“How are you doing?” is the question most asked of me each week. Let’s start with this: My kidney function is fine (consistent with all the “pee”s in the title above), a criteria necessary to receive IV contrast dye for my cycle 6 post-treatment CT scan yesterday.
How I am doing is purely perspective considering my Labor Day proclivity in a world of precious, personable and perhaps today’s posted pretentiousness. I will break down the P’s as we progress through this post.
I’m not an overly religious guy, perhaps in part because I’m a scientist, but I do venerate religion and the multitude of sacred scriptures that come with each. I am grateful for all the prayers I’ve received from so many friends and family of various faiths – it can only help!
Many people have asked me, “How long can you survive with Stage IV colorectal cancer? If you’ve been following these blogs, it should be quite obvious that there are many factors; some we can control, many treatment decisions are made for convenience, policy, or guidelines without consideration to or driven by individual patient factors (not for this guy), and perhaps some are decided upon by a Devine being.
For the Jewish faith, this past week was the High Holy Days, Rosh Hashanah and Yom Kippur, the latter of which ends this Thursday at sundown. Although I don’t regularly attend temple, the following has been ingrained in me over many years of attending the High Holy Day services.
On Rosh Hashanah it is inscribed, And on Yom Kippur it is sealed.
How many shall pass away and how many shall be born,
Who shall live and who shall die,
Who shall reach the end of his days and who shall not,
Who shall perish by water and who by fire,
Who by sword and who by wild beast,
Who by famine and who by thirst,
Who by earthquake and who by plague,
Who by strangulation and who by stoning,
Who shall have rest and who shall wander,
Who shall be at peace and who shall be pursued,
Who shall be at rest and who shall be tormented,
Who shall be exalted and who shall be brought low,
Who shall become rich and who shall be impoverished.
Maybe there’s a Devine reason for my cancer; maybe not. Perhaps some lack of peace, torment, misery, or forfeiture of a “long” life is offset by “how many will be born” healthy. On some days, at fleeting moments I have wrangled with whether palliative chemo is all worth it – I assure you in my case that it is! Notwithstanding, I am all about accepting the cards dealt to me in exchange for lemonade in the form of two more healthy grandchildren due February 2022, the recent birth of grandchild #5, Emily as mentioned in the prayer above, “how many will be born”, and the good times I have enjoyed since the original diagnosis and also anticipation of upcoming fun times.
So here’s a freaky twist for someone like me that isn’t a religious zealot or superstitious. Today, 9/10, the day I am entering this into my log for the blog, I was about to leave the house when I saw this dirt smudge on our window as I was walking out the front door. See the pic of Hebrew letters and compare it to the door smudge.
Wow, a bit “paranormal”. This smudge is the Hebrew word for chai. Do you know what the Hebrew word chai means? Chai (חי) is a symbol that means “life,” “alive,” or “living.” In the Jewish numerological tradition of gematria, the number 18 has long been viewed as corresponding to the Hebrew word “chai,” meaning good luck and Mazel tov. In fact, a common Jewish toast is “l’chaim!,” which means, “to life!”
This scientist will take it, religious or not!!!
(Revised from https://www.learnreligions.com/chai-in-judaism-2076800)
So far, so good! Cycle 7 with a twist (of lemon) started on 9/14. Dr. Onc had received the results of my CT scan from yesterday. This visit was pleasurable with excellent communication, and collegial conversation – best visit ever with Dr. Onc! There is NO visible tumor mentioned at the sigmoid-rectal junction. For non-medical folks, the sigmoid colon is at the end of large intestine on your left side where the large intestine meets the top of the rectum, and several inches down is the anus. This is where my original primary tumor was found, the proximal rectum (sigmoid-rectal junction) – today tissue thickness only is reported with no specific mention of a tumor, and the lymph nodes adjacent to that tumor outside the colon? GONE! No new metastasis found anywhere, but in particular the lungs or liver where we would expect to see them first. As we know from previous posts, there was no ability to see tumors in the peritoneum (abdominal area containing organs and surrounding the outside of small and large intestines). What will this mean for chemo this cycle?
Let’s start with the visit today for the start of cycle 7. The blood chemistries were great. The hematocrit (HCT, measures the volume of red blood cells compared to the total blood volume of red blood cells and plasma) was 32.2%, red blood cells (RBC) were 3.55 X 10^6/uL, and the hemoglobin (HGB, the main component of red blood cells, serves as the transporter for oxygen and carbon dioxide in the blood). It is rich in iron – that was 10.3 g/dL. What do these number all mean? Let’s just say they are slightly low but VERY much improved from previous values and certainly high enough for normalcy in terms of performing daily activities. How about the iron levels? Recall conversations I had about receiving IV iron is previous blogs? Well, that turned out to be the right call – Iron, total iron binding capacity, and % iron saturation were all perfect! The ferritin levels were so elevated, they were twice normal. So, I’m not tired at all typing this today.
