Friday, October 23, 2009

End of the First Cycle

Well, my first cycle did not have much to contribute to the state of my wellness. We had a brief discussion of the treatment and its side effects, including the chemo brain. Unfortunately, the was a screw up and I didn't get any blood tests results until until after the oncologist's visits. I'll get the blood tests results next week. In the meantime, I'll start another cycle next Monday. The chemo brain will be treated by the temodar, whether its caused by cancer or is a result of fatigue.

The best news of the week is our acquisition of "Angel," a Cairn Terrier rescue pup from a kennel in Brevard, NC.



Angel is a 3-year old female, who has had 2 maybe 3 litters, and has had no training. We'll have plenty to do to get get her up to speed, but a super-abundance of love to repay for the efforts.

Monday, October 19, 2009

Day 23: Ending the Third Week ...

Ending the third week tomorrow; I'll be seeing my oncologist this Thursday. I have something something new to talk about with her. I discovered a new (to me) side effect, which I've been informed is called "chemo brain."

While I was at a mid-day "pig pickin' party" yesterday, I found I was having difficulty recalling certain words and became hung up completing sentences. I didn't think it was drink related -- less than than three ounces of a white wine, but it felt a bit like I'd had 5-6 glasses of a 14%+ red many, many years ago, except the effects where limited to my brain. A friend told me it sounds like "chemo brain."

Thanks to the Internet, it was discovered at UCLA in 2006, but didn't really hit the public press until July 8, 2009, where chemo brain was described as "... a trend between chemotherapy and cognitive abilities, but it hasn’t identified a cause." (L. Fayed, How to Manage Chemo Brain)

At that time, the ACS estimated that about 25% of patients who show these symptoms do so because of chemotherapy, now referred to as a "cognitive deficit." Seems it that it carries over into word processing too. Doesn't seem to effect my listening and reading vocabulary.

Wonder how it will effect my golf game?

Saturday, October 10, 2009

Days 10 & 11: So, so ...

Hit some golf balls yesterday and will probably got out again later today. The fatigue factor seems to have settled in at about 75%. I do well when not exercising, but tire fairly quickly doing anything moderately strenuous. I also have cold-like symptoms, many sneezes.

This morning, I took Cookie on a long walk, longer than intended when I got lost in an unfamiliar part of town. If you know anything about Pinehurst, you probably know that many of the streets are circular, which makes it pretty easy to get turned around. Eventually, I hit one of the few straight radial streets going 180 degrees from the way I thought I was walking. Fortunately, I made a good guess which way to turn and got going toward home again.

Thursday, October 8, 2009

Day 9: Great Day ...

Fabulous day here - Carolina blue skies and and mild weather! As promised yesterday, I went golfing this morning. As hoped for yesterday, my stamina was not not. I did OK for the first seven holes, then the bottom fell out and I quit after nine.

I'll just keep nicking away at it and see how long it takes to come back.

Wednesday, October 7, 2009

Day 8: Progress ...

Feeling reasonably good today; no evident symptoms. About 10:30 AM, I went over to the golf club and hit 50-60 practice balls. Afterward, I did feel some fatigue, but not enough to prevent me from booking a tee time for tomorrow. I'll take a cart in case I feel the need to bail out.

Later, on the Internet, PLX4032 was in today's OncologySTAT with a repeat of the prior Phase I trial and a more recent article from the 2009 October 1 Elesvier Global Medical News, "Targeted Therapy PLX4032 Takes Center Stage in Metastatic Melanoma." Like Gleevec, PLX4032 requires a gene mutation, BRAF/V600. Unlike Gleevec which requires requires C-KIT mutation which occurs in about 5% of melanoma sufferers, the V600 mutation occurs in about 60% of patients.

A Phase II trial is expected to be completed by the end of 2009, with a randomized Phase III trial to begin shortly thereafter. Something to keep in mind for possible next steps.

Tuesday, October 6, 2009

Day 7: Fatigue ...

Well, I do have to admit to some fatigue today. I went to the Fitness Center this morning and found my normal workout to be a bit too much. I managed everything but the second set of reps came down from 15 to 12 on three of the 8 machines and I was puffing more than usual after the elliptical run.

I'm home now and will shower after finishing this blog post - feels like a return to bed would be welcome after the shower, but I'm going to to try to maintain my normal routine. It's not a nap if I fall asleep in the chair while reading, is it?

Monday, October 5, 2009

Day 6: After the Chemo...

My first day without chemo meds the night before began at 3:30 AM when I woke up with major stomach cramps, followed by five hours of distress. I'd been told to expect fatigue on the sixth day. I don't have any fatigue, unless you call voiding your bowels repeatedly fatigue - I certainly got tired of that concept quickly.

I called off my 12:30 golf game at 8:00 AM, but by noon I was thinking, well, I probably could have played. It was raining, so I didn't pursue this thought very long. I'll be monitoring progress and post anything of interest. October 19th starts the week that I should expect negative impact on my blood counts. My next doctor's appointment is October 22, 2009.

Sunday, October 4, 2009

Day 5: Last Day with Temodar

Here we are, on Sunday morning. I took my last dose of chemo meds last night; no evident side effects as of 10:14 AM. Walked Cookie, followed by grooming (not her favorite event), then I went to the Fitness Center.

After lunch, we're going to the movies to see "The Informant," then home for the golf matches on TV. Tough day.

I'm waiting to see what happens tomorrow and the next day when I've been told I will feel very fatigued. If I don't, I will really wonder if I got $2,500 worth of drugs or just some empty capsules.

Stay tuned.

Day 4: Normal, normal, normal...

Sorry I missed the post yesterday. A normal day, a long walk with Cookie, then 18 holes of golf. I slopped around the front nine with three pars in the middle surrounded by 6's and 7's for a 47. I was more consistent on the back nine, which I think is more difficult, for a 44.

Renee sauteed a very nice trout for dinner and I snitched a glass of 2007 Firestone Riesling, very good at a ridiculously low cost.

Friday, October 2, 2009

Day 3: Same-o, Same-o

Again, a good nights sleep followed, today, with a trip to the Fitness Center. Still no evident side effects, although I'm feeling a little less energetic at the moment. So far, I'm finding this an interesting experience.

I've stopped aspirin - I didn't know it, but it take two weeks to get it out of your system. The third week in the four week temodar cycle is when your blood system takes the biggest hit, if it is going to happen. I'll see the doctor for tests in the fourth week to determine what's needed next.

Thursday, October 1, 2009

Day 2: More of the Same with Golf

The second administration went well; good night's sleep and up early for a round of golf. The golf was OK, but inconsistent. Couldn't seem to score well, missing more putts from 3' - 4' that I was making on Monday. I seem to be coming down with a cold that I've been avoiding for several days.

So far, Temodar has produced no side effects. Let's hope it's doing something good.

Wednesday, September 30, 2009

Day 1 Is Lots of Fun

Not a problem. There I was, all prepared for projectile vomit, with a waterproof wastebasket and towel by the bed, and nothing happened. What a relief. The only apparent side effect is constipation.

