Insistence of Persistence

“Yet because of his persistence he will get up and give him as much as he needs” (Luke 11:8)

While teaching his disciples about prayer, Jesus relates a story about a man who finds himself with an urgent need in the middle of the night. Weary guests have just arrived from a long journey and he has nothing to feed them. With no 24-hour convenience store available, he goes to the house of a friend, bangs on the door to rouse him from sleep, and calls out his request to borrow some bread. The friend is indisposed, having already settled himself and his family securely in their beds, and does not immediately respond. The knocking on the door and the plaintive appeals continue. Finally, because of his persistence, the friend gets up and gives him all that he needs.

We are learning the necessity for perseverance, i.e., the insistence of persistence, in this battle with cancer.

We just returned from Charlottesville where I underwent a full day of imaging studies and consultations once more. There is good news and bad news. The good news is that a repeat PET scan shows no evidence of active metastases below the neck. The lesion in the left hip region which was treated with radiation therapy in late October is now slightly smaller and expected to continue to resolve. I have had no pain or limitation of motion (no limp), all vital signs remain stable and labs are entirely normal. (This is nothing short of miraculous, given the devastating picture of widely disseminated lesions “too numerous to count” just six months ago!)

The bad news is that there is at least one new metastasis in the brain, which measures 5 mm and is located near the center of the left hemisphere. (Linda sighs, "Honey, it's all in your head!" :-) The source of the brain metastases is unknown, given the lack of evident tumor growth elsewhere, but they are thought to have pre-existed as microscopic clusters of cancer cells which only now have grown large enough to become visible on imaging studies. Regardless, the oncologist, radiation oncologist and neurosurgeon all agree that the most prudent approach is to repeat the gamma knife procedure to destroy this remaining brain lesion. Other options, including whole-brain radiation, repeat Interleukin-2 therapy or monoclonal antibody infusions were offered as secondary considerations. We are scheduled to return this Friday, December 5 for my fourth gamma knife procedure.

Our confidence is in the Lord and in the power of persistent prayer. We are not discouraged. Right after telling his story, Jesus reassures the disciples with these words: “Keep asking, and it will be given to you; keep searching and you will find; keep knocking and the door will be opened to you…” (Luke 11:9) Our God is pleased when we, like the man in the middle of the night, acknowledge that we have no other friend to turn to meet our need. As Peter once said, “Lord, to whom shall we go? You have words of eternal life.” (John 6:68)

Grateful for your persistent prayers,

Dan

Giving Thanks, Gathering Joy

“In everything give thanks…” (1Thes 5:18)

As I write this entry in the journal of my journey with cancer, a quiet and gathering joy inhabits my thoughts. And I am as intrigued by the phenomenon as I am pleased at the opportunity to express my gratitude.

Words are hardly adequate to describe my appreciation to the hundreds of you who have prayed earnestly for me, sent cards, offered practical acts of kindness, and buoyed me up with words of encouragement. I have also received excellent professional care and the well wishes and support of many colleagues. The outpouring of love, genuine concern and generosity has overwhelmed both me and my family. We thank God for each one of you.

Of course He is the One to whom all praise is due – for demonstrating His steadfast love, His faithful presence, His power to heal, His mercy and grace. I smile as I contemplate the beauty of how He has worked “all things together for good.” (Rom 8:28) Among the many lessons learned over the past several months is a new understanding of the transforming power of irrepressible gratitude and pervasive praise. Let me review…

Before any of us drew our first breath God saw our brokenness and the consequences of a creation gone astray. While still in a state of rebellion, He declared clemency for us through the sacrifice of His own Son, (Rom 5:8) thereby sealing forever the certainty of His love. (1John 4:10) With faith enough to recognize this gift, as a young man I turned myself in and received His forgiveness. My life was changed and my future secured.

Relative prosperity, excellent health, a fulfilling career, a wonderful family, and pleasant circumstances engendered an attitude of gratitude over the years that was reinforced by numerous examples of divine protection and providence. Almost everywhere I turned and everything I touched affirmed I am loved of God, a beneficiary of His goodness. Under such circumstances, what's not to be thankful for?

