Physician, Heal Yourself!

This entry is one of the more difficult ones to write. (No, it is not about the debate over healthcare reform.) For those of you who have been following these writings for over a year now, I am compelled to share a sobering lesson. With each journal entry I have sought to relate some element of truth that our experience has brought to light or perhaps was made more powerful through its practical application in this difficult situation. Each entry has also proved to be a therapeutic outlet for me as it has challenged this left-brained physician to exercise those more creative faculties traditionally thought to reside in the right cerebral hemisphere.

Now after six gamma knife procedures, targeting 43 metastatic deposits in the brain, I am facing the reality that recent studies indicate the persistence (and active enlargement) of at least four of these malignant growths. In addition several new metastases are evident elsewhere in the body in spite of four toxic multi-dose courses of Interleukin-2. We are currently awaiting the collaborative recommendation of my oncologist and neurosurgeon at UVA. The treatment options are extremely limited.

Although I am currently having remarkably few symptoms, I am forced to recognize the very real potential that, with or without further intervention, my faculties may (soon) progressively decline. In the past, as I have witnessed this same phenomenon in my patients (either due to malignancy or other degenerative process), I have been moved to console the family and help them compensate for their loved one's deteriorating mental capacities.

Now threatened with the same potential decrepitude, I am prompted, while I still may, to share with you what many may deem obvious: Worship the Giver and not the gift!

My sincere desire, in offering these biographical musings over the past 18+ months, has been to share some of the lessons learned along this difficult journey with cancer. Your comments, prayers, and heart-felt support have bolstered both me and my family as we have travelled this road together. I also recognize that the very challenge of sharing these thoughts in some creative and constructive way has been a source of great personal satisfaction... and potential pride.

The threat of losing those faculties that have made this creative outlet possible is perhaps the most difficult to face. But as I ponder why this is so, I am forced to recognize that I have subtly arrived at the place where I have worshipped the gift above the Giver. It is far more healthy to hold all such gifts with an open hand. (This is a hard pill to swallow.)

Even as Jesus was consoling Peter who had failed miserably during his greatest testing, He warned him that "when you grow old, you will stretch out your hands and someone else will gird you, and bring you where you do not wish to go." (John 21:18) Jesus' love for Peter had not diminished and his future was never more secure. But that streak of independence would yet yield to complete surrender.

Regardless of what lies in our path just ahead, the good Giver has not changed... He will not stop giving all the grace we need for the journey.

Gratefully,
Ummm... Oh, yeah, thanks honey... Dr Dan

PS -- I invite you to check out Linda's latest blog. You will find her creative juices still flowing freely!

Update on My Noodle

In the PET-CT gantry I lay like a mummy
As rads pulsed in and out once more
All I could hear was a grumbling tummy
Until I awoke to my snore!

This study is aimed to inform my physician
If the brain MRI changes they see
Reflect an ongoing destructive condition
Or the remnants of dying debris.

Though the tech says the study is 'perfect'
All that means is the image is sharp.
We'll now have to wait for the verdict...
Will I play with the kids or a harp?

"Some trust in chariots and some in horses..."
Yet our future is His and not man's
So we'll await the next treatment courses
As we rest secure in His hands.

Thanks so much for your thoughts and prayers,

Dr Dan

Joy in the Journey

Fair weather or foul, the joy indeed is in the journey! Linda and I just returned from a three-week vacation to the Pacific Northwest. During the first week we caught up with life-long friends in a lakeside cottage near Eugene, Oregon. The next week we explored the Olympic National Park region and spent a day basking in the elegant beauty of Victoria, British Columbia. Finally we boarded a cruise ship in Vancouver and spent the next week exploring the southern coast of Alaska all the way to Anchorage. We even had a chance to visit my eldest brother, Dennis, during an extended layover in Denver.

We had great weather in Oregon and Washington state, but on this our first journey to Alaska we encountered back-to-back days of cold, rain, and cloudy skies. Although this was a disappointment, we were still awe-struck with the magnificence and expansiveness of our surroundings. Knowing this would probably be our only trip to this region, we made the most of each day, enjoying one another's company, feasting on great food, and imbibing the natural beauty (misty as it was) that surrounded us. We did spy whales, porpoise, sea lions, moose, and many varieties of birds.