Turns out this is a side effect of the anti-nausea medication, Zofran. I learned this little tidbit during a visit to my radiation oncologist today in Chapel Hill. I also learned that the Cyberknife radiation treatment three months ago did what it was supposed to do - shrunk the tumor on my heart very significantly, from 1.6 cm to 1 cm. Yea!

The temodar treatment continues for 4 more days. Based on last nights experience, I'm planning on playing golf tomorrow morning.

Tuesday, September 29, 2009

Beginning Treatment

Fed Ex is on the job - the chemotherapy drugs arrived today. Temodar (temozolomide), the jet fuel based chemo drug, Zofran (ondansetron HCL) and Prochlorper, both anti-nausea drugs. Zofran is taken before the Temodar to prevent nausea and vomiting, the other afterward, as needed, to prevent "breakout out events."

Since I haven't taken any drugs yet, there's not much to report. I will say how blessed I feel to have Medicare Part D and my supplemental insurance covering the Temodar costs - $2,500 for five days worth of pills.

Drum roll ...

Saturday, September 26, 2009

Finally...

Yesterday, after seven weeks of waiting, I finally heard from Dana-Farber that my tumor tissue did not show evidence of the C-KIT mutation needed to participate in the Gleevec trial. The news was anti-climactic, because I had a CT scan on Thursday which showed continued tumor growths and my doctor and I felt more aggressive treatment was needed now.

The bottom line is that I will be starting on Temodar (temozolomide) on Monday. Temodar is an alkylating agent most active in the resting phase of a cell, but is non-cycle non-specific. It is classed as a Hydrazine or Triazine, which also include Altretamine, Procarbazine, and Dacarbazine. Like Dacarbazine, Temodar is a "pro-drug," which needs to be transformed to its active state by the patient's metabolism.

After nearly two months of waiting, it's pretty cool how fast things moved once the decision was made. A lab tech appeared and took blood samples for analysis, followed by a nurse who gave me a flu shot, then the nurse navigator took me down to the person who handles chemo prescriptions, who had already figured out how this was going to be paid for. All she needed to know was when I wanted to start. If I had said, "today,' she would have had the scrips (Temodar, plus two anti-nausea drugs) couriered over from the provider. Since I opted for Monday, the drugs will be sent to me at home.

Treatment consists of three 100 mg capsules taken two hours after my last meal each day for five consecutive days, preceded by a Zofran tab (anti-nausea) thirty minutes before the Temodar. There is also another anti-nausea drug to be taken every six-hours. (Guess what's a major side effect of Temodar). The five-day pill-taking cycle is followed by 23 days of doing nothing, other than recuperating from any side effects. I've been told I will be very fatigued on days 6 and 7.

Other side effects include the possibility of hair thinning, anorexia, headache, constipation, and myelosuppression (low blood counts). The last could lead to anemia and a weakened immune system, hence, the flu vaccination.

The plan is to do two 28-day cycles of Temodar, then, depending upon the outcome, decide what to do next. Stay tuned for progress reports.

Tuesday, September 15, 2009

Side Effects II

It's all in the timing,

I've been waiting over five weeks to hear whether or not I have the appropriate tumor gene mutation (C-KIT) to participate in a Gleevec trial. I was supposed to know within three weeks.. This was to be my first choice of treatments.

This morning, the Wall Street Journal published an article on "Living with a Lifesaving Drug's Side Effects" (WSJ, Thursday, September 15, 2009, D3). The gist of the article is that some lifesaving cancer treatments produce side effects that "... threaten the quality of their prolonged lives" and we're not talking about minor changes in lifestyle.

Wouldn't you know it, the featured example was -- Ta Dah -- Gleevec. I'm living a normal, symptom-free life, despite the presence of melanoma mets in my lungs, liver, and heart area. When I start chemo, clearly, my life will no longer be "normal." How different life will be cannot be predicted in advance, but neither can the efficacy of the treatment.

At age 74, which is better - a few good months or a few more lousy months/years?

I've added several web links, prefaced by SE, in the sidebar, where you can find more information about the side effects of specific drugs; however, you won't know your actual side effects, or their severity, until you begin treatment.

Timing? If I had received the gene analysis as originally proposed, I would already be committed to treatment or no longer considering Gleevec and this brain twister would be academic.

Tuesday, September 1, 2009

Guided Imagery for Self-Healing

"Truth in Advertising" - this post tells you why imagery is important to healing, not how to do it.

Guided Imagery for Self-Healing is the title of a book by Martin L. Rossman, M.D. (see "Books & Articles" sidebar). The title also serves well as an introduction to another aspect of the mind-body connection.

Can you heal yourself by using your imagination?

We know that we can be "worried sick," why not imagined healthy?

Ever had a nightmare and awakened terrified, in a cold sweat, with a pounding heart?

The images created by your brain (imagination) produce the same physiological fight-or-flight response that would occur when confronted by the real thing. Film and TV images cause us to laugh, cry, sweat, faint and other emotional responses. Imagined images can, and do, produce the same physiological effects as externally generated images. From here, it is a small step to see how imagery can support wellness, too.

Research in psychoneuroimmunology (PNI) (cf my August 31, 2009 post) has identified a number of mechanisms that help us to understand how images affect the immune system. For example, research at Georgetown University by Nichols Hall has shown that visualizing an active immune system produces increased levels of the hormone alpha-thymosin which increases production and activation of T-cells, an essential immune system function. A 1996 meta-research review by Dr. Karen Olness at Case Western Reserve, found 18 out of 22 studies investigating whether or not the use of imagery can affect the production and activation of T-cells reported positive results.

In addition to direct effects, such as immune system support, imagery can be used for stress reduction, too. Stress has negative physiological effects, which lead to high blood pressure and other heart diseases, over-eating and obesity, diabetes, asthma, cramps and muscle pain, insomnia, headaches, and many other physical symptoms. Cancer patients, as I can attest, suffer from stress. Stress reduction using guided imagery or other relaxation techniques (breathing techniques, hypnosis, meditation, chanting, etc)are a useful first step toward attaining "right-mindedness" for the effective use of imagery for self-healing.

Everyone has the capacity to improve wellness through imagery; not everyone is willing to make the effort. The first requirement is the "willing suspension of disbelief;" the second is proper technique; and, the third is practice, practice, practice.

It's just like golf. Anyone can hit a golf ball; the hard part is to consistently hit it well. First, you have to believe you can hit the shot (visualize it); next, you strike the ball well, and lastly you practice doing the first two over and over again until you achieve automaticity - that is, to be able to repeat the stroke without conscious thought - the golfer's mantra: "Empty mind, Loose body"

Like golf, to use imagery to promote self-healing, you must believe that it can help the healing process,or at least willingly suspend disbelief; learn to practice effective techniques for relaxation and visualization; and, practice, practice, practice.