Then in January of this year dramatic events shattered this pollyanna perception of what constitutes God’s blessing. I was given six months to live and by my professional experience I knew that it likely would not be a tranquil passage. From the stunning moment I learned that I had disseminated cancer, through the nights of intractable pain, during the rampant decline in strength, amidst all the side effects of Interleukin-2 therapy, He graciously reassured me that He had not changed. His love had not diminished and He was no less deserving of my praise. In fact, it was often in those moments of extremis that His intimate presence was most palpable.

So I learned to give thanks in the midst of the pain. As I related in a previous entry, I would combat the pain with anthems of praise or humming to recorded hymns. Notice I gave thanks not for the pain, but in the pain. For it was in the pain I could appreciate the quality of love that constrained His Son to suffer unimaginable agony for me while uttering “Father forgive them…” (Luke 23:34) And it was in the pain that, without answering why, I was aware of His personal favor.

I also learned that the surprising consequence of giving thanks in the midst of suffering was an exhilaration and imperturbable joy that both eased the pain and produced a settled peace impervious to further adversity. I am aware that there are biological correlates to this phenomenon that to me only reinforce the wisdom of the Creator’s instructions: “Rejoice always. Pray without ceasing. In everything give thanks...” Sow gratitude; reap joy.

Through this experience and in my astounding recovery I have gained a new certitude and capacity to celebrate the profound and changeless love of God.

My wish for you and your family is not simply a “Happy Thanksgiving” but rather the lasting joy of giving thanks.

Gratefully,
Dan

PS – We return Monday, December 1, to Charlottesville for a full day of imaging studies and follow-up exam. I will keep you posted.

Wrestling with God

Then Jacob was left alone, and a man wrestled with him until daybreak. (Gen 32:24)

One of the strangest stories in the entire Bible is that of a man who, during one troubled and sleepless night, literally wrestles with God. The man, of course, is Jacob, who finds himself facing what he believes to be almost certain death at the hands of his brother whom, years earlier, he cunningly robbed of his rightful inheritance. Left alone to contemplate his fate, fearful for himself and his family, he is desperate and destitute. He grapples with God.

It is a long night…

When the struggle is over, he is left with a gimp and a new name. His life will never be the same. Having been “touched [in] the socket of his thigh”, he is told by his contender that his name will no longer be Jacob (deceiver, supplanter) but Israel (one who prevails with God). (Gen 32:25-28) He walks away with a physical reminder of the encounter in his hip and a brand new identity. The God of covenant not only saved his life, but protected his family, gave him a new purpose for living, and fulfilled the promise to make him the father of a great nation.

Two weeks ago I found myself lying on a table, left alone as a remotely controlled machine directed a powerful invisible beam of ionizing radiation to my left hip. As I lay there looking up at the artificial skylight created through back-lit ceiling panels, I thought of Jacob.

Our experience has taken us through many long nights. Spent of human resources, desperate for answers, we wrestled with God – and came away with His blessing. The permanent marker used on my thigh to map out the precise direction of focused radiation reminded me that I am now a marked man and will never be the same. I have encountered a faithful God who has assured me of His lovingkindness and secured my destiny.

As I contemplate this story further, I am impressed with the honesty of Scripture. The One who sacrificed His own Son so that we might “have life and have it abundantly” (John 10:10) is not dismayed at our honest contending with Him. In the story of Jacob, He invites the wrestling match. (Gen 32:24) The God of the universe is not too busy to set aside time for a one-on-One encounter that, though it may last the long night, leads us to a clearer understanding of His ultimate plans for our good. If we don’t give up, we not only survive the night, but face the day with a new confidence and hope.

A friend and former patient is still going through that long night. Some years ago, he lost his teenage son, a boy that I was privileged to deliver while practicing in Michigan. I cannot imagine the pain. He has an honest grievance with God. He recently wrote me, “If God loves us, why does He keep hurting us?” My heart aches for him and many like him who have suffered an enormity of loss I will never know. What I do know is that God does not shrink away when we honestly grapple with Him. Even His own Son, whose love constrained him to lay down his life for us, experienced the struggle. (Luke 22:42-44)

Having prevailed through our own long night, I have experienced His touch and the blessing that follows. In Jacob's own words: "I am unworthy of all the kindness and faithfulness you have shown your servant." (Gen 32:10) Daybreak has illumined a clearer confidence in the reality of His promise, the fulfillment and unimpeachable joy that comes with a new identity as His child. My prayer is that my friend will someday know the same.

