Rewards

Enjoy life with the woman whom you love all the days of your fleeting life which He has given to you under the sun; for this is your reward in life and in your toil in which you have labored under the sun. Ecc 9:9

This past week Linda and I celebrated our 40^th wedding anniversary with laughter and tears. This was the anniversary that almost wasn’t – since early on in my diagnosis neither of us expected me to be here through the summer.

We gathered our three daughters, their husbands, and the newest granddaughter (too young to be separated from her mother) for dinner at the Sheraton’s “City Dock” restaurant in downtown Norfolk. Then we all boarded the American Rover for an evening cruise on the Elizabeth River. It was a spectacular evening, complete with a golden sunset, followed by a full moon that kindly framed itself in the forward rigging of this 135-foot schooner as gentle breezes filled the sails and a strolling balladeer serenaded us with some of our favorite ‘oldies’. What a gift!

Speaking of gifts: A remarkable recovery from disseminated malignant melanoma – a gorgeous and healthy new granddaughter – the chance to celebrate 40 years of shared adventures with the wife of my youth – surrounded by three bright & beautiful daughters and their masterful godly husbands… each a reward of worth beyond my deserving. I’m telling you, this life of faith demands unbearable sacrifice! :-)

I have often taught in our adult Bible study class that the life of faith – the life that dies to self and follows Christ with full abandonment – is actually a form of Christian hedonism. It is not a life of selfishness, not driven by self-interest, but one that is rewarded in ways that selfish ambition could not imagine nor hope to gain. Scripture is full of examples (Ps 19:8-11, Ps 37:4, Prov 22:4, Matt 5:3-12, Matt 6:3-4, Luke 6:35, Phil 3:8, Col 3:23-24).

Christ himself is our model: “…Jesus, the author and perfecter of faith, who for the joy set before Him endured the cross, despising the shame, and has sat down at the right hand of the throne of God.” Heb 12:2 The Son of God, who loved us enough to pay the ultimate price, was moved and empowered by the knowledge that, in the end, there would be great reward.

It is ironic that the path to an abundant life requires a conscious choice to die, to surrender my plans, desires and energies to His sovereign purpose. The very things that I hope to gain through my own striving and clever design are ultimately achieved only by putting them to death. “For whoever wishes to save his life will lose it; but whoever loses his life for My sake will find it.” Mat 16:25

I have been blessed beyond belief. This journey, which has taken me to the brink of death and back, has already produced rewards I could not have anticipated, not the least of which is the outpouring of genuine concern and prayers from so many. I am enormously grateful.

But the greatest reward continues to be a deepening relationship with the One whose love and grace transcend this fleeting life – for He reminds me “…I am your shield, your exceedingly great reward” Gen 15:1

Gratefully,
Dan

PS – I cannot overstate the reward Linda has been to me over the past 40 years, and particularly through this most recent leg of our journey together. As a token of my gratitude for her love and faithfulness, I offered the following toast at our dinner celebration, along with the gift of a diamond “journey” pendant.

The Final Report (Part II)

We finally received a call late yesterday from Dr Grosh with details of the imaging studies and labs done on Monday -- and it is great news!

The MRI of the brain was reviewed in detail with the neurosurgeon, Dr Sheehan. It shows no new metastases and all previous tumors are either gone or in the process of disintegration from the second gamma knife procedure.

The bone scan, for the first time, shows significant improvement and maturation of the healing process from the previous extensive multiple metastases. No new lesions or signs of active destruction are evident.

The CT/PET scan, which detects any rapidly growing activity of tumor cells throughout the body, was essentially negative. There was one faint and ill-defined area of increased tracer activity in the left hip region, but no corresponding anatomic abnormality there on either the CT scan or bone scan -- so it is thought to be an artifact. There are still radiographic abnormalities in the liver which likely represent residual architectural changes caused by the previous tumor growths there. All labs were normal, including liver enzymes and non-specific markers for tumor activity.

Compared to the devastating images six months ago, this is nothing short of miraculous!

We will return to Charlottesville in late September to repeat these same studies and monitor the progress of healing. Meanwhile no active treatment is planned. We are enormously grateful to you for your prayers, to the physicians who have cared for me, and most of all to our God for His faithfulness, mercy and love.

