It's All in Your Head!

Actual mapping MRI of Dr Dan's brain, horizontal cross-sectional view at the level of the orbits
(yellow spots represent melanoma deposits)








Truer words were never spoken. We just returned from Charlottesville after another round of imaging studies, lab tests and consultations with both the neurosurgeon, Dr Sheehan, and the oncologist, Dr Grosh. The PET scan indicates no evidence of active disease from the neck down, but the MRI of the brain demonstrates at least nine small tumors which have progressed in size since the last study. All but one of these appear to have been present on the previous scan (final report still pending). I remain remarkably free of any signs or symptoms from these metastatic deposits in the brain. So, indeed, it’s all in my head!

From a medical standpoint I appear to be somewhat of an enigma. It is unusual to demonstrate progression of melanoma tumors in the brain and yet have no evidence of active disease elsewhere, especially in light of the extensive metastases found throughout my body at the time of initial diagnosis.

Although it is clear we still face a formidable foe, it is also clear that nothing short of the miraculous could have brought me this far. One year ago I was immobilized with pain, emaciated, pale, unable to eat, hardly able to draw a breath at times, at the brink of death. Today I am pain-free with renewed energy, an insatiable appetite for all that life has to offer, and a little over-weight :-)

How we face the formidable foes in our lives is a matter of the head. The awesome reality of God’s peace that I have experienced through all this is a direct byproduct of how I choose to fill my head. Listen to these encouraging words: "You will keep him in perfect peace whose mind is stayed on You, because he trusts in You.” (Isaiah 26:3) "And the peace of God, which surpasses all comprehension, will guard your hearts and your minds in Christ Jesus." (Phil 4:7) I have put this to the test and know it to be true.

We have reviewed the treatment options with our consultants (whole brain radiation, stereotactic radiosurgery, ipilimumab infusions, or other investigational therapy) and have chosen to proceed with the gamma knife procedure. Because of the number of lesions to be treated, this will be done in two sessions, now scheduled for April 10 and April 20.

Meanwhile, I rest in this thought: “You, O Lord, are a shield about me, my glory, and the One who lifts my head.” (Psalm 3:3)

Dan

Living Life by the Slice

"Give us this day our daily bread..." Matthew 6:11










My wife makes the most delicious homemade breads. Mmmm… Just writing about it makes my mouth water: the fresh-baked aroma, steam wafting from a warm loaf as I sunder through the delectable crust and render that first slice. At times Linda would urge me to continue paring the loaf until it was thoroughly divided into nice even slices, ready to be packaged and placed in the freezer for later consumption. But I prefer to sever and savor one slice at a time, while it is still oven-fresh, moist and delicious.

Now that is the way we are living life – one slice at a time.

To catch you up, on Wednesday, February 25, my local surgeon, Dr Randy Gould, removed a subcutaneous nodule from my left posterior shoulder, about the size of a small grape. This appeared for the first time on the PET-CT done at UVA on February 11 and proved to be an isolated recurrent melanoma. Then on Thursday, March 5, we traveled to Charlottesville to consult with Dr Grosh once more. At that time he thoroughly reviewed the recent imaging studies, biopsy results, and treatment options.

Because of subtle, inconclusive findings on the last MRI of the brain, the appearance of this new lesion of the left posterior shoulder (now removed), my stable physical condition, and the lack any laboratory abnormalities, it was decided to simply arrange another series of studies at the end of this month. If at that time there is evidence of progression of the cancer, Dr Grosh is considering a tertiary referral for entry into a clinical trial that uses the monoclonal antibody, ipilimumab. If there are limited brain metastases and no new systemic metastases, repeat gamma knife surgery may be considered.

But you notice the sentence begins with ‘if’ – that is a slice we have not yet sampled. And so it is for all of us, is it not? "If I finish this course as planned... If the economy turns around... If my 401K doesn't completely tank..." Life revolves around 'if'!

Knowing our penchant to want the whole loaf divided for us in clearly defined slices, Jesus urges us to trust the Father for each portion on a daily basis: “Give us this day our daily bread… your heavenly Father knows… So do not worry about tomorrow; for tomorrow will care for itself. Each day has enough trouble of its own.” (Mat 6:11, 32, 34) This caution is not just an accommodation to the harsh reality of life – rather He is advocating a healthy diet, a way of living that nourishes and satisfies our soul’s deepest hunger pangs.