Glad for the gimp,

Dan

PS – There is no more powerful and effective treatment concerning the dilemma of personal pain in the presence of a loving God than the best-selling novel called The Shack. I highly recommend it to you.

The Race Set Before Us

“…let us run with endurance the race that is set before us” (Heb 12:1)

One of the delights I have had during this lengthy period of convalescence has been the opportunity to spend more time with my grandchildren. And our favorite family activity when the weather turns cold (next to one of Mama Crabtree’s homemade pizza parties) is to compete with one another on the popular and highly interactive Wii video game system. Everyone from 3-year-old Evie to Grandma and me enjoy manipulating their look-alike Wii characters as they perform super-human feats of athleticism, high-speed vehicular stunts, or goofy bare-back competitions on cud-chewing farm animals.

In the midst of all the fun, there is plenty of opportunity to work on building character: persistence, patience, the value of teamwork, how to lose with grace, and (one I am still working on) how to win with humility :-) Clearly the lessons are not all aimed at the little ones.

The other day, my 7 year old grandson Matthew enthusiastically took charge of the Wii remote to enter the long-distance island run, an event among the Wii Fit games that requires running (in place) with a cadence that optimizes aerobic endurance. As his Wii character strode through parks, over green hills, past a beautiful waterfall, and dozens of encouraging on-lookers, I noticed that he was required to follow a pace-setting guide. His guide not only set the pace according to his ability, but also directed him all along the course, sometimes taking him off the beaten path. When he slowed down, his guide did not leave him in the dust, but waited for him to catch up. And when on occasion he ran ahead of his guide, his Wii character would inevitably fall flat on his face, then dust himself off and resume a more measured stride behind his vanguard.

I am so grateful that we have had a Great Guide along this journey, that He is setting the pace, ensuring our well-being, and marking out our course. (Hebrews 12:2) Past experience has taught us to keep Him in sight, avoid running ahead or lagging far behind. We have also learned He will sometimes take us off the beaten path. The words of the late Tony Snow come to mind and are worth repeating: “We want lives of simple, predictable ease—smooth, even trails as far as the eye can see—but God likes to go off-road. He provokes us with twists and turns. He places us in predicaments that seem to defy our endurance and comprehension—and yet don't. By his love and grace, we persevere. The challenges that make our hearts leap and stomachs churn invariably strengthen our faith and grant measures of wisdom and joy we would not experience otherwise.”

It is tremendously reassuring to know that He has set the course that lays before us; He knows the terrain and has personally conquered every obstacle. Ours is to keep pace, follow His lead, get up when we stumble, and share the joy in the journey. This is an exciting and highly interactive enterprise, which invites neither resignation nor hubris, but a growing confidence in the beneficent purpose and plans of the One who has run the race before us (2Cor 12:9). This is not a game for couch potatoes!

These past few weeks have demonstrated that He is indeed setting the course before us. Linda and I had the opportunity to visit family and friends in five states, witnessing with joy their response to the remarkable story of my battle with cancer, accentuated by the visible evidence of God’s power and grace. (Matthew 10:27) We also attended a Christian Medical & Dental Association conference aimed at exploring what new directions our Pacesetter may have in mind for those of us who have the finish line in view.

Then last week I alone returned to Charlottesville for consultation with my oncologist as well as the radiation oncologist to determine the best course of action to address the persistent tumor in my left femur. After some deliberation and authorization from my insurance carrier, a specially focused high-intensity radiation protocol was set up to take place in three daily sessions. (“Standard” radiation therapy protocols call for up to thirty sessions spread over six weeks.) As there was an excellent continuing medical education course offered at UVA later in the week, I had already arranged to stay in the area in our cozy camper, commuting to the conference and enjoying the fall colors. I simply excused myself when needed to jump over to the radiation therapy center for the 15-20 minute treatment session and ducked back into the conference. I have had no pain, nor worsening fatigue, nor other side effects usually associated with radiation therapy.

