

3. Once in while, in spite of overwhelming odds, the good guys do win.

4. It's a long season, and a long journey with cancer.

5. You gotta play hurt.

6. There are always certain doctors, nurses and coaches willing to go above and beyond the call of duty to see that the interests of the player/patient are put first.

7. Sometimes you need to fire the doctor or manager to move forward.

8. Sometimes the rules of the game change - scientific breakthroughs, interleague play, etc.

9. As long as a game is played well, it is still enjoyable even if your team loses.

Tom's words take me back to days of my childhood, as we used to engage in endless games of "Hit the Bat," out in the middle of our suburban street – playing on until the occasional car passed by, at which time we would quickly pick up the bat and saunter over to the curb. (Hit the Bat is a stripped-down version of baseball, suitable for those times when you don't have enough kids to field a proper team.)

There's something about baseball that's different from most other sports. With its regular rhythms of play, and its series of innings (that can go on much further than nine, if you're not counting), baseball at its best and most laid-back can have about it a whiff of eternity.

Play by play, base by base, inning by inning, you move forward. You enjoy some triumphs, you commit some errors, you move on. There's no choice: the game itself will move you on. And sometimes, on a sticky summer evening, with just enough daylight left to see the ball, you sense that the rhythms of this particular game are in sync with the rhythms of a much larger game, one that was and is and is to be.

Tom, who knows from what his doctors tell him that he's getting into the final innings, cites the oft-quoted words of Yogi Berra: "It ain't over till its over."

Indeed it ain't. Play ball!

Tuesday, July 03, 2007

July 3, 2007 - The Surgeon Bows Out

This morning, I receive a voicemail message from Dr. Gornish, my surgeon. After examining the results of the ultrasound I had last Thursday, his recommendation is that I undergo an ultrasound-guided needle biopsy, rather than a surgical removal of one of the problematic lymph nodes.

The ultrasound, he said, reveals “three areas” of concern in the vicinity of the right neck. The one by the clavicle (collarbone) is “deep” – hard to access, in other words. The one by the mandible (jawbone) is “mild” (by that, I think he’s meaning to say it’s not so swollen as the other one). He doesn’t mention anything more about the third location.

Dr. Gornish is very clear, though, that he’d rather not proceed with an excisional biopsy. The combination of my breathing issues and the deeper-than expected location of the one lymph node would require “more extensive surgery.” By that he probably means general anesthesia, rather than the conscious sedation he was proposing to do. The only concern is that the needle biopsy will produce a large-enough sample for the pathologists to examine.

That’s fine with me. I can go with that. I’m feeling a bit frustrated, though, that it took this sort of trial-and-error approach (one that involved nearly a month of waiting for a surgery date, then a trip all the way to the operating table) to make that decision. Couldn’t we have just gone with the needle biopsy in the first place? I’d have had the results weeks ago.

It may have been Dr. Lerner who was pushing for the excisional biopsy. He remembers, I’m sure, the difficulty grading my cancer back in December of 2005, after the needle biopsy of my abdominal mass. That core sample ended up being mostly scar tissue, with only a small portion of it being useful to the pathologists. There was a difference of opinion between two doctors over that one, with the pathologist from Memorial Sloan-Kettering ultimately overruling the pathologist affiliated with our local hospital. The small size of the tissue sample, I was told at the time, was the reason for the discrepancy.

A subsequent series of phone calls with Janet, a nurse in Dr. Lerner’s office, confirms that my needle biopsy will take place sometime on Tuesday, July 10th, at the interventional radiology suite at Ocean Medical Center.

That means I’ll need to decide whether it’s worth my time to head up to our Adirondacks place after the 4th of July, for a long weekend. I’ll probably jump at the opportunity. With subsequent medical appointments, both locally and at Memorial Sloan-Kettering, it may end up being the only time I get up there this summer.

Like I said before, cancer takes no vacation.