Chemo plan moving forward? Let’s have a little lesson. Recall I am on 5-FU (5-fluorouricil), oxaliplatin, leucovorin, and various anti-emetics (to prevent nausea and vomiting). To keep it simple, rather than getting into too much biochemistry and biology , oxaliplatin and 5-FU are cytotoxic (toxic to cells). They both are antineoplastics – that means they inhibit neo (new) growth, and they affect rapidly growing cells first (like cancer cells, hair follicles, the gastrointestinal lining which constantly is regenerating cell’s, bone marrow which produces RBCs, WBCs, and platelets). Essentially antineoplastics inhibit cell growth and replication by getting to the cell’s DNA. They may prevent the DNA strands from separating; they may replace normal chemical bonds within DNA with weaker bonds so that when RNA comes along to replicate the cell, the DNA strands fall apart; they may affect spindle fibers or chromatids which are important cell components in metaphase (wow – am I giving you general biology nightmare?). You get the picture – these are toxic to cells. And that’s why fast-growing cells (hair follicles, gastrointestinal lining, pluripotent stem cells in the marrow) are affected by antineoplastics in the form of hair loss, nausea/vomiting, and diminished blood cell counts as outlined above
Why did I give you this background? Remember in my previous blogs we talked about oxaliplatin induced neuropathies and how that toxicity accumulates and how the data shows that 9 treatments are not better that 6 treatments in terms of efficacy? Well, my neuropathies are clearly worse. More tingling and numbness from cold touch, coming on sooner and lasting weeks instead of days, and more intense. We call these sensations paresthesias, another pee word from the title!
In this case I gave you some preemptive information because I am going to replace oxaliplatin with bevacizumab. What the heck is that you may ask? The “mab” stands for monoclonal antibodies. The “zu” tells us where it comes from and how it is derived. In this case the “zu” means that it is “humanized”. In short, it is made in a lab by combining a human antibody with a small part of a mouse or rat monoclonal antibody. The murine (mouse or rat) part of the antibody binds to the target antigen, and the human part makes it less likely to be destroyed by the body’s immune system. Generics for these drugs don’t exist because it’s very much like brewing beer. It’s not a simple chemical replacement like we see with other branded drugs, but involves a complex process. For this reason, there are instead “biosimilars”. Why is this important? Because insurance companies don’t want to pay for the more expensive original brand (in this case, Avastin), Instead they will pay for the biosimilar equivalent called bevacizumab.
Is this an antineoplastic? No, it is a vascular epithelial growth factor receptor inhibitor which results in decreased cell growth and diminished tumor growth that otherwise depends on this epithelial growth factor to proliferate. This will likely be the future instead of injecting antineoplastics. But, I will remain on 5-FU which is an antineoplastic. And the leucovorin mentioned above is basically the active form of folic acid (or folinic acid) which improves the 5-FU cell kill activity.
Teachers and Pupils and Proclivity (more pee from the title)
Every year for the last several years, I had a proclivity to be at PainWeek which starts the day after Labor Day annually in Las Vegas. Last week was the PainWeek Symposium where professionals from various disciplines gather to learn and be updated on the latest and greatest treatments for pain. The conference is very unusual compared to others. No nametags identify you as “Dr”, MD, PharmD, NP, PA, Phd, DPT, DC, DPM or xyz. The names are simply the names, because the conference organizers recognize that medicine, therapeutics, and interventions are a team sport! And the art, is to die for – that’s why I didn’t go this year; I didn’t want to shorten my lifespan by another notch. Nah, just kidding. The real reason is because of anti-vaxxers, the COVID19 Delta variant, and the fact that I’m immunocompromised. Thank you very much to those that still feel the vaccine is a way to track your location – please, if you’re worried about that, get rid of your mobile phone first, then ditch your computer, Alexa, Google Home, Apple Dot, or whatever devices you use. Ah, but I digress. Highly respected thought leaders from all over the country lead lectures on various topics with ample opportunity for one-on-one discussion with attendees. The abstract artistic posters created for each session are indescribable (thank you Darryl). And the comradery? I can’t even explain the bond that all these professionals and learners alike have for each other and the PainWeek leadership.