We also encountered some very wonderful people, including Ramona Douthit, the widow of a very good friend (Howard) who lost his battle with cancer last year. Howard was (and continues to be) an inspiration to me as a man who, in spite of dreadful suffering, found joy in the journey. His steadfast love of God and unshakable devotion to his family helped him navigate tempestuous waters with inspiring courage and strength.

It appears that we, too, are headed for troubled waters once more. Within hours of returning to Norfolk, we travelled to Charlottesville for another full day of imaging studies and consultations. The news is mixed: While I have few symptoms and lab studies remain normal, there are several new lesions identified on the PET-CT (involving the neck, axillae, and left hip region) and troublesome findings on the MRI of the brain. The brain images suggest either swelling and disintegration of previously treated lesions, or possibly progression of these same metastases. The good news is that there do not appear to be any new brain lesions.

After deliberation, my consultants have recommended a dedicated PET-CT of the brain to determine if the lesions there are actively growing or resolving. Resumption of high-dose Interleukin-2 cannot go forward if these lesions are actively enlarging, so it is not yet clear what course of action will be recommended. We return to Charlottesville this Friday, August 7, for the PET-CT study.

Meanwhile, our confidence in the Master travel agent is unshaken. We don't yet know what is beyond the next bend, but have learned to expect jaw-dropping vistas of His faithfulness and love.

May you, too, know joy in the journey,
Dr. Dan

PS -- I was given the distinct privilege of speaking to our church congregation on "Facing Our Fears" this past Sunday. You can listen to the message by clicking HERE. Feel free to write me if you want a copy of the outline and/or PowerPoint presentation.

Declaration of Dependence

On the eve of our nation's celebration of Independence Day, we have just returned from UVA where all the recent imaging studies and the path report from the recent needle biopsy of the right axilla have confirmed that our personal battle with the tyrant called malignant melanoma is not yet over. Given what is recognized by all as a 'remarkable' response to high-dose Interleukin-2, Dr Grosh has recommended another course of this 'biological warfare' agent.

Interestingly, on the Fourth of July last year I was still in the hospital completing the fourth and 'final' round of this rather toxic regimen. (See blog entry of July 6, 2008.) Having cancelled our usual holiday activities, I limped home to recoup and await the outcome of that particular skirmish. One year later, I continue to be amazed by the extent of my recovery (as do my physicians :-) and by the awesome grace afforded me by a loving and faithful God.

The Fourth of July is a big deal for our family and this year I look forward to celebrating the holiday enthusiastically with them. As we all celebrate the freedoms we enjoy as a nation on this Independence Day, I am compelled to reflect on the life-changing liberty I have discovered in the midst of this ongoing battle with cancer -- a liberty that derives from an utter and complete dependence on my Maker. Therefore, with all due respect to the founding fathers, I would like to share with you my "Declaration of Dependence" (You may need to click on the image to read it):


Declaring one's inadequacy and dependency on another is not a macho nor popular thing to do, but this battle with cancer has exposed for me the folly of a Rambo-I'll-do-it-my-way approach to life. Because I have learned to depend on Him completely, having surrendered any presumption of 'unalienable rights', I now thoroughly enjoy Life to the fullest, Liberty that emancipates me from all fear and worry, and irrepressible Happiness that comes from His loving pursuit of my well-being and a settled sense of hope and purpose.

May you, too, enjoy such freedom this Independence Day.

Dr Dan

PS -- Because there are no new brain metastases, a repeat gamma knife procedure is not deemed necessary at this time. We are scheduled to return to UVA July 30 for repeat imaging studies and pre-admission workup, anticipating hospitalization for IL-2 therapy on August 3. Should be a fun summer!

The Purpose of Pain

"God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains: it is His megaphone to rouse a deaf world." C.S. Lewis, The Problem of Pain





We just returned from UVA where I underwent an ultrasound-guided needle biopsy to assess whether or not the three small areas of increased metabolic activity in the neck and right arm pit that lit up on a recent PET/CT scan actually represent recurrent melanoma. The experience served as a helpful reminder to me that pain has a purpose.