Basking in His grace,
Dan

The Final Report

Clip art licensed from the Clip Art Gallery on DiscoverySchool.com

We have all experienced it – the anticipation (sometimes apprehension) while waiting for the final report, whether that was a grade in a course, a performance evaluation at work, a biopsy finding, or a test result. While waiting, we ruminate on the “what if’s” and the consequences of various outcomes. Our mind takes us down paths that will likely await us depending on those results.

This week has been a week of waiting for the final report on the extensive imaging studies performed at UVA on Monday, August 4. This series of imaging studies included a high-resolution MRI of the brain, a bone scan, and a whole-body CT/PET scan using a glucose-linked tracer called FDG to pick up any areas of high metabolic turnover (such as rapidly growing tumor cells). Having completed the full course of Interleukin-2, the results of these tests should reveal the degree of response and have a significant impact on future prognosis. After a very long day of fasting, poking, prodding, and lying perfectly still on a cold table for hours at a time, we anticipated learning the results when we met with the oncologist late in the day. Unfortunately, none of the final reports on these studies was available.

When we met with Dr Grosh he was able to pull up the images on the computer screen and together we reviewed the pixilated representations of my brain, skeleton, and vital organs. The preliminary verdict: no evidence of new or active tumor growth! But subtle changes here and there, and the possibility that a review by the radiology consultants on their high-resolution monitors could pick up additional findings, compelled him to defer any definitive assessment to those final reports*. We agreed he would call me in a couple of days, once the official reports were available. Although his nurse called to let us know he was pursuing the matter, we are still waiting…

Yep, we’re back in the waiting room (see my blog entry of 7/06/08). It has become a familiar place. We have learned that time spent here can be very valuable. While waiting to hear what the final reports may reveal, we have been listening to what the Lord may be trying to teach us.

During the wait, several thoughts have come to mind. First and foremost: God is still in control. Our future hope is not pinned to the result of some therapeutic agent or study result. Our hope is in Him. Psalm 20:7 puts it this way: “Some trust in chariots, and some in horses, [and some in PET scans], but we will remember the name of the Lord our God.”

Our future is secured, indeed guaranteed (Rom 8:38-39, Heb 6:17-19). We have asked Him for healing and He has given us far more – He has rewarded faith with fruit that cannot be measured in survival statistics nor calculated on a computer screen. Our lives have been unalterably changed for the good; we have a more intimate understanding of His love and faithfulness; and if my prayers have been answered, so have many of you.

Secondly, while waiting for the final reports we have the giddy notion that, precisely because God is still in control, the details of the results will not matter. Not that I will ignore the results, nor fail to act on them according to sound medical advice – but it will not alter my confidence in the One who knows my end from the beginning. In practical terms, even if the radiologist should report heretofore unrecognized new metastases in the brain or elsewhere, God’s eternal plan will not be altered.

In the Old Testament story of the men sent by Moses to spy out the promised land, those who understood the power of their God rendered a final report that was far different from those who did not. While both groups observed the obstacles to victory, those who knew the faithfulness of a covenant-making God reported “we will surely overcome” (Num 13:30). Their enemies, though formidable, would become their prey (Num 14:9). Regardless of any possible disparaging news in our final reports, any residual cancer will find itself in the cross hairs of a powerful and faithful God. All fear is eclipsed by God's lovingkindness. (1John 4:18)

Finally, I realize that there is ultimately only one final report that really matters. That is the report that I will receive when I enter into the presence of the Lord. C.S. Lewis wrote: “You don’t have a soul. You are a soul. You have a body.” This body, though very much cherished, is destined to fail me some day. The report that matters is the one that assesses the status of my soul.

A good friend and outstanding Christian leader entered into God’s presence yesterday. Howard Douthit, fellow elder at Tab Church, beloved husband to Ramona and father to Nathaniel, Joshua and Jonathan, succumbed to complications of cancer after a prolonged battle during which he inspired many of us with his courage and unflagging devotion to God. I am confident he has received his final report: “Well done good and faithful servant… Enter into the joy of your Master.” (Matt 25:21)

That is the final report I look forward to.
Dan

* Please understand that the preliminary results of the tests done on Monday are extremely encouraging. My clinical exam is essentially normal, my weight has stabilized, and I have reached an improved level of strength. My progress has exceeded most optimistic expectations and we are rejoicing in what the Lord has accomplished. I will update you once I receive word on the final reports.