Pretentiousness and Paranormal #2
At the risk of sounding pretentious, the PainWeek executive staff, unbeknownst to me, paid homage to my contributions over the last several years for my teaching, mentorship, love for my work and the people I have taught (pupils, another “P”), and the patients I have treated. They did it in part because they knew it was difficult for me to NOT attend in person and it did send a positive message to my immune susytem. It started with a couple of pics from a colleague of mine, Dr. Courtney Kominek, a PharmD who practices in Missouri. She boarded a plane with me and got me into the cockpit of the plane. Her mission – fly me to PainWeek. Thank you, Courtney, for taking care of me. This paranormal version of me by the way was not vaccinated against COVID19 and the flight attendant did not require me to wear a mask. I thought, okay this is pretty funny, thank you PainWeek. Then I was told “you haven’t seen anything yet?!?!
Next up were the artistic blocks in the convention hall. My goodness – when I was sent these pictures I just cried. Then I was told again, “you haven’t seen anything yet”. I’m like, what?!?! Haven’t you all shown me enough love?
Before I knew it, my email box, social media, and texts were filled with all sorts of lookalikes. At first it was “the chair”, but then I found myself all over the convention hall with my friends and colleagues. I just couldn’t believe the outpouring of love. I was celebrated to a level that in my mind was unfathomable. There were so many emotions. I was grateful, a little embarrassed, loved, appreciated, tearful, excited, but most of all I was with my friends and colleagues who embraced the tribute to me.
People have asked me, how do you keep going? I’ve shared family events, births, gatherings, and activities in previous blogs. But this? This is my professional life, my other family – this was an unexpected exhilaration for the immune system beyond that which anyone can imagine. Here is an album of colleagues and friends that met up with me throughout the conference. And a special thanks goes to Dr. Saleem Naina for hooking me up with Spiderman, Waldo, and various celebrities.
But why am I telling you this if I’m not looking to pat myself on my own back or be pretentious? I’m glad you asked – again with the religion thing…
Maimonides in his great code of Jewish law has an entire section devoted to teaching, teachers, students and the concept of knowledge and education. In short, teachers are to be respected and given honor. One should rise before one’s teacher, speak respectfully to one’s teacher, and treat one’s teacher with greater probity than even one’s parent. Jewish civil and ceremonial law state that “parents bring a child into this world but a teacher can bring a child into the World to Come” – into a world of spirit, creativity, ideas and self-worth and ultimate immortality.
But the teacher-student relationship is reciprocal. Maimonides teaches us that in Judaism the teacher-student relationship is really a parent-child relationship. A teacher must not only respect one’s students but must love them. (Above is from Rabbi Wein’s Blog)
Bottom line here? ALL teachers, whether elementary school, public school, religious school from any faith, colleges, universities, or whatever, influence more people than they could ever imagine. Teachers are generally underpaid, overworked, but nonetheless dedicated to helping their pupils and mentees to think for themselves, improve society, and teach others to flourish in a complicated world. PainWeek has taught me that the influence one person can have on society is immeasurable. This means that while a teacher can have a positive influence, they can also have a negative influence. So, this is not a callout to me, it is a trumpet (in this case “saxophone”, as it has been said I’m the saxiest man in the world) to all teachers that YOU are valued, that you influence people, and more likely than not, have an influence and impact on the world because these teachers beget more teachers who are omnipresent worldwide. You are the mentors and influencers of our world. I am fortunate to have a PharmD son-in-law and a PharmD daughter (no, they are not married), both of whom teach student professionals and of course their patients. I also have a daughter that is a fulltime teacher – she teaches health and physical education. I am especially proud of these three for making the world a better place! And, I’d be remiss not to thank Dr. Tim Atkinson for taking on all my lectures at PainWeek, especially with all of his own lectures there – he was my first resident about a decade ago and like all of them is a shining STAR! I of course am proud of all my resident graduates who continue to teach, publish, and influence the world.
On 9/11 we picked up Robin’s dream car, a Subaru Outback Touring XT. After lunch on this day, I drove to do some errands. Feeling back to “verynormal” versus paranormal, and with lots of energy, I drove home while enjoying that new car and leather seat smell and taking in the breeze from the sunroof. I have to hand it to Robin, her dream car turned out to be an awesome choice. Lots of room, even for an 8-foot 2 x 4, although my construction days are on hold for now.
I’ll drive away into the sunset for now (7:06PM EST), and until next time, have a healthy and happy New Year as they say on Rosh Hashanah and Yom Kippur. As usual, I’d love to hear your comments. L’chaim!