So these days we mark our calendar in pencil. We consciously live life one slice at a time and savor each morsel. Though we may not know what the future holds, we know who holds the future and are truly satisfied.

The Bread of Life is right – it’s fresher by the slice!

Dan

PS – To complete this thought, consider an earlier blog entry that includes a poem “To End with ‘And’”

Patient is a Virtue

The student lounge was filled with young men and women, each attired in crisp hip-length white coats that identified them as medical students. I had been invited by Dr Grosh to speak to the second-year class at UVA School of Medicine as part of a course he directs on the psychosocial aspects of cancer. I was happy to oblige.

As the students settle into the chairs and couches scattered about the room, I invite you to listen in to some excerpts of our conversation:

“It is great to be here today. If you ask me, I think Dr. Grosh is simply showing off his most successful cases. In fact I’m pretty sure he would not have asked me to participate if I had already succumbed to my cancer as planned six months ago. I am glad to be here today!

“Let me tell you a little about my medical career… I enjoyed a very busy practice with over 3,000 patients… increasingly frustrated by the economic realities of modern medical care that drove a wedge between the patient and his/her physician, sometimes developing a ‘fortress mentality’ in the office… I then launched a solo subscription practice that allowed me to focus on personalized, prevention-minded, proactive care that was mutually satisfying for both me and my patients…

“All this ended abruptly on January 23, 2008 with the startling news of disseminated malignant melanoma… I knew my prognosis was grim… underwent countless studies, punctuated by numerous emergency room visits while waiting to qualify for Interleukin-2 therapy… experienced rapid decline, shaking chills, night sweats, bone-wracking pain, weight loss, nausea, vomiting, and extreme weakness...

“The hardest task was sharing the news with my grandchildren… adjusting to life no longer defined by my profession… an altered body image… concerns regarding my wife’s future financial security…

“Throughout the diagnostic work-up and the demanding treatment protocol I gained a greater appreciation for the consequences of orders I had blithely written for patients in the past… a liver biopsy that resulted in excruciating pain following the procedure… a complete spinal MRI that demanded one to lie perfectly still on a cold hard table in a cramped noisy tube for 1½ hours… the toxic hospital food… the session with a nutritionist who persisted in inquiring about my dietary habits undeterred by my convulsive contributions to the emesis basin… the breezy hospital gowns… the frequent vital signs that ensured sleepless nights… the drug-induced diarrhea (and accompanying embarrassment of soiled bed linens)… the drug-induced constipation (and accompanying hemorrhoids)… [They heard all the gruesome details…]

“From this physician-turned-patient who still faces a life-threatening illness, let me leave you with three earnest recommendations:

1 – Cultivate a fortress mentality… but place the ramparts so that your patients and your family are safely within the fort. Boundaries are necessary but you must work diligently to place them so that you do not compromise your professional integrity nor sacrifice those you love the most. Gain the confidence needed to maintain a relationship with your terminal patients, even when you are no longer the treating physician. Regardless, recognize the unintended consequences of the orders you write and own them.

2 – Strike a balance between honesty and hope. I don’t believe ignorance is bliss, but brutal honesty without genuine caring and sensitivity can be abusive. On the other hand, hope propped up by false or vacuous claims is deceptive. Your goal is to help your patient live and to live each day to the fullest. In reality, none of us is guaranteed tomorrow.

3 – Don’t run from conversations about faith. When it comes to issues of mortality, your patient’s world view is absolutely critical in determining their response to a life-threatening illness. If you do not feel personally equipped to do so, ensure that a pastor, chaplain, or spiritual counselor is available to your patient.

“As a doctor who became a cancer patient, my faith has made all the difference. Although I would not have written this chapter in my life, I am extremely grateful for the lessons it has taught me. The experience has been transformative. Because of my faith in a loving and sovereign God, I have no fear of tomorrow but gladly celebrate each day. My hope for you is that, in the midst of your intense medical training and the unending reach for that next goal, you won’t neglect the rewards in store for you today.

“Thank you for your attention. I’ll be happy to answer any questions.”

I fielded a number of questions that day, but the one that is most memorable was asked by a young woman who said: “You seem to have weathered some difficult times with a very positive attitude and a bright outlook for tomorrow, but how do you handle the patient who clearly has no hope of survival, where death is imminent?”

“Great question. First of all, there were several times in my own experience when I thought death was indeed imminent. What buoyed me up in those times was a confidence that God was with me and that He had secured for me a future that transcends this brief earthly existence. I am convinced that if I did not have that hope, I would have been in deep despair.