Life, Celebrated Daily!

If you fly into our town, you will be greeted with this sign as you leave the airport: It welcomes you to the city of Norfolk with the motto “Life, Celebrated Daily” and the ubiquitous mermaid, a symbol of the area’s maritime history.

The city motto has taken on special meaning for me over the last six months. This past week marks a significant milestone in that on January 23, 2008 I first learned that I had far advanced cancer throughout my body with a life expectancy of less than six months from that date. Not only have I survived beyond that initial predicted life span but have every hope of complete eradication of a cancer that at one time had invaded brain, lungs, liver, spleen, lymph nodes and nearly every major bone of my body. I have experienced an overwhelming supply of love from others and the magnificent power of God’s grace and healing touch.

And to make this celebration even sweeter, this week we welcomed our eighth grandbaby into the family. On July 22 our youngest daughter Christianne Page gave birth to Adelaide Joy, weighing in at 7# 5 oz, 20” long. Kudos to Dr Holly Puritz who skillfully performed an urgent (repeat) cesarean delivery and provided much needed encouragement and TLC for both mom and daddy David throughout the procedure. As you can see, Adelaide is beautiful, healthy, and one of grandma and grandpa’s greatest joys. We are enormously grateful to be so blessed with this new little life at the same time that we are celebrating my new lease on life.

Through it all, the entire family has learned to celebrate life daily. None of us is guaranteed tomorrow. Each human encounter is precious. The marvelous promise that Jesus made 2000 years ago has become our daily experience: “I came that they may have life and have it abundantly.” (John 10:10)

Abundant life… We have learned that He was not talking about longevity, nor prosperity, nor even necessarily fun and happiness. He certainly was not talking about a pain-free existence or a life bereft of difficulties, trials, or adversity. What He has promised and delivered is a life of superior quality, a life abundant with meaning and purpose, a life rewarded with unimpeachable joy and a transcendent hope – all experienced daily.

Those of you who have participated with us on this journey through prayer and expressions of heart-felt concern are one source of our joy. May each of you be as blessed as we with an abundant life… celebrated daily!

Gratefully,

Dan

PS – I highly recommend Linda’s recent blog as she reflects on the significance of the arrival of Adelaide Joy.

Surprise! Surprise!

God loves a surprise. He has a penchant for the unpredictable. Tracing His activity is a study in sacred spontaneity. I don’t think you will find this stated anywhere in Scripture, at least not explicitly, but just observe a few examples:

Surprise, Sarah! Though you haven’t had a period in 40+ years, you’re pregnant! (Gen 17:17, 21:2) Surprise, Job! All your livestock have been stolen or destroyed in the same day, your servants have been killed, and tragedy upon tragedy, all your children were lost in a house collapse! (Job 1:13-19) Surprise, Peter! Notwithstanding your protestations to the contrary, caught off guard, you denied me three times. (Matt 26:69-75) Surprise, Paul! Suddenly blind, you will soon see all I have in store for you. (Acts 9:3-16)

There are many more such instances of the unexpected in Scripture. This is not to say that God is caught unawares, nor that His actions are arbitrary or capricious – quite the contrary. It is often that an event that appears quite unexpectedly to an individual was foretold long before it occurred (e.g., Sarah, Peter). Further, not every sudden turn of events is a result of divine intervention, but rather the result of our own fallen and imperfect state and the presence of evil in this world. (Deut 30:17-19, Prov 6:14-15, Luke 13:4) We are even warned to be prepared for the unpredictable. (Mark 13:35-37, 1Cor 10:12)

And with every unexpected alteration in the fabric of our lives, God weaves a pattern that leads us to a greater understanding of His unstoppable love, mercy and grace. (Prov 16:9, Jer 29:11, Rom 8:28) Tony Snow, who was recently promoted to the life hereafter, said it best: “God relishes surprise. 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.”