There are dozens of books, tapes, CD's, and DVD's available to assist in learning effective techniques, but beware, there is a lot of woo-woo stuff out there, so choose carefully. For those of us who need a "pro" to guide our practice, I suggest seeking out a licensed practitioner (M.D., Ph.D.)who is associated with a teaching hospital and specializes in pain management and cancer therapy, or an established center of practice, such as the Simonton Cancer Center.

Here is a non-exhaustive list of practitioners/authors/researchers for your use in seeking resources: Jeanne Achterberg,PhD; David Bresler,PhD,LAc; Hyla Cass,MD; James S. Gordon,MD; Stanley Krippner,PhD; Lewis Mehl-Madrona,MD,PhD; Emmett Miller,MD; Dean Ornish,MD; Kenneth R. Pelletier, PhD,MD(hc); Martin Rossman,MD; Francine Shapiro,PhD; C. Norman Shealy,MD; David Sobel,MD; Andrew Weil,MD.

Keep your eye on the ball and practice, practice, practice.

Monday, August 31, 2009

The Mind-Body Connection

Google "mind-body connection" and you'll get more than 4.7 million hits covering everything from affective response to yoga. Too funky a reference, try "integrative medicine," or"psychoneuroimmunology."

Belief that the mind contributes to illness and wellness has existed least as long as there has been recorded history. "Writing near the time of the birth of Christ, the Stoic Lucius Seneca allowed that "it is part of the cure to wish to be cured." (Felten)

In 1981, neurobiologist David Felten and researchers at the Indiana University School of Medicine "...discovered a hard-wire connection between the human body's immune system and the central nervous system under control of the brain." (Felten). This finding gave substance to earlier research at the Rochester University Medical Center by pychologist Prof. Robert Ader (1974) who in rat studies, demonstrated the capacity of the rat-brain to shut down the immune system.

More than twenty years later there is still resistance from the traditional medical community to so-called "alternative medicine" based on the mind-body connection. The general response seems to be, "I doubt that it will help, but it probably won't hurt you either, so go ahead if you think it will help."

There is an interesting twist, probably unintended, within that comment. According to proponents of alternative medicine involving the mind-body connection, "...if you think it will help" is precisely when it will help. The opposite is true too, if you think it won't help, it won't. This is essentially the same premise on which Viktor Frankl's theory described in his Man's Search for Meaning (1956), is based, as well as the many books about the importance of "hope" for surviving cancer (see "books" sidebar).

In 2007, during my 50th University of Pennsylvania undergraduate reunion, I attended one of many seminars offered to alums. This one was at the Medical School, home of the Abramson Family Cancer Research Institute. During the presentation on new trends in cancer treatment, the following "story" was told;

The patient, an older man, was in the final stages of cancer, within days, weeks at most, of dying. The doctors didn't want to admit him to a clinical trail that had received very favorable initial reports, but the patient and his family insisted until finally he was admitted. Within days, his tumors began to shrink, and within months there was no evident disease. Shortly, thereafter, a more detailed research study of the drug effects was published showing the initial optimism was not justified and the new drug was no better than the standard treatment. After being made aware of the new data, the patient's tumors returned within days and the patient died with a few weeks.

Apocryphal? Possibly, even probably, but not uncommon of the kind of anecdotal evidence widely available and used to justify further research and to support a variety of mind-body practices.

Next post: Self-healing through Guided Imagery

Sunday, August 30, 2009

Beer and Pizza?

I workout three times a week. Here I am this morning grinding away on the elliptical and watching CNN on the TV to help pass the time. A medical segment comes on - "The Beer and Pizza Diet - a Cancer Cure" turns out it really isn't, but the segment is about the effect of diet generally on cancer prevention. View it at CNN.com (sorry about the commercial lead-in).

Coincidentally, I was planning my next posts on so-called "alternative therapies," so I'll begin with food. First off, there are no magic silver bullets, but there are some very interesting avenues for exploration. One is the effects of food as a form of chemotherapy; another is food and the mind-body connection - food today, mind-body tomorrow.

All foods consist of chemical components which are absorbed into the body with beneficial or detrimental effects. Green leaf vegetables like spinach, kale, and broccoli, root vegetables such as carrots, and fruits, notably blue berries, are associated with positive effects. High fat foods, red meat, and fried foods are associated with negative effects.

Generally, the positive effects work through supporting one or more essential bodily functions, notably, the immune system. As I learned from posting about immunotherapy, the immune system and its ability to generate T-cells is critical to the bodies defenses against cancer. It may play a less significant role than was once thought, but with costimulation or inhibition the performance of the immune system can be significantly improved. The bottom line, give your immune system all the support you can by eating healthily.

Conversely, combinations of foods consumed in quantities which lead to obesity are bad. When I was (much) younger and competing at an international level, I consumed 6,000 to 8,000 calories a day and had trouble keeping my weight up to 175 lbs. Within three months of retiring from competition, I was eating less than 2,500 calories a day and still ballooned to 220 pounds.

At the time I retired from work the first time in 2000, I weighed 195 and was leading an active life skiing in the winter and working outdoors in the summer. I decided to go to my high school 50th reunion in 2003; coincidentally, the year I first learned that I had melanoma. I decided that I would make the effort to get down to my high school graduation weight, 185 lbs - ah, vanity. It took about six months, but I did it.

When I learned I had melanoma, one of the first treatments I considered was chemotherapy that involved a toxic cocktail the side effects of which were so devastating and the reward so small, that I did not choose it. The experience did, however, convince me this was going to be a physical fight, so I'd better get into the best shape possible. Six years later, my weight is stable at 185, I've lost 4" around my waist, and I'm hitting my drives 15-20 yards farther - good stuff. The melanoma has spread, but I still feel healthy and mentally prepared for whatever the next treatment brings.

Next post: the mind-body connection.

Wednesday, August 26, 2009

My Treatments

I've posted about the chemicals and vaccines. Now it's time to put the information to use to clarify my treatment options that I posted on August 13, 2009.

Option 1: Gleevec (Imatinib Mesylate). This drug is a protein-kinase inhibitor, specifically tyrosine kinase. It has been FDA-approved previously for the treatment of chronic myeloid leukemia (CML). It specifically targets an enzyme that allows the growth of cancer cells. This drug has been shown to significantly reduce the number of CML cells in treated patients within one to three months. The purpose of this trial is to determine how effective Gleevec is for melanoma that has spread from the skin to other parts of the body. The spread of melanoma cells is facilitated by the protein C-KIT, which is expressed as the result of a genetic defect in the tumor cells.

Gleevec is thought to bind to these defective cells and stop the spread of cancer. Side effects include fluid retention and edema, rashes, nausea and vomiting, diarrhea, heartburn, and headache. More serious side effects, which occur less frequently, include liver toxicity and internal bleeding.
This trial is available in Boston or Chapel Hill, NC. About one person in five whose melanoma began on the skin (as mine did)is expected to manifest the C-KIT mutation. My tumor tissues have been sent to a lab to determine if I have the C-KIT mutation present. If not, I'll proceed to Option 2.