“I recognize, of course, that not everyone shares this world view, so I simply invite them to consider it. Dr. Sigmund Freud, for example, embraced a different (naturalistic) world view. Resigned to the harsh reality of his world view, he described death as 'the terrors of eternal nothingness' and actually arranged for his own euthanasia when he determined that he could not face another day with cancer.

“I view my role as a physician to help patients live, even when (especially when) their days are few.”

I have learned that being (a) patient is a virtue!

Dan

PS – Want to rent a great movie that portrays a doctor who learns the virtues of being a patient? Check out the 1991 film starring William Hurt, The Doctor. A helpful discussion of the film aimed at medical personnel is found here.

Uncharted Territory

Ask my family and you will discover that I love an adventure… often to their dismay. When hiking an unknown mountain path, I must explore what lies beyond the next bend, or discover what vista surely waits just over the next rise (sometimes leaving Linda to rest upon a rock). Whether sailing straight into a fog bank, canoeing through a mangrove maze, or schussing down a slope of virgin snow in cross-country skis, I love to go “where no man has gone before”.

I vividly remember one occasion in which my penchant for exploring uncharted territory could easily have ended in disaster. Wanting to share the thrill of adventure with my family, I loaded them into our new Jeep Wagoneer and set about on an off-road exploration of the Tennessee back country. Careening over the crest of a hill, and with lightning reflexes animated by my wife’s blood-curdling screams, I slammed on the brakes just feet from the edge of an 80-foot crevasse.

When the computer game called Myst was released in 1993, I was hooked. In this highly textured fantasy world, I was free to satisfy the need for exploration without risking life or limb or loved ones. The family was glad to make this venue of adventure a regular birthday gift.

Once more we are embarked on a real-life adventure into uncharted territory. Once riddled with cancer, by God’s grace I have navigated successfully through four gamma knife procedures to the brain, two cycles of systemic high-dose Interleukin-2, and three sessions of external beam radiation to the left hip. I have arrived in a place that few with stage IV melanoma have lived to experience. I am feeling great but there are challenges just ahead.

Our most recent visit to UVA on Wednesday, February 11, revealed a complex landscape: imaging studies suggest both significant improvement in systemic control of the cancer and possible persistence of tiny growths in the brain. All pertinent labs and my exam remain normal. Although my oncologist and neurosurgeon are exploring various options, there are no road maps to guide us through the next steps. There is no proven protocol for survivors like me.

I am reminded of another adventurer, spoken of in scripture. In Genesis 12:1, God tells Abraham to venture forth “to the land which I will show you”. Not knowing precisely what lay over the horizon, he set out, trusting God to guide him and supply his every need. He was not disappointed.

As we await the recommendations of my highly-competent physicians on this next leg of our journey, experience has taught us to fully trust in God as our guide. I’m looking forward to yet another adventure!

Dan

PS – On this Valentine’s Day, I am truly grateful for the one the Lord has given me as a faithful companion on this journey. As I awoke this morning, these were the thoughts I shared with Linda:

Waking to another day
Joy fills my heart anew…
The greater gift, I cannot say:
This breath I take, or you?

Happy Valentine’s Day!

Carib-being

As I have shared on a number of occasions, one of the lessons learned on this incredible journey with cancer has been to celebrate each day, knowing that none of us is guaranteed tomorrow. And so indeed Linda and I have faced each and every day with a new-found joy and excitement, acknowledging "This is the day the Lord has made; we will rejoice and be glad in it!" (Ps 118:24)

Nevertheless, some days elicit more celebration than others -- like this past Friday, January 23, 2009. That date marked the one-year anniversary since the day we discovered my body was riddled with cancer and I was given less than six months to live.

Happily we found a very special way to celebrate my survival: we embarked on another 7-day cruise vacation in the Caribbean! For those of you who have followed our story, you will recall that one year ago at this time we had already booked a Caribbean cruise and our sail-away date was imminent. The timing could not have been better. My oncologist suggested there was no better medicine for the present than a romantic get-away with my sweetheart. (Reading between the lines: "Enjoy the next few days, for I fear your days are few.") By God's grace, the "Big C" did not deter us from creating some great memories on the high seas.