None of these lesions was palpable on exam and the ones in the neck were too tiny to even attempt to biopsy. The interventional radiologist therefore directed his attention to the right arm pit. The aim was to visualize the exact location of the suspicious nodule with high-frequency sound waves, impale it with a large bore hypodermic needle passed through the skin into the center of the lesion, and aspirate tiny bits of tissue into the shaft of the needle and attached syringe.

He began by pressing the ultrasound transducer firmly into my right axilla and in short order identified an abnormal lymph node deep in the recess. After prepping the area and providing a local anesthetic, he made a tiny incision in the skin and guided the needle toward its mark. Because of the relatively small size of the target lesion, the difficulty visualizing the needle on the ultrasound image, and the typical reluctance of lymph nodes to hold still while being attacked by a sharp instrument, repeated thrusts with the needle failed to produce any tissue. These maneuvers did produce considerable pain, however.

The radiologist offered additional local anesthetic to the deep space in my arm pit, but I declined. “It looks like we have a tough guy here,” he quipped to the technician. “Not really,” I replied, “But by the nature and location of the pain, I can tell when your needle is pressing against the involved node.” So I turned from passive subject to active participant in the procedure.

As the physician made repeated attempts to skewer the elusive mass from different angles, my grimaces and muffled yelps served as confirmation that his stiletto-like probe was zeroing in on the intended target. This game of thrust and parry continued for a full hour. Then with an “Arghhhh… Ohhhh, yeah… That’s it!” the hard little mass could resist no longer: a delft stab through its midsection finally yielded adequate tissue for pathologic examination.* The cheers arising from the gallery were deafening :-)

I’m really not a glutton for punishment, and now that the procedure is over, I’d say the level of pain was really quite tolerable. It certainly cannot be compared to the still-vivid memories of excruciating torment that attended a complicated liver biopsy eighteen months ago. Nor am I averse to taking pain meds when needed – More than once has Dilaudid brought me from the brink of unconsciousness triggered by unbearable pain to a state of complete relief and relaxation.

But this most recent encounter with pain has underscored the positive role that noxious stimuli and their physiologic response play in our lives. Indeed, pain produces a reaction in us that is both protective and life-affirming. Repeated admonitions to a toddler to avoid the hot stove or the flame of a candle are seldom heeded until that first misadventure. It took the painful experience of a dislocated toe to teach me not to descend our slick hardwood stairway in stocking feet!

This beneficial role of pain is dramatically and tragically revealed in those medical conditions in which the normal pain mechanism is impaired, such as the peripheral neuropathy that often accompanies advanced diabetes. I recall one diabetic patient of mine who suffered third degree burns to her feet by exposing them to excess heat without any awareness of pain or injury. She ultimately lost both feet.

Of course there are those conditions which produce chronic debilitating pain that seemingly has no positive protective purpose (e.g., fibromyalgia, reflex sympathetic dystrophy, primary neuralgias, etc.) And many suffer unbearable emotional pain from the loss of a loved one, repeated rejection, or other adversity. To be honest, it is in these circumstances that pain seems to mock us rather than preserve us.

As one who has experienced the destructive side of pain, the intractable bone-wracking pain that accompanies the rampages of disseminated cancer, I can sympathize with those for whom this type of suffering is a daily experience. My entire professional career (and that of my colleagues) was devoted to preventing and/or alleviating this kind of misery.

Nevertheless, even here I have found that pain has a purpose. I can say with honesty that, as strange as it sounds, I never felt more alive than during those long nights when I was immobilized with pain from head to toe caused by the rapidly advancing malignancy. In the midst of what was clearly “the valley of the shadow of death”, my head and heart were compelled to confront whether life consisted solely of this biologic existence or indeed encompassed eternity.

As C.S. Lewis suggests, it was in the midst of this kind of pain, that God used a megaphone to reassure me of His promise: “I came that they may have life and have it abundantly.” (John 10:10b) He came. He lived as one of us. He knew rejection. He suffered a measure of pain I will never know. And He did it all that I might know what it is to truly live. My personal experience with pain stripped me of any pretense of self-sufficiency. It taught me to celebrate His presence and His promise, secured by trusting Him fully. It continues to be a remarkable journey.