Option 2: Temodar + ABT-888. Temodar (temozolomide) is classed as a lipid-soluble alkylating agent which crosses the blood-brain barrier, and has been used previously for treating certain brain tumors. ABT-888 is a PARP (Poly ADT-ribose polymerase) inhibitor. The PARP enzyme is active in cell growth and repair. Blocking PARP, may prevent the cancer cell from growing or repairing itself. Using the two in combination may make Temodar more effective.

This is a randomized, double-blind study with three arms, two of which use both agents in different dosages; the third (control) arm uses Temodar alone. Possible side effects include low platelet count increasing the possibility of bleeding, fatigue, constipation, nausea, diarrhea, vomiting, anorexia, and headaches.

This option is available in Charlotte, NC.

Option 3: Biovex. The lead product of Biovex Inc., now a part of Triathlon Medical Ventures, is OncoVEX, a manufactured, virus-containing vaccine to “carefully pollute cancer cells” while leaving other cells unaffected. The virus appears to be able to affect melanoma cells even after metastasis has begun. The assumption is that the cell pollution will lead to apoptosis or senescence.

The chief drawback of this trial is the there most be one or more tumors on or sufficiently near the skin surface for periodic biopsies to track the vaccine effect, a condition which I do not have at the moment. Side effects are unknown at this point. This treatment would be available in Chapel Hill.

Option 4: Avastin + Ipilimumab. Avastin (bevacizumab) is a monoclonal antibody produced in a laboratory and used in the treatment of colorectal cancers. It is classed as an Angiogenesis inhibitor. Avastin functions by blocking the action of the VEGF protein (vascular endothelial growth factor) which stimulates the growth of new blood vessels (angiogenesis); therby, denying new blood needed for tumor growth.

Avastin side effects include increased blood pressure, fatigue, muscle weakness, blood clots in veins, diarrhea, nausea, loss of appetite, low white cell count, headache, nosebleeds, and pain at the tumor site. More serious, less frequent effects include perforations, inability of wounds to heal, internal bleeding especially in patients with lung cancer, bleeding in the brain resulting in strokes, blood clots in arteries, uncontrolled high blood pressure, and kidney damage.

Ipilimumab is a human monoclonal antibody that binds to to a molecule on T cells (CTLA-4)that plays an important role in activating and regulation the immune system. Ipilimumab blocks CTLA-4 function, which otherwise suppresses the immune system. Maintaining an active immune system should make the Avastin treatment more effective and less debilitating.

In prior trial uses Of Ipilimumab, there has been about a 2% fatality rate and 20% auto-immune response. This trial is currently not recruiting, but might be available again in Boston in November.

Option 5: Temodar (temozolomide). This is currently the standard treatment for metastatic melanoma. Its function and effect would be the same as Arm 3 of Option 2 above.

This creates a quandary for me. If I chose Option 2, there is one chance in three of getting the same treatment as Option 5. The only differences are that I will have to go the Charlotte rather than Chapel Hill and participate in a significant number of procedures (exams, scans, blood tests) the only purpose of which would be to maintain the integrity of the double blind research design.

This point is irrelevant if my tumor profile shows the C-KIT mutation needed for participation in Option 1, so I’m holding my breath for another few days to get the answer.

Tuesday, August 25, 2009

Immunotherapy

Is Vaccination against Cancer the Answer?

Initially considered a part of chemotherapy, cancer immunotherapy is evolving into its own class of treatments. The basic purpose is to stimulate a person’s immune system to build up its defenses against cancer to prevent its spread and eventually eliminate cancerous cells. The process, which most of us have experienced in childhood, is vaccination with a laboratory-manufactured antigen (vaccine) which stimulates the creation of disease fighting antibodies. Cancer vaccines can be made from the patient’s own tumor antigens or cells (autologous vaccine) or from someone else’s (allogeneic vaccine).

The elements of the immune system are your body’s soldiers. Dendritic cells act as scouts seeking out infections or diseases. When found the scouts capture data about the foreign cells and instruct the killer T-cells to attack and destroy it. The problem is that our “armies” are under-staffed, so the number of killer T-cells programmed to attack the tumor are insufficient to overwhelm it, unless the immune system can be stimulated to attack more aggressively (co-stimulation). The objective of immunotherapy is to get the immune system to direct a greater percentage of its killer T-cell army against the patient’s tumor to increase the probability of victory. Hoooah!

All T cells derive from haematopoietic stem cells in the bone marrow.

There are several types of T cells, each with its own function:

(1) Cytotoxic T cells (Tc), also know as C8+ T cells, destroy viral infections and tumor cells and are instrumental in transplant rejections.

(2) Helper T cells (Th) when activated divide rapidly and secrete small proteins (cytokines) that help the immune response. These cells are also the target of HIV infection.

(3) Regulatory T cells (Treg) act to shut down T cell mediated immunity toward the end of an immune reaction to prevent a body-damaging autoimmune response. Treg cells can be distinguished from other T cells by the presence of a FOCP3 intercellular molecule. Mutations of FOXP3 can prevent Treg development leading to a fatal autoimmune response.

(4)Natural Killer T cells (NKT) are lymphocytes that link the adaptive immune system with the innate immune system. Once activated these cells can perform the functions of Cytotoxic and Helper T cells, the release of cell killing molecules and cytokine production.

T cell Development and Activation


All T cells derive from haematopoietic stem cells in the bone marrow. The activation process begins with the release of hematopoietic (blood forming)progenitor stem cells populate the thymus and expand by cell division to create immature thymocytes - a lymphocyte that develops in the thymus and is the precursor of a T cell.

The thymocytes pass through a multi-stage process and emerge from the thymus into the surround tissue as immunocompetant T cells. Only 2% of thymocytes complete the process. The surviving cells are then activated through interaction with certain pre-existing antigen complexes or by molecular co-stimulation with antigen-presenting cells (APCs).

Certain cancer vaccines have added ingredients (adjuvents) that increases the antigenic response. Adjuvents include things like cytokines, proteins, bacteria, viruses, and chemicals. There have been promising results from studies in which vaccine has been used before or after treatment by other Cytotoxic treatments, as well as, vaccine alone.

Some vaccines, such as Ipilimumab, using monoclonal antibodies, identifiable by drug names ending in –mab, have shown promising results for some cancers, including melanoma.

The first vaccine approved in 1981 for cancer prevention protects against HBV infection (hepatitis B). Most children are vaccinated against HBV infection shortly after birth. In 2006 and 2008, Gardasil was approved for prevention of cervical cancer caused by human papillomavirus (HPV) types 6, 11, 16, and 18. Types 6 and 11 cause about 90% of genital warts; 16 and 18 cause about 70% of cervical cancers.