So one year later we found ourselves once more imbibing in God's goodness and reveling in the joys of His creation: walking along a palm-lined beach, warm white sand fondling our toes... gazing at an endless horizon as the sun's rays shattered into a dazzling display of dancing rivulets on waters that vacillated between emerald green and deep azure (all the while, of course, slathered in a gelcoat of SP-30!) Our spirits soared as we witnessed a kaleidoscopic sunset, embraced tropical breezes, or gazed at star-studded skies, refusing to exhale the deliciously pure night air.

We are all drawn to such experiences -- encounters with our senses that elicit both delight and a deep insatiable yearning for perfection and beauty, a foretaste of a deeper reality whereby we long to be immersed in Eden once more. For the one-time atheist, C.S. Lewis, it was this universal human experience of yearning for the eternal (which he describes as "joy") that first drew him to acknowledge the existence of God. As the writer of Ecclesiastes declares, "He has set eternity in their hearts". (Eccl 3:11)

And as Linda and I have reflected on the events of the past year we have gained a new perspective on life. Well, perhaps not a new perspective, but one that is now more certain and consequential than ever before. It is an eternal perspective, one that affirms we are destined to embrace a reality that transcends this brief excursion on planet earth. In short, that we are made for paradise.

We also know that in this life we will not experience paradise. Many of our troubles, strife, and fears evaporate once we recognize that our struggle is rooted in a frustrated longing for paradise on earth. We are learning to smile on rainy days, to persevere through life's reversals, to more readily forgive each other's shortcomings, and to appreciate the potential for good in the most devastating of circumstances.

Yet He graciously continues to dole out free samples of the boundless joy that is to come. Check it out, next time you witness the birth of baby, or spy a soaring eagle, or stand breathless before a mountain range, or capture a rainbow in the afternoon sky. One year after the diagnosis of an unusually aggressive disseminated cancer, I am basking in the warmth and beauty of His goodness, love, and grace.

Dan

PS -- We return to UVA in Charlottesville on February 9, 2009 for repeat scans and a check-up. I will provide an update then.

Taste and See!

As difficult as this year has been, it has been indeed one of the BEST years ever. Just witness all He has done in the following pictorial review of 2008 for the Crabtrees. (Please be patient as the program opens and the slide show begins -- hope you enjoy)

Make a Smilebox slideshow

May you savor the goodness of God in the New Year!
Dan

Just Deserts

The other day Linda and I attended a Christmas performance by the Old Dominion University madrigal singers held at our church. As we entered the spacious atrium decorated to resemble Narnia, we were greeted by one of the hosts who invited us to first visit the serving table, announcing “We are providing just desserts this evening. May I offer you some?”

I responded, “Jay, if I got my just deserts, I would not be here this evening!” To which he quickly replied, “That is true for all of us, isn’t it?”

Eleven months ago today, I was given a death sentence, informed that I had widely disseminated cancer that turned out to be an aggressive form of malignant melanoma. By all reasonable expectations (my own included), I should not be here today. Now after two cycles of high-dose Interleukin-2 therapy, radiation treatment to a left hip lesion, four gamma-knife procedures to the brain, a complicated port-a-cath removal, and a deep vein thrombosis, I am very much alive and anticipating the celebration of Christ’s birth with those I love. Do I deserve such favor?

The harsh reality is that we all have a death sentence. We have all been diagnosed with a terminal condition – it’s called the human condition. For all the millennia past, our mortality rate has been virtually 100%. In spite of all the advances in medicine, nutrition, and relative prosperity on the one hand, and all the devastations of war, disasters, and disease on the other, the death rate has remained unchanged.

And that is what we deserve. I know that is not politically correct, but the truth is that none of us deserves tomorrow. Genesis tells us that a good God gave us life, choice and sex so that we might propagate the gift of life. We squandered that gift when we each proclaimed our independence from the Creator. (Rom 3:23, 6:23) The natural consequence of my rebellion is death. But when I exercise the gift of choice and surrender my will to His, by His grace He restores my life. God sent His only Son to live a life that shows me how to truly live and to die a death that would conquer the grave. (1Pet 3:18)

And there’s the icing on the cake! Not only am I promised eternal life, but the life I now enjoy (day by day) is filled with joy, purpose, and peace. (Gal 2:20, 5:22-23) At the birth of Christ the angels proclaimed “peace on earth to men on whom His favor rests.” (Luke 2:14) The offer of “just desserts” still stands.

For me this has become a vital reality. I have tasted the bitter flavor of my just deserts, but in the days that remain I will satiate myself with His favor and feast on just desserts.

May you have a blessed Christmas!
Dan