When I look back on the last six months of my own life, it is rife with surprise…

• Jan 23, 2008 – Without warning, a “routine” CT scan performed for a prostate problem demonstrates disseminated cancer
• Jan 31, 2008 – A liver biopsy report returns, demonstrating that the cancer is a particularly aggressive form of malignant melanoma. I am referred to UVA for consideration of Interleukin-2 therapy.
• Feb 7, 2008 – Extensive test results reveal the cancer has spread to the brain, lungs, liver, spleen, spine, ribs and long bones. No primary source is found. Because of the brain tumors, I do not technically qualify for Interleukin-2 therapy, but Dr Grosh is willing to consider it if the tumors can be treated successfully with gamma knife surgery.
• Feb 8, 2008 – Severe pleurisy-like pain raises the question of a blood clot to the lung. None is found.
• Feb 11, 2008 – It is discovered there are actually five small tumors of the brain. All are treated with gamma knife surgery.
• March 4, 2008 – After numerous imaging studies, several trips to the emergency room to rule out complications, IL-2 therapy is again postponed due to questions about possible pneumonia. Meanwhile I am losing weight (~20 lbs), in nightly pain, and getting weaker by the day.
• March 10, 2008 – Having ruled out active infection, we finally begin high-dose IL-2 therapy (one week in hospital, one week recovering at home, then back for second week of therapy).
• April 21, 2008 – Imaging studies show a remarkable response to the IL-2 therapy, unusual for someone with such extensive disease.
• May 28, 2008 – The Port-a-cath device has to be removed due to breakdown of the overlying skin. Fortunately, no infection is found.
• June 9, 2008 – Repeat imaging studies show persistent regression of the tumors elsewhere, but there are eight NEW brain tumors, again suggesting a fairly aggressive cancer. Repeat gamma knife surgery is arranged. This development again calls into question whether future IL-2 therapy will be tolerated. The decision is made to proceed.
• June 14, 2008 – Unexpectedly, I develop recurrent pain in my left arm suggesting a nerve impingement in the neck. An MRI shows no nerve compression and the pain “spontaneously” subsides.
• June 16, 2008 – We begin the second cycle of high-dose IL-2 therapy, suffer significant toxicities during each week of treatment, but avoid serious or permanent damage.

Then this past week we were hit with yet another surprise – one that threatened to shake our faith to the core.

Three days after discharge from the hospital I discovered a firm, tender nodule in my left arm pit. It was rounded, fixed, and rapidly enlarging without associated signs of infection. The clinical assessment was that this could very well represent resistant melanoma – particularly bad news having just completed the “final” course of IL-2 therapy. I alerted the oncologist and managed to arrange an open biopsy with a surgical colleague and friend, Dr Randy Gould.

Having experienced God’s faithfulness through a series of surprise developments, Linda and I determined that our trust in God would not be moved. His character (His unchanging love, mercy, and grace) are not determined by our circumstances. Even if this “surprise” meant my life here may be shortened, we affirmed that His goodness and lovingkindness are unwavering.

July 16, 2008 – Dr Gould examines me and is also concerned. He promises to get tissue at least to establish a diagnosis. During the procedure he spies a black hard mass, still highly suspicious for melanoma. But on further examination he discovers that the mass is simply a clot which had mounded up inside the vein where my previous central catheter had been placed. Pathologic examination of the vessel wall reveals no cancer and there are no surrounding lymph nodes. Subsequent venous ultrasound studies show the extent of the clot. No immediate treatment is necessary and I am reassured that this will resolve on its own with time. It is not the sort of clot that travels to heart or lung.

The God who loves surprises never stops loving us. His love for Job, Peter and Paul were never diminished, despite their circumstances. He is God, the sovereign One, and there is no more secure place than in the palm of His hands. We now look forward to whatever awaits us around the next bend: repeat total-body imaging to be performed on August 4 at UVA.

Continually surprised by His love,
Dan

A Word About Weakness

as·the·ni·a (ās-thē'nē-ə) n. Loss or lack of bodily strength; weakness; debility.