At this point, there are no other vaccines approved as mainline cancer treatments. There are many vaccines being tested in clinical trials, forty-five listed for melanoma. Here’s a typical example:

Vaccine Therapy in Treating Patients With Recurrent Stage III or Stage IV Melanoma That Cannot Be Removed by Surgery

Alternate Title: Pilot Study of a Peptide Vaccine Comprising MART-1:27-35 Peptide, gp100:209-217 (210M) Peptide, and Tyrosinase Peptide With Sargramostim (GM-CSF) and CpG 7909 Emulsified in Incomplete Freund's Adjuvant in Patients With Unresectable Recurrent Stage III or IV Melanoma.

Purpose: Vaccines made from peptides may help the body build an effective immune response to kill tumor cells. Giving vaccine therapy together with GM-CSF, CpG 7909, and incomplete Freund's adjuvant may make a stronger immune response and kill more tumor cells. This clinical trial is studying the side effects and how well vaccine therapy works in treating patients with recurrent stage III or stage IV melanoma that cannot be removed by surgery.

More information about vaccines and clinical trials can be found at cancer.gov.

So, forget all the mumbo jumbo, forget about looking for a quick fix, and support stem cell research. When the breakthrough in cancer treatment comes it will be huge and vaccines will be an important element.

Monday, August 24, 2009

Chemotherapy - Drug Classification II

Mechanisms of Action

A second method of classification involves grouping by the mechanism of action – how the drug of choice works. The two main ways in which anti-cancer drugs work is through inhibition or disruption of normal DNA functions.

Angiogenesis Inhibitors

Cancer tumor cells require additional blood supply. Angiogenesis is the process by which cancer cells form new blood vessels to support tumor growth. These blood vessels also facilitate the spread of cancer cells (metastases). Inhibiting angiogenesis “starves” the tumor cells leading apoptosis or senescence and may limits the spread of cancer cells to surrounding areas. Thalidomide, associated with severe birth defects, is now being considered for anti-cancer use because of its angiogenesis inhibiting properties. Other drugs used include Endostatin, Fumagillin, Genestein, and Monocycline, etc.

DNA Intercalators/Cross-linkers

Intercalation refers to the act of inserting a DNA altering substance. Cross-linking involves building a connection (link) between gene strands. Either process is intended to alter the DNA structure of a tumor cell to disrupt its function. Carboplatin and Oxyplatin form cytotoxic adducts with DNA and induces apoptosis. Bleomycin inhibits DNA synthesis, induces breaks in base DNA sequences, and inhibits tumor angiogenesis. Other drugs in this group include Carmustine, Chlorambucil, and Cyclophosphamide.

DNA Synthesis Inhibitors

Synthesis is the process by which cancer cells split and proliferate. Synthesis inhibitors, as the name suggests, are more active in the S phase of the cell cycle. These drugs bind to specific DNA types to block production of enzymes needed for cell synthesis. For example, Menthtrexate and Aminopterin are folic acid antagonists which block thymidine biosynthesis by which cells in S phase are synchronized. Other drugs in this class work similarly to inhibit production different enzymes also affecting synthesis.

DNA-RNA Transcription Regulators

During cell synthesis, the cell’s DNA template synthesizes messenger RNA to carry genetic information from the DNA molecule to new cells. This process is called transcription, a necessary function for cell replacement. Unfortunately, it works as well for tumor cells as it does for normal cells. DNA-RNA Transcription regulators attempt to block synthesis and or induce apoptosis in cancer cells by inhibiting or reversing production of RNA components. For example, Actinomycin D works by inhibiting cell proliferation and blocking production of mRNA by RNA polymerase to induce apoptosis.

Enzyme Inhibitors

Molecules that bind to enzymes and decrease their activity are called enzyme inhibitors. The following picture shows a representation of HIV protesase enzyme as red, blue and yellow ribbons with the bound protease inhibitor ritonavir as a stick-and-ball model in the center.


Different drugs bind to different enzymes to increase the specificity of drug choice. Enzyme inhibitor binding is either reversible or irreversible. Irreversible inhibitors change the chemical composition of the enzyme. Reversible inhibitors produce different types of inhibition depending upon whether it binds with the enzyme, the enzyme sub-strate complex, or both. In either case, the purpose is interrupt the enzyme activity resulting in apoptosis and/or interruption of synthesis and transcription.

Gene Regulation (therapeutic gene modulation)

This class of drugs alters the expression transcription, translation, and phenotypic manifestation) of a gene at one of the various stages. Most clinical research seems to be in the area of translation through RNA interference. Examples include Melatonin which inhibits proliferation of breast cancer cells by inhibiting estrogen receptor action and Tamoxifen, a selective estrogen response modifier used with estrogen-sensitive tumors.

Microtubule Inhibitors

Microtubules are cylindrical, hollow structures that support cell structure and facilitate cellular movement and transport. Tubulin, a globular protein, is the basic structural constituent of microtubules. Most drugs in this class function by binding to tubulin or β-tubulin to induce apoptosis or prevent cell division. Paclitaxel and Navelbine are two examples.

New drugs are appearing almost weekly, many with unique functions that do not easily fall into on of these classes.

For more information about specific drugs, visit Chemocare.com

Sunday, August 23, 2009

Chemotherapy - Drug Classification I

Drugs used for chemotherapy can be classified in several ways. From my perspective, the two most useful ways are: (1) Chemical basis; and (2) Mechanism of Action. In the post, I’ll discuss the former in this post; subsequently, the latter.

There are seven major classes of chemotherapy drugs, two of which are most active during the M phase of the cell cycle. For each, I will summarize the chemical source and main side effects. For additional information on this topic, select the link for each class. A more detailed version from which this post is abstracted can be found here.

1. Alkylating Agents

The oldest class of anticancer drugs is nitrogen mustards originally developed for military uses (poison gas). They bind to the negatively charged oxygen, nitrogen, phosphorus and sulfur atoms in DNA. By doing so, cellular activity is stopped and the cell will die. Alkylating agents are effective at all stages of the cell cycle and are used for most types of cancer. All alkylating agents can cause secondary cancers, the most common of which is Acute Myeloid Leukemia, even long after treatment is completed.

2. Antimetabolites

Based on work with folic acid by Dr. Sydney Farber in 1948, antimetabolites are synthesized to target naturally occurring compounds or key enzyme reactions during metabolism. Nearly all antimetabolites interrupt metabolic pathways, including those necessary for DNA formation. Antimetabolites are most effective during the S phase when DNA formation is most active. Patients with certain natural enzyme deficiencies may suffer severe toxicities when treated with antimetabolites which target enzyme reactions.

3. Anthracyclines

Anthracyclines are derived from naturally occurring sources (fungi). They work through the formation of free oxygen radicals, which cause DNA strand breaks and enzyme (topoisomerase) action, both of which inhibit DNA formation, replication, and transcription. They are not cell cycle specific agents. Since the free radicals created also attack the heart muscle, cardiac toxicity is a major concern.

4. Antibiotics

Everybody has probably used an antibiotic, such as streptomycin or neomycin. Guess what, bleomycin is a small peptide synthesized from Streptomyces verticullus fungus and is used in chemotherapy. It action is similar to that of the Anthracyclines – free oxygen radical formation. It is an active agent used in testicular cancer and Hodgkin’s lymphoma. Lung toxicity due to free radicals is of greatest concern.