Dr. (Pincushion) Dan

*As expected, the microscopic analysis of the needle biopsy specimen demonstrated the typical pigment-laden, distorted cellular architecture of malignant melanoma. We return to UVA next week to discuss treatment options with Dr Grosh.

Sufficient Grace

Is the glass half empty or half full?

The way I answer that often depends on what is in the glass! I recall gagging down two very full glasses of liquid chalk (unsuccessfully disguised as a peppermint shake) in preparation for a contrast-enhanced CT of the abdomen... ugh! Examining the small amount that remained in the Styrofoam container, the technician chided me with a malicious smile: "Ah, but Dr Crabtree, you know you must drink it all." Chugging the last remnant of this awful concoction seemed an impossible task.

When Jesus faced the unimaginable horrors of the crucifixion (and the imminent separation from the Father) He implored "My Father, if it is possible, let this cup pass from Me... if this cannot pass away unless I drink it, Your will be done." (Matt 26:39, 42) Fortunately for us He found the strength to drink the full cup to the dregs.

Then there is the apostle Paul who speaks of a "thorn in the flesh". (1Cor 12:7-8) While Bible scholars debate precisely what physical disability Paul suffered, it is clear that in this regard he was running on empty and he desired to be full -- i.e., to be whole once more. Three times he asked the Lord to remove this ailment. (Hmmm, only three times?) What really intrigues me is the Lord's response...

Whether faced with a bitter cup of suffering that must be drunk to the full, or drained of strength and longing for a full cup of refreshment, our Lord assures us "My grace is sufficient for you." (2Cor 12:9) Nice words, but what help are they really? I am learning the liberating reality of what these words reveal about the life of faith.

Regardless of my circumstances (no matter what is in the glass), God's grace (those gifts that attend an intimate relationship with Him, Eph 1:7-14) will literally fill up or overwhelm whatever the need is so that I can declare "I am satisfied" -- it will be sufficient for me. The Father sent an angel to minister to Jesus in the garden and He was strengthened. (Luke 22:43) Paul was able to conclude: "Therefore I am well content with weaknesses, with insults, with distresses, with persecutions, with difficulties, for Christ's sake; for when I am weak, then I am strong." (2Cor 12:10)

I am happy to report that my glass is more than half full! On June 11 we returned to UVA for a repeat PET/CT scan and MRI of the brain. As of yesterday we learned the results: Of the 18 brain tumors that were treated with the gamma knife procedures in April, all but 3 have regressed and there does not appear to be any new intracranial lesions. The 3 remaining lesions are only slightly larger and display some surrounding edema, suggesting positive effects of the radiation. The PET/CT, on the other hand, reveals three tiny new areas of increased metabolic activity, two in the posterior neck region and one in the right arm pit. These may represent newly developed metastases outside the brain. None of them was detectable on physical exam. Aside from some degree of increased fatigue, I am doing well with no pain and no apparent neurologic impairment. My doctors agree, compared to the devastating disease noted when first diagnosed one and a half years ago, I am doing remarkably well.

Dr Sheehan, the neurosurgeon, recommends simply observing the brain lesions for now and repeating the MRI of the brain in two months. Dr Grosh plans to pursue a needle biopsy of the lesions of the neck and/or right axilla, if the interventional radiologist determines this is feasible. Should the results of the biopsies prove positive for melanoma, I may face a repeat course of high-dose Interleukin-2. I will keep you posted.

Although I had hoped for a complete remission by now, I am truly "well content". Filled up by His grace, my glass is brimming with goodness, knowing His faithfulness, refreshed by evidences of His love (powerfully displayed in the love of family and friends), and constantly satisfied with the rewards of walking this journey with Him. Thanks for your continued prayers.

Dr Dan

PS -- Please pray for my sister-in-law, Genelle. For years she has suffered a progressive neurologic condition that has left her with extreme weakness so that she is now hardly able to speak and has difficulty breathing at times. Initially thought to have MS, a subspecialist has confirmed that she actually has Lou Gehrig's disease (ALS). Her husband, my brother, Paul has been a tower of strength, but I suspect his glass also could use a refill.

