Tuesday, September 4, 2012

All's Well That Ends Well

There’s a covered bridge, closed to vehicles, less than a mile from our home that I’ve passed through hundreds of times over the years. It’s become a spiritual sanctuary of sorts. Every time I'm within its whitewashed, clapboard walls I receive its benediction, and in return I praise God for the peace and beauty of where I live and for the gift of life.

Lately, my prayers have given way to brief meditations. I’m a walker these days, instead of a runner or biker, and I take the time to stop and listen for Him while on the bridge. I seek divine guidance at all times, but most especially of late for direction on my cancer treatment. My health is a little dicey, but the world no less beautiful or full of wonder.

Irish Bend covered bridge in winter
There’s a complex array of choices about how we might proceed in attempting to control the melanoma that lurks within me. We know for sure there’s a lymph node in my right armpit that’s cancerous. It was seen by PET/CT on Aug. 1 and was biopsied after my brain surgery a few days later. My surgeons also believe traces of the tumor that came out of my temporal lobe a month ago still remain and need to be cleaned up. They were conservative in their surgery, not wanting to remove a margin of tissue from the healthy brain that surrounded the tumor. I’m all for that, as this approach avoided damage to my sight, speech and movement. The tradeoff is that without aggressive post-op treatment it’s more likely that the cancer will grow and create havoc for me again in short order.

I’m opting for whole brain radiation (WBR) instead of focused radiotherapy (e.g. Gamma Knife) because there’s a good chance the melanoma has or will spread microscopically beyond the original tumor bed. I’ve been told the region previously occupied by the tumor is simply too large for the Gamma Knife to be completely effective. It appears to work best on smaller lesions. While there’s controversy among specialists on this matter, I’m betting on a strategy that seems to offer the best chance of never having brain cancer again. The downside is the likelihood of side-effects that prompt some patients to choose doing nothing at all rather than risk any loss of neurocognitive function.

I totally sympathize with this perspective. In fact, it’s was mine for most of my cancer journey: a committed medical minimalist. I’ve believed in doing the least treatment and surveillance necessary, to go out and live life, and to let the chips fall where they may. Until a month ago, this approach served me well. If being consistent mattered to me or I was just plain mulish, I wouldn’t even bother talking to doctors. I’d simply opt out of becoming grist for the cancer mill and instead focus solely on recovering from brain surgery.
In that department, I’m doing pretty well. I’m much less dizzy in recent days and have put away the cane for good. My stamina is better, as are my powers of concentration. I’m still mostly deaf in my right ear, but have been told this will eventually resolve. When they were digging around inside my skull, the surgeons went right up against my temporal bone, which houses such vital structures as the inner ear. Swelling from the surgical wound creates pressure on this bone that’s the source of my discomfort and it can take months to completely resolve.

The choice I’ve made for treatment is to give myself the best shot possible at a durable remission while I’m in good constitutional health. If I were to opt for no therapy, I might do perfectly well for weeks or months, but unless I was exceptionally lucky, I would eventually relapse with what might then be a lethal volume of cancer. The mutations in my unique melanoma genome accumulate, and now that mel has moved from skin to brain it’s Katy bar the door. The cancer could spread anywhere in my body and there’s no telling when. Based on my interpretation of what I’ve read in the medical literature, the odds for people in my melanoma cohort to be alive a year from now are less than 50/50. I expect to do better than that.
This is why I’ve also chosen to undergo a course of systemic treatment with Yervoy, the new standard of care for most folks with metastatic melanoma. While WBR covers the most likely site of recurrence, Yervoy affords protection against recurrence in the whole body, including the brain. About 15% of patients are responders, meaning their tumors shrink or disappear. A lucky few out of this subset have full and lasting remissions. This is the Holy Grail of cancer treatment that occurs infrequently in melanoma patients. It’s my goal, however unlikely that may be.

I’m a realist but also an optimist. I have reason to believe that as a biological specimen, I have physical, psychological and social advantages that many in my straits don’t. I also have spiritual resources that make a difference that’s intangible, unmeasurable, but nonetheless very real. I’ve opted to give this a shot because I believe it’s what God wants me to do. I know I have the prayer support of many friends and family, which means at least as much to me as anything the health system can throw at melanoma.
Among the many side-effects of the treatment regimen to which I’m committing, the one that concerns me most is the impact of radiation on my thinking. Many patients tolerate it well, but others suffer some degree of short-term memory loss. I’m at an age where “senior moments” are coming into play anyway, so it’s possible no one will notice any slippage. Nevertheless, it’s something I think about a lot and fret over. If you pray, this is something you could speak to God about on my behalf. Ask that he protect not only my brain but also my mind. As the old joke goes, I’d rather come out of this with a bottle in front of me (preferably a good Oregon pinot noir) than a frontal lobotomy.

My therapy schedule isn’t official, but it appears I’ll have the first of four Yervoy infusions on or about Sept. 14 at Providence Cancer Center in Portland. They will be repeated every three weeks. An infusion only takes 90 minutes and I’m then released for home. Compared to the interferon I staggered through four years ago, Yervoy should be much more easily tolerated—no rigors, fever or severe fatigue.

The first of 20 radiation fractions spread over four week will commence the week after Yervoy at the cancer center here in Corvallis. I have a consult with a radiation oncologist I know and respect next Monday to set up my program. WBR is pretty much cookbook medicine, so I feel confident about having this part of my care provided at Good Samaritan. They did a great job with the radiation I received after my lymph node dissection in my left inguinal crease (groin) in 2008. I was told before treatment then that it was unlikely I’d ever run again, but the tissue fibrosis was milder than usual in my case and I ended up completing a marathon a year later.

Three weeks after my last Yervoy infusion (mid-November) I’ll have a whole-body PET/CT scan and brain MRI to see if there’s activity anywhere in my body. Any sign of cancer would not be good and we’d then have to make decisions about how to proceed. If cancer is not detected, then the Yervoy would be declared a success. The node in my right armpit is being left intact for now to serve as a marker of Yervoy’s effectiveness. A clear scan doesn’t mean melanoma won’t return sooner or later, but it would still be a cause for celebration. It would represent an extension of my days and a chance to enjoy more of life.

I have 10 days before I'm swallowed into the belly of the beast, so I plan to make the most of them. Nick, his girlfriend Sara and I will be going to our sea shanty this week for a short visit that will include a beach run at Bayshore—my all-time favorite route. Nick will also be my escort on an overnight trip next week to Ashland where I’ll hook up with my biking mates who will be midway on their CycleOregon tour through southern Oregon (I had to cancel). We’ll eat, drink and take in a show at the Oregon Shakespeare Festival. I’m not sure what we’re seeing, but I’d happily settle for “All’s Well That Ends Well.”


Carl Pelz said...

Hey Peter, thanks for the details and the window into your decision making process. Very helpful to know how to pray including the short term memory retention. Love the photo of the covered bridge in winter!

RBS said...

God bless you Peter. I will pray just as you've asked. I'm following your journey with lots of hope and an interest in decisions that I will probably face too. So far the Zelboraf continues to shrink the remaining tumors in my lungs and that's good.

You continue to inspire and humble me. Ron