5. Camptothecins

The enzyme Topoisomerase is required for ongoing DNA formation (cf Anthracyclines). Camptothecins act by forming a complex with topoisomerase and DNA which disrupts mitosis in the M phase of the cell cycle. They are synthesized from a naturally occurring alkoloid found in plants such as the Chinese Happy Tree, Camptotheca acuminata. Other chemotherapeutics, although not classed as Camptothecins, are derived from the mandrake plant and Vinca rosea (periwinkle) and function similarly. The main toxic side effect is neurotoxicity (nerve damage, loss of feeling).

6. Taxanes

Taxanes such as paclitaxel and docetaxel were first derived from the bark if the Pacific yew tree, Taxus brevifolia . Paclitaxel was identified as the active component in 1971. Taxanes are M phase specific agents. They bind to the microtubules, which support DNA movement during cell division (mitosis), where disrupt the microtubule function. The most common side effect is anemia.

7. Platinums

Metal derivatives used in the treatment of cancer create cross-links between two DNA strands or within one strand which inhibit DNA synthesis, transcription, and function in any cell cycle phase. Cisplatin, used in lung and testicular cancer, is a first generation platinum derivative significant kidney toxicity. Carboplatin, a second generation derivative, has less effect on the kidneys. Oxaliplatic, a third generation derivative, has not kidney toxicity, but may result in nerve damage (neuropathies).

The long a short of it is that all these chemotherapeutics function by inhibiting normal DNA function leading to suspension of cellular activity (senescence) or cell death - apoptosis or necrosis. The former is “normal” cell death by which cells commit “suicide” when they are no longer useful and are absorbed into surrounding tissue or shed, Cancer cells do not do this and will continue to multiply unless apoptosis can be induced by use of chemotherapeutics or other treatments. The latter, necrosis, is cell death from injury, disease or other pathologic state, including some chemotherapies. Necrotic cells do not send the same signals to the immune system as do apoptotic cells, so they are not removed from the body by a natural process, which leads to a build up of dead tissue and cell debris – not a happy prospect.

Saturday, August 22, 2009

Chemotherapy – Targeting

In my most recent (I don’t use “last” anymore) post, I mentioned the 4-phase cell cycle and suggested that tumor cells are most sensitive to chemotherapy in the G1 and M phases. Sounds like a logical approach to targeted treatment would include identifying the cell state and treating it when it is most sensitive. Logical, but unfortunately not practical, as cells don’t cycle through their phases in lockstep and the time span of each cycle will vary and be too short to be useful.

So what can be done to improve targeting? Virtually all of the newest research is focusing on DNA/RNA for the answer. Preliminary results suggest that the genetic structure of a person’s cells, especially tumor cells, can provide valuable information about how to attack cancer for a specific individual, as well, more general approaches.

Targeted therapies, which include cell growth inhibitors and immunotherapy, are emerging as a fourth approach, different from chemotherapy. A distinction being made is that traditional chemo- is a “chemical approach to a biological program,” where as targeted therapies can be characterized as a “biological approach to a chemical problem,”

Although there is a growing belief that traditional chemo is more limited in what can be achieved than targeted therapies, there are still benefits to be gained from genetic research, especially in choosing the most appropriate chemical approach and avoiding more harmful ones. It is likely, therefore, that genetic profiling will become one of the baseline tests for cancer treatment. Lobby you insurer and Congress folk to make sure it is covered by private insurance, Medicare, and Medicaid – it’s not cheap yet.

Truth in advertising – genetic profiling is a powerful tool in the fight against cancer. Unfortunately, in order to be most useful, tumor cells must be present and accessible. For example, when I had my first episode of a very small tumor in my lung, it was removed surgically. At that point, I was “NED” – no evident disease. Shortly thereafter a promising clinical trial opened up, but I was ineligible because you must have detectable, observable tumors so the clinician-researchers can determine the effect of the treatment being tested. For a melanoma patient, this is particularly frustrating, because you know the mutated cells are there, they’re just too small to be detected.

Again, within the last month, a new trial for an immunotherapy agent was announced. This time, with tumor aplenty, I am still ineligible because the lesion must be on the skin or sufficiently close under the skin so it can be accessed physically and fairly frequently. Mine are out of reach without significant surgical damage – ineligible.

In my next post, I will have more to say about traditional chemical approaches and how it is being modified by new knowledge.

Pip pip – stiff upper lip.

Friday, August 21, 2009

Chemotherapy – Introduction

The object of chemotherapy, as is true of all cancer therapies, is to kill cancerous cells without doing significant damage to normal cells in the surrounding tissue. As discussed in earlier posts, radiation therapy attempts to do this with targeted beams of energy radiation (cf my May 22, 2009 post). Surgery physically removes cancerous cells, whenever possible using minimally invasive procedures, such as video assisted thoracic surgery (VATS).

At its most basic level, all cancer is dysfunctional cellular mutation; that is, cell mutation which produces negative consequences. Until relatively recently, chemotherapy has been limited to the use of drugs which do not discriminate well between cancerous and non-cancerous cells. The results from the Human Genome Project are now contributing to the development of more targeted approaches for chemotherapy, allowing potential intervention at the sub-cellular level (DNA/RNA) to inhibit further mutation or induce cell death in cancerous cells by interrupting its growth cycle.

All cells go through four phases, referred to as the “cell cycle,” G1, S, G2, and M. G1 is most active in protein synthesis, during which few chemotherapy agents are effective. DNA replication is most active during the S phase, during which the cell is highly sensitive to some chemotherapy drugs. During G2, RNA is most active and some protein is formed. The M phase is when cell division (mitosis) occurs.

Consequently, many of the new approaches involve DNA modification of destruction. However, the human body has its own defenses against DNA damage, which work to repair damage, whether its from the cancer itself or a well-meant attempt to kill cancerous cells. The result is that, while the chemical intervention may kill the cancerous cell, it may also overwhelm the immune system, with its attendant risk of infections, or so stimulate the immune system that it produces an auto-immune response with risks, such as lupus or rheumatoid arthritis. The challenge of chemotherapy, as always, is to get the right drug, to the right cell, in the right amount, at the right time.

More about how that is happening later.

Thursday, August 13, 2009

Update on My Treatment Plan

After a visit to Dana-Farber Cancer Institute in Boston earlier this month and some additional reserch, my UNC oncologist and I now have a treatment plan, with contingencies. It looks like a Imatinib Mesylate (Gleevec) clinical trial at Boston or Chapel Hill, if my tumor shows a KIT mutation; if not, a Temodar + ABT-888 trial in Charlotte, NC, or Temodar (temozolomide) alone at UNC. If that doesn't work and there is a lesion on or just below the skin, a Biovex trial. No skin lesion, an Avastin + Ipilimumab trial.