Clearly the course had already been set out before me. I am now scheduled to return to Charlottesville December 1 for repeat imaging studies and follow up. Thanks once more for cheering us on.

Keeping the pace with gladness,
Dan

PS -- And hoping to finish well...

Endurance and Endorphins

Therefore, since we have so great a cloud of witnesses surrounding us, let us also lay aside every encumbrance and the sin which so easily entangles us, and let us run with endurance the race that is set before us (Hebrews 12:1)

Although I have never aspired to run in a marathon, I can recall a time when I actually enjoyed running long distance in college. I remember the daily 3-mile route through campus and down tree-lined neighborhoods. I remember the times I would get a stitch in my side or a cramp in my leg that would ease as I ignored the pain and lengthened my stride. I remember the cold, crisp mornings when icy air threatened to freeze-dry my lungs only to thaw as I pushed through to a steady cadence and continued to stoke my metabolic engine. Breathlessness was transformed into resonant rhythmical respiration followed by an almost invincible sense of strength fueled by endorphins. On the days I did not feel like running, my roommate could be counted on to goad me out of the dorm, then encourage me all along the course, often setting the pace.

Notwithstanding our desire to sprint to the finish in our competition with cancer, it is now clear we have signed up for a marathon event. When we returned to UVA on Thursday, October 2, a high-resolution MRI uncovered not one but six new metastases of the brain. These were all treated without complication by the marvelous technology of gamma knife surgery. Another MRI of the left hip region revealed that the previous suspicious area of increased PET scan activity corresponded with a one-centimeter lesion in the bone marrow of the proximal femur (thigh bone).

Although none of these lesions is causing symptoms, the oncologist concedes that the declaration of a remission from the melanoma was premature and he anticipates that further intervention is needed. Considerations include local radiation to the hip, another course of high-dose Interleukin-2, or some other novel therapy. There is no sure strategy for this segment of the course we are set upon.

The parallels to long-distance running are clear. Endurance is the key to finishing the race and finishing well. We have already pressed through much of the pain and have a foretaste of the endorphin rush. We are catching a second wind and hitting a new stride. In large measure our progress is credited to many of you, our “great cloud of witnesses”, some of whom have run the same course.

Most of all, however, it is because of the One who has set the pace for all of us, who has run through every muddy mile and won for us the promise of an invincible life… and who runs along side us still, sometimes prodding and always cheering us on. (Hebrews 12:2)

More than anything else, our strength is renewed because “the lovingkindness of God endures all day long.” (Psalm 52:1)

Dan

PS – We are currently traveling, visiting friends and family in Michigan and Illinois while awaiting word regarding specific treatment recommendations. We will keep you posted

Father Knows Best

But He knows the way I take; When He has tried me, I shall come forth as gold. Job 23:10

This is not going to be anything close to a perfect analogy, but for those of you old enough to remember the classic TV sitcom from the 1950s and 1960s starring Robert Young, you will get my point.

Imagine you are able to select from a number of alternate endings to this most recent episode in the series on the life of Dr Dan, who has just returned from UVA and another round of extensive imaging studies to assess the progress of his response to Interleukin-2. Which would you choose?

A – No trace of cancer is found

B – Imaging studies are unchanged (architectural changes persist, but no new tumors)

C – There is evidence of a limited number of new metastases

D – Extensive recurrent metastases are discovered

Well, you can guess which ending I would have chosen… but (fortunately) I am not the author of this drama. The writer of this episode has chosen option “C”: The MRI of the brain shows a tiny new tumor of the left frontal lobe and the PET scan shows an area of faint but suspicious activity persisting in the left hip region. Lab studies remain normal, there is no associated pain and the patient’s clinical condition is stable.

The next scene, therefore, will take us back to UVA medical center on Thursday, October 2, where I will undergo another gamma knife procedure to eradicate the brain tumor, then an MRI of the left hip and possibly radiation therapy to that region as well. This is akin to extinguishing a few "hot spots" where once there was a raging forest fire.

Although I would have chosen (and honestly was fully expecting) version “A” with a “happy-ever-after” ending to this episode, I am grateful not to be playing the lead role in version “D”. And after some contemplation, I am truly looking forward to the page-turning adventure of a script that only the Master Author can create. I must admit that I would not have written any of this story. But then I would not have known the depth of intimacy with my Creator, nor the wonder of His provision… the power of prayer… the peace of His palpable presence.