Identity Lost (& Found)

Identity theft is on the rise. The FTC reports that 10 million Americans fall victim to identity theft each year resulting in over $50 billion in lost revenue to businesses. A stolen identity can rob you not only of economic resources but also of emotional security and future financial opportunity. Not surprisingly a whole industry has emerged to provide an array of safeguards designed to enhance identity protection.

Linda and I had a recent encounter with a salesman that reminded me of the enormous power that personal identity wields in our lives. Not at all predisposed to purchase what this young man was selling, we concentrated our efforts on getting to know him and sharing a bit of our story. He was very engaging and did not shy away from this disarming discourse in personal matters. We learned that he is one of three sons of a local pastor and, although he is the only one in his family who did not pursue a college education, he has been very successful in his chosen career with obvious gifts, persuasive common sense and a compelling personality. In fact, once we opened this door he was more than eager to tell us every detail of what made him outstanding and unique.

Long story, short, we were introduced to his fully researched heritage as a descendant of the Moors of North Africa, inspiring him to abandon his father's faith and embrace the Muslim religion. We listened with genuine interest as our enthusiastic guide introduced us to the critical role that the (majority) non-white population played in our nation's formative years. We were exhorted to recognize Benjamin Banneker, a free black man, mathematician and astronomer, as a true founding father whose influence preceded that of George Washington. We were tutored in the role that the Masons played in designing our government, rooted in Moorish cosmology and culture. We even learned of the blessings that accompany those who are genetically endowed with a generous measure of melanin.*

Clearly our new acquaintance derived an enormous sense of self-worth and personal significance from his carefully fashioned and thoroughly articulated identity. Attesting to the tremendous power it held in his life was not only the fervor with which he shared its details (emotionally charged with hubris and a hint of anger), but also the sacrifice it must have cost him in his relationship with his father and siblings. It provided for him a basis for personal pride, a perceived context for his life, and a sense of destiny.

We all cling to that which makes us unique as individuals... to those characteristics of our past, our personality, passions, pursuits, or progeny that form our identity. The search for significance is universal and it is intimately wrapped up in our need to embrace a particular identity. When that identity is threatened, or its underpinnings found to be inadequate to sustain our self-esteem, we face a major personal crisis... a crisis more devastating than a stolen credit card.

When a rampaging cancer robbed me of all strength one year ago, a major underpinning of my identity was kicked out from under me. No longer able to make it through a full schedule of patients, I was forced to close an innovative new practice that I had begun less than 3 years earlier. The daily satisfaction derived from my identity as personal physician to so many individuals evaporated overnight. I was forced to examine the bedrock foundation of my true identity.

Of course my identity as husband, father, grandfather, brother, etc., had not changed and in these relationships I found (and continue to find) great reward and in each a renewed source of strength and fulfillment. Yet as satisfying as these relationships are, they too are inadequate, for they ultimately depend on the fidelity (and presence) of others to provide a sustained sense of personal purpose and selfhood. I could look to other characteristics to embellish my identity, such as clever blogger, handyman, great lover... (the list goes on :-) But experience has taught that all of these self-ascribed characteristics are ephemeral and not an enduring basis for one's true identity.

My experience with cancer has taught me not to rely on any of them. There is only one reliable and invulnerable foundation for my identity. It is unaltered by my circumstance. It cares not about my past or where my family is from or what I have achieved. It is more powerful even than my DNA. It is found in this verse of scripture: "See how great a love the Father has bestowed on us, that we would be called children of God; and such we are." (1John 3:1) I do not need to look elsewhere for my ultimate purpose, for self-esteem or fulfillment. There is but one right that I know is guaranteed and cannot be stolen from me by any man: "But as many as received Him [Jesus], to them He gave the right to become children of God, even to those who believe in His name." (John 1:12)

In this identity, as a child of God, I find my place in the universe, impervious to pain and adversity, confident in who I am and whose I am. What freedom! Free to be me and compelled to share His great love with others. I now pray for my salesman friend that he too will come to reclaim his true identity.

Dr Dan

*We all enjoyed a round of laughter as this white boy with malignant melanoma pointed out that I probably carry more melanin in my body than he ever will!