I stuck this post in here between blogging about new treatment options, so you can see that at least one person may be benefitting from the availability of research and clinical trials for melanoma and gets to feel good about contributing to the knowledge base.

Keep smilin'

Thursday, August 6, 2009

Advances in Cancer Treatment

I am in awe of the changes in cancer treatment that have occurred since I was first diagnosed with prostate cancer in 1998.. At that time, I had three options: (1) Surgery (the "gold standard'); (2) radioactive seeds; and (3) watchful waiting. Now, surgery, in most cases, is the last choice.

In 2003 when I was first diagnosed with melanoma, I had four choices: (1) Surgery; (2) radiation; (3) chemotherapy; and (4) watchful waiting. Surgery meant whacking out cancerous body parts, when necessary replacing critical parts, if available.

Chemotherapy consisted of injections of various and sundry combinations of highly toxic chemicals which killed cells, both mutated and normal, with the hope that with the correct dosage, you wouldn't die from the treatment before the normal cells had time to regenerate.

Radiation was, similarly, a shotgun approach - fire a beam through the tumor to kill it and every other cell in the beam path before and after the targeted tumor.

Now, in August 2009, I still have the same four choices at the macro level: (1) Surgery; (2) radiation; (3) chemotherapy; and (4) watchful waiting, but a world of difference at the micro-level.

Surgical options now include minimally invasive procedures, for example, in 2007, when a lesion was found in my lung, I had it removed by Video Assisted Thoracic Surgery (VATS), procedure which require three 1" incisions for the insertion of a fiber optic connected video camera and two resection tools, used a bit like chopsticks, to remove the tumor. I was out of the hospital in three days and playing golf in less than 4 weeks. The surgeon had suggested a shortened back swing would probably help my golf game. In my case, the surgeon was physically present, but similar procedures, and even much more complicated ones, are now done routinely using robotic surgery during which the surgeon may be hundreds, even thousands of miles distant.

Radiation need no longer only be a through-and-through blast as from a shotgun. In my May 23 entry, I described my experience with Cyberknife, a way to deliver multiple low doses of radiation with very narrow beams intersecting at the tumor site. The dose level for each beam is so low that it is lethal to cells only at the point of intersection where all the beams, 270 in my case, converge to kill cancer cells with their cumulative effect.

If this is not enough, you can bring out the really big gun - proton beam therapy - which uses a particle accelerator, once called an "atom smasher," to fire an atomic particle (proton) at a tumor where it "explodes" releasing its energy to kill the tumor cells without affecting the surrounding tissue. Like Cyberknife, the entire process is computer-controlled and the proton delivery can be controlled in 3-D to the exact size and configuration of the targeted tumor.

Although not a treatment option, cancer care has been dramatically improved by the use of radiation for scanning for both diagnosis and during treatment to track progress. While X-rays are still used for two-dimensional imaging, computed axial tomography (CAT or CT scans), Positron emission tomography (PET scans), and magnetic resonance imaging (MRI scans) offer 3-D images in great detail. Although similar in concept, each has its strengths , and in some instances are used sequentially for greater resolution or in different areas of the body. For example, a brain scan is usually done with MRI. Scans may be done with or without "contrasts," which are injected or swallowed fluids which include a dye, radio-opaque substance, or radioactive tracer used to improve the tumor image.

I've had them all multiple times and can attest to the fact that they are not invasive or painful. Yes, there may be discomfort from lying still for 30 or 40 minutes or from an MRI's loud thumping (ask for earplugs if they are not offered), or the threat of mild claustrophobia from the tight quarters of the short tunnel through which you slide during the process. My strategy is to ask how long will the process take, figure out how many seconds it will be, close my eyes, and start counting breaths. If I don't fall asleep, which usually happens, my count never reaches the estimated number of seconds before the process ends, so the end comes as a pleasant surprise.

The advances in Chemotherapy are so numerous that they warrant a post of their own. That's next.

Wednesday, August 5, 2009

Access to Clinical Trials

I went up to Boston this past Monday in anticipation of a visit to the Dana-Farber Cancer Institute to see Dr. F. Stephen Hodi on Tuesday. Coincidentally, that day the New York Times, published an article by Gina Kolata, "Lack of Study Volunteers Hobbles Cancer Fight, (NYT, August 3, 2009) the gist of which was that "There are more than 6500 cancer clinical trials seeking adult patients" .... (but) ... "More than one trial in five sponsored by the National Cancer Institute failed to enroll a single subject, and only half reached the minimum needed for a meaningful result, ..." The entire article is worth reading.

I shared the article with a friend and cancer co-warrior. I'm repeating her response for anyone thinking about finding or struggling to get into a trial:

"Maybe they ought to make it easier to get into trials."

"It should be patient choice if you want a study drug over the "gold standard", which only has a 7% response rate and horrendous side effects. But you have to be debilitated first by the gold standard and watch your disease progress before they let you into the majority of trials."

"They need to make trials more attractive."

"A lot of new drug trials won't let you increase your dosage as new safety and efficacy info comes through. So, as in my case, women all over the world are getting twice the dosage for parp inhibitors that I get and I'm stuck at this dose because I'm in a trial)."

"They also need to make information from the trials more accessible to the patient."

(In a trial involving PARP inhibitors)..."Why shouldn't I be told if there is any PARP inhibition going on in my body. They've got my blood. They could tell me. If the drug isn't doing anything I should know early on and not wait weeks for scans to tell me my cancer is progressing."

"Right now, trials are largely for the benefit of the researchers and pharmaceuticals and patients 15-20 years down the road. They need to make trials for the people who are in them. We're already taking risks and undergoing far more exams and scans than normal."
As a statistician/researcher myself, as well as a cancer patient, I understand the basis for the tension between the need for clean research and the needs of the patient. The sicker I get the less sympathetic I am toward the research needs - no surprise there. Because of this, the European "laxity" in the limitations to drug access becomes more appealing - assuming it's not sloppiness or greed-driven - of course, I believe babies are found in a cabbage patch and there's a pot of gold at the end of the rainbow, too - Not.

What's Happening

Obviously, from the dearth of posts, not much has happened since July 5th; however, thanks to a visit to the Dana-Farber Cancer Institute, that is about to change. Rather than one big post, I'm going to do several shorter post organized by topic, most of which relate to news about clinical trials.

Keep on, keepin' on , friends!

Sunday, July 5, 2009

The Faster I Run, the Behinder I Get - II

The good news is that the latest CT scan suggests that the Cyberknife treatment was successful in eliminating the nodule on or near my heart (see the May 22 post, "Cyberknife Strikes Again").

The bad news is that the two small nodules in my left lung are growing and new ones are visible in my right lung and liver.

This, of course, gives me a reason to continue researching treatment options to share with readers by blogging - how's that for a positive spin on otherwise unpleasant news.

Since my condition is now consider "systemic," I'm focusing on chemotherapy options, including the newer gene-based approaches (see my post on June 7 and the link to "genetic profiling" in the sidebar).