Recently I had to complete paperwork to qualify for disability benefits – I never envisioned being at the other end of that process! When asked what about my condition prevented me from being able to work, I wrote down “weight loss, fatigue, asthenia”. Not currently in any significant pain, the predominant debilitating symptoms are these. No longer am I able to breeze through 12-hour days, mostly on my feet, and certainly not on any sustained basis. Loathe to admit it, I am too weak. I lack the sustained physical energy, muscle and mental stamina, to manage the longitudinal care of hundreds of patients as I once did.

As I have tried to share with you lessons learned during this journey with cancer, the one lesson I have yet to learn is how to accommodate my own weakness. Perhaps it is because I have almost always had more than my share of energy. “Blessed” for years with subclinical hyperthyroidism, my metabolism was in hyper-drive. Even after treatment for the thyroid condition, I required higher-than-average doses of synthetic thyroid medication, which seemed to keep me revved up, getting by with less than six hours of sleep, running circles around my wife, and driving her crazy with my ability to eat most anything without gaining weight.

Perhaps my difficulty adjusting to this new reality of weakness is my tendency to equate weakness with a defect in character or will. Of course I know better, but I have always operated on the semi-conscious notion that if you simply “buck-up”, you can overcome most any obstacle. Ask any one of my daughters how their doctor-daddy responded when they wanted to stay home from school because they did not feel well or it was “that time of month”.

And, although I am reluctant to admit it, part of my difficulty with weakness is that my self-esteem is linked to an achievement-oriented mentality and the desire to "be strong" for my woman whatever the circumstance. After all, she is the weaker vessel, right? Like it or not, I have a hard time shaking off these deeply ingrained patterns of thinking. I may yet need to learn (like a friend recently observed) how to become a human being (as opposed to a human doing).

Now I am confronted with a condition in which both the disease and the treatment rob me of energy; and no amount of self-will, positive thinking, or even sincere faith seem capable of restoring. This last course of high-dose Interleukin-2 zapped me of energy like I have never experienced before – just getting up from a chair or climbing a flight of stairs required enormous effort. Only now am I able to stay upright most of the day.

I know intellectually that there are lessons to learn through this experience of sustained weakness but I have yet to embrace them fully. The apostle Paul was apparently well tutored by weakness as he related to the Corinthian church his struggle with a “thorn in the flesh” (2 Cor 12:7-10). Beset with some chronic malady he was told by the Lord that he would not be rid of this condition, but rather “My grace is sufficient for you, for power is perfected in weakness.”

Power is perfected in weakness… Hmm, how does that work? Apparently that is what I must yet learn. What is the nature of this power? It certainly is not physical. No Olympic athlete cultivated weakness in order to achieve greater strength or stamina. It must be spiritual power, or as Paul puts it, “the power of Christ”. I must yet learn what that means experientially – this is not something to be comprehended through mental gymnastics. I suspect people like Joni Eareckson Tada and Dick Woodward know a bit about power perfected in weakness.

One thing I have learned: that is to be satisfied with uncertainty. In a conversation with my Dad the other day, he asked “When will you know you have been cured?” My short answer: “Never.” From a medical standpoint, I know the physicians will never declare me “cured”, even if no evidence of active cancer can be found. Rather, knowing that not every renegade melanoma cell can possibly be accounted for by any existing scan or test, they will declare me “in remission.”

And that is okay with me, for in this state of uncertainty (vulnerability, weakness), I am totally dependent on Him as my source of peace, hope and strength. That is where I belong. That is where I will stay. And one day I will be able to say with Paul: "Most gladly, therefore, I will rather boast about my weaknesses, so that the power of Christ may dwell in me."

Still learning and loving each day He gives,

Dan

The Waiting Room

Aaah, we are all familiar with the waiting room, that place where you arrive to be seen by your physician, then wait (and wait) until he can finally actually see you. It is a place where many anxious moments pass ever so slowly. I have been on both sides of that room lately. At Personalized Family Medicine we eliminated the waiting room (retaining a small, pleasant reception area) through intelligent scheduling and allowing adequate time for each type of patient visit. But admittedly we did not eliminate all waiting. In God’s economy, I am now learning the value of waiting.