Linda and I agree, there is no going back to a “routine” life, one that runs on automatic pilot. We are forever changed, living by the moment, fully dependent and surrendered to a loving, wise, and awesome God. Indeed, Father knows best!

The LORD is good, A stronghold in the day of trouble, And He knows those who take refuge in Him. Nahum 1:7

Stay tuned for the next episode...
Dan

For Goodness' Sake!

God saw all that He had made, and behold, it was very good.
(Gen 1:31)

I remember the first day of my college ethics class… the professor asked us to define “good”. Go ahead, give it a shot. You will quickly find yourself either chasing your tail in some circular reasoning or appealing to some other moral determinant that supercedes the essence of good. You will also quickly learn whether you are a moral relativist (i.e., that perceptions and circumstances define what is good) or subscribe to absolutism (i.e., that objective good exists, regardless of my perceptions and/or circumstances). It is not my intent to solve that debate here.

We all get comfortable, however, with our suppositions about what “good” looks like – “You made a good choice… It’s been a good day… The fundamentals of our economy are good…” In normal discourse we rely on a common understanding of what good is and often assume that our audience shares that understanding. Of course the opposite also applies: We make judgments every day about what is “bad” – “That was a bad decision… It was one of my bad hair days… The bailout is a bad idea…”

Now we don’t always agree on what constitutes good and bad, and at these times, we appeal to some standard, characteristic, or outcome that would convince our listener of the merits of our position. When we do this, we reveal to ourselves and others the basis upon which we determine the true nature of what we consider good.

If you were to ask me six months ago about my situation, it would have been disingenuous of me to say “It is good.” I had rapidly shed 20 pounds; I had frequent waves of nausea and no appetite; nearly all my strength was gone; there were nightly episodes of bed-soaking sweats, fever and chills; bone-wracking pain in my ribs and spine was a daily experience; and cancer was continuing to spread to brain, lungs, liver, spleen, lymph nodes and throughout my skeleton. Surely that cannot be considered “good”.

But in retrospect, it was good. More precisely, it resulted in many good and wonderful things.

If you have been following this blog since the beginning, you have seen the good – I have a faith in God that is stronger and more pervasive in my life, having passed the test of adversity; I have a relationship with my Creator that is more intimate, real and consequential than ever before; I have a greater appreciation for the steadfastness and power of His love, mercy and grace; armed with the certainty of eternal life, the prospect of death holds no dread nor fear; I have been humbled by the outpouring of genuine concern by so many and awed by the power of prayer; like never before I have learned to value the relationships I have with family and friends; indeed every human encounter now carries a weight of eternal significance in the light of this new perspective.*

Against incredible odds, I have experienced an extraordinary response to the high-dose Interleukin-2 therapy. As of my last check-up, my cancer is declared to be in remission. I am no longer in any pain; my strength and stamina have improved; I have recovered most of the weight I lost (and don’t need those extra pounds I was carrying anyway!) In one more week we will return to UVA for another series of imaging studies and examination to determine the trajectory of this remarkable healing.

But what if the outcome of my treatment were different? What if, like 94% of stage IV melanoma patients, I did not respond to Interleukin-2? What if ...? You can fill in the blank. You can probably write your own story. None of us is guaranteed a happy ending to every story. Ultimately, we are all terminal.

Among all the blessings of this difficult journey, the one that stands out the most is that I have learned that God’s character is not determined by my circumstances. When it comes to proving His character, He nailed that one forever when He sent His only Son to suffer and die for me on a cross. (Romans 5:8) Whether my situation is deemed good or bad, His goodness is unchanged. (Hebrews 12:5-6, James 1:2-3)

There is a popular song of praise that repeatedly answers the question “What is good?” The chorus rings “God is good all the time! All the time God is good!” I am one who now sings that phrase with greater confidence and joy than I have ever known before. And I will continue to sing it until time is no more.

Dan

*If you want a good read on how the prospect of imminent death might change your perspective, consider the book One Month to Live, by Kerry and Chris Shook.