I've added a new link to Chemocare.com in the sidebar. It's an excellent source of information about the many drugs used for chemotherapy and includes a message board for clients and care givers.

In the meantime, I'm keepin' on keepin' on.

Thursday, June 25, 2009

The Faster I Run, the Behinder I Get

At lunch today with a friend and fellow cancer survivor, I learned a new term, actually several new terms, but the one that caught my ear was "epigenetics." In an earlier post, I commented on the importance of genetics to cancer treatment. It turns out that the treatment you chose may also modify the way your genes are expressed after treatment - that is, the treatment may modify the patient's genetic DNA structure.

In effect, once you begin treatment, you become a moving target for subsequent treatments. This is good when the effect is limited to DNA in (already mutated) cancerous cells, but may not be beneficial treatment result in DNA modifications which inhibit subsequent treatment or, in the case of a patient of child-bearing age, if the induced mutated DNA is subsequently passed on to the next generation.

In other words, "epigenetics" is the study of a repetitive process of induced DNA mutation resulting from all kinds of sources, including the food you eat, your life style, and cancer treatments involving radiation and chemotherapy.

As the below video will demonstrate, although identical twins have the same DNA structure at birth, their genetic structure grows increasingly dissimilar over time due to environmental factors. For more information, view this video (13 minutes) from Nova scienceNOW at pbs.org, which produced the video, and visit their web site.

Monday, June 8, 2009

New Web Links

Please see the sidebar for the new melanoma web links added today.

Sunday, June 7, 2009

More about Genetics and Melanoma

In addition to the Genetic Profiling link in the Sidebar to an article about the work a Mass General, there was a brief article in the June6, 2009 Wall Street Journal, which illustrates why genetic profiling is valuable for cancer treatments. The article by Ron Winslow, "Skin-Cancer Drug Uses Genetics," reports that "... nine of 16 patients with the malignant skin cancer (melanoma) experienced significant shrinkage of their tumors when given a drug know as PLX4032," which is being developed by Roche Holding AG and Plexxicon, Inc.

The genetically signicant fact is that all of the tumors treated had "... a mutation in a gene for a protein called BRAF that is believed to play a critical role in up to 60% of patients with the cancer." The drug is one of a class of emerging products called BRAF-inhibitors. Although the role of the BRAF mutation has been known since 2002, to date there has been little success in efforst to target the defect.

It's too early to tell whether or not this newest effort will prove out, but, to me, it makes the effort at Mass General even more important and gives me some ammunition with which to prod my oncologists and the barest hint of a ray of hope for the future.

C'mon guys, keep kicking in those bucks for cancer research!

Friday, May 29, 2009

Side Effects...

Last week, I received Cyberknife radiation treatment three times on Monday, Wednesday, and Friday. I was warned that I might experience side effects including fatigue, shortness of breath, and chest soreness.

I played 18 holes of golf on Tuesday, Thursday, and Saturday. No problem, no apparent side effects - lovely.

On Monday this week, I experienced shortness of breath, mild chest pains, and vertigo. I panicked, and the anxiety reawakened my GERD, which produced a sore throat and stomach pains from the acid reflux - RATS!

With a drastic change of diet and a conscious effort to chill, by Thursday I was five pounds lighter and able to go out to the range and hit a bucket of golf balls. Overestimating my capacity and underestimating the effects of the radiation and heat (82 degrees, 85% humidity), I went out this morning to play 18 holes with my regular Friday group.

Bad idea! I lasted 4 and 3/4 holes - one par, one bogey, and two doubles - until I accepted reality and hitched a ride with the ranger back to the clubhouse.

Wednesday, May 27, 2009

About Faith and the Unseen

While we lived in Redstone, Rabbi Harold Kuschner, author of When Bad Things Happen to Good People, spoke at least once every year at the Aspen Chapel. On one occasion, Rabbi Kuschner told of an encounter he had at the Johns Hopkins Medical Center several years ago. As I recall it the story went like this:

Rabbi Kuschner is asked by a patient there, a 32-year old Episcopal Priest dying of AIDS, to come see him. Kuschner agrees, goes down the hall with the medic and meets this young man, as Kuschner says, “pale, emaciated, lying in bed hooked up to several intravenous tubes.”

Kuschner asks, “How are you doing?”

The man replies, “Not too good. But I’m getting used to it.”

Kuschner then asks if the man "... somehow feels that he’s been brushed aside by God, locked out, diminished because of something in his character or behavior."

The young man replies, "No, just the opposite. The only good thing that has come out of this is that I found out something I always wanted to believe is really true. No matter how much I have messed up my life, God hasn’t given up on me. I’ve felt his presence here in the hospital room. God can love me even when I find it hard to love myself."

He pauses to gather his strength before continuing.

"When I was young, I thought I had to be perfect for people to love me.My parents gave me that message, threatening to withhold love every time I offended them. My teachers in school gave me that message. My Sunday school teachers reinforced that lesson. We didn’t go to one of those hellfire and brimstone churches, but we heard a lot about how much pain we were causing God every time we sinned, and I think that was just as bad, especially given the list of things we were told were sins."

The young man continues, "I tried so hard to be perfect so that my parents, my teachers, and God would love me. I probably went into the ministry in part so that people would think that I was morally perfect and love me for it. But every time I did something that I knew was wrong and every time I told a lie to cover up for myself, I would hate myself for being such a phony, and I was sure that God was as contemptuous of me as I was of myself. But lying here in this hospital bed , knowing I’m going to die soon, I had this insight: God knows what I am like and God doesn’t hate me, so I don’t have to hate myself. God knows what I’ve done and he loves me anyway. I’ll be leaving the hospital soon, not because I’m getting better but because there’s nothing more they can do for me and they need the bed for someone they can help."

"I don’t know if my congregation will take me back now that they know I’m gay and I have AIDS and I am dying. I hope they will, because there is one last sermon I want to preach to them.I have to share the lesson my illness has taught me. You don’t have to be perfect. Just do your best and God will accept you as your are. Don’t expect your children to be perfect. Love them for their faults, for their trying and stumbling, even as our Father in Heaven loves us."

The Rabbi concludes, “Oh, young man, you’ve got it!You have made a claim, not on the seen, but on the unseen, the unfathomable and undying love of God reaching out for us, whoever we are, whatever our condition, indeed, however distant we may feel, eager to succor, to hold and to sustain us.

Part 4. "The heart and soul of our everyday living" (continued)

Now, I propose that the unseen and unseeable, these free creations of our minds, the products of inward sight, are important because they are the stuff which binds us together in relationships and interconnect us to create, in Christian verbiage, “the fellowship of the Holy Spirit.” to the secular mind, they are the connective tissue or energy which bind the parts of a system into a unified whole.

In Why God Won’t Go Away, Andrew Newberg et al state that “every religion relies on a form of interconnectedness. There is either a union of mankind with the rest of the world or a union of the individual with a greater individual. ” Andrew Newberg, Eugene G. D'Aquili, Vince