One of my favorite passages in Scripture is from Isaiah 40:31 – “But they that wait upon the LORD shall renew their strength; they shall mount up with wings as eagles; they shall run, and not be weary; and they shall walk, and not faint.” While scholars have debated the nuanced meaning of Isaiah’s poetic interlude, this promise from the Lord especially captured me this past week with practical power.

My first hope was that I would perhaps avoid this second series of hospitalizations altogether (“mount up with wings” and fly over this mountain) by receiving an “all clear” report from the imaging studies – that did not happen. Then, determined to make the most of it, I was anxious to race through this course in as short a time as possible, not miss a dose, and put the week behind me (“to run and not be weary”). Well, that did not happen either.

I discovered that this situation required me to learn to “walk and not faint”… to persevere, to plod through the day-by-day, hour-by-hour, minute-by-minute buffeting of my body and psyche in order to achieve the optimal outcome that my doctor (and my God) desire for me. It meant patiently waiting to collect the pre-treatment data (chest X-ray, EKG, lab); then riding inexorably through the many expected and unexpected side effects of treatment: chills, severe rigors, painfully strained muscles, limiting mobility, nausea, repeated vomiting, watery diarrhea, abdominal distress/distension, generalized swelling, shortness of breath, carpal tunnel syndrome due to the fluid retention, stomatitis, loss of all appetite, extreme fatigue and weakness, and, appropriate for the Fourth of July, a red splotchy itching rash surrounding pale white islands of raised whelts and blue lips!

With each new dose came a new combination of toxic effects, a strategy to ameliorate those effects, and in many instances the next dose postponed to allow time to recover. This particular course required the longest hospital stay yet to complete just 8 doses of IL-2, sometimes getting only one dose in over a 24-hour period. Beyond a doubt this fourth (and hopefully final) session of high dose Interleukin-2 therapy was the most difficult and protracted.

What was I to learn through this? First, He does not provide wings to surmount the circumstances in every situation. I have experienced that kind of rescue in the past, where I could view the problems in the valley from a lofty perspective and my only worry was to avoid plunging inadvertently into the next snow-capped peak! Sometimes He has us run like a troop through the thickets that would otherwise slow us down, renewing us with energy, quickening our pace, and cheering us on over the next hill. And sometimes He places us in a position that running or flying will just not achieve the best outcome – He comes along side to sustain us through the drudgery of the challenge we must endure and our strength is renewed to the very end. He reminds us, "It's the relationship, stupid!" He wants me to learn to know Him more intimately and it is during these times that I slow down enough to hear His heart beat (Isaiah 26:8, Psalm 46:10).

My role is to discern which course of action is most needed and to “wait” on Him to help me through it. It was just a day before being admitted to the hospital for this final round of IL-2 therapy when one of my mentors, Hap Struthers, a fellow elder at Tab church and a Hebrew scholar, pointed out that the verb translated “wait” in the King James version (elsewhere translated as “trust” or “hope”) has its roots in the Hebrew term for “lying in wait”, as in an ambush. Rather than a passive activity, it describes the one who seeks new strength as a person poised for action, every muscle taut in anticipation of God showing up in the midst of a difficult situation.

I like to think of this waiting process as similar to the mental attitude of well-wishers at a surprise birthday party for someone they love, all quiet and crouched behind the furniture. Together they are poised to spring upon their friend to lavish him with praise and affection as soon as he arrives. (Notice that passage does not say “he” that waits upon the LORD, but rather “they…”. This is a group endeavor!) I have sensed that I am joined by my many believing friends and family who were fully expecting God to show up in this situation, anxiously anticipating what He would do. Well, my friends, I am happy to report He did show up, and He is deserving of all our praise.

And of course, He kept His promise: Through this week, I have walked (sometimes crawled) through the most difficult circumstances yet, and I have not fainted. Thanks for being part of the waiting room party! May you, too, experience His renewed strength on your journey today.

Celebrating Him,
Dan

PS – Linda had a few more adventures while staying at the camper during the week and has been a tremendous source of strength from the Lord to me. I expect to be discharged today. We will spend one more day in the camper to recuperate and head back home for what we hope will be a full recovery. Next round of tests are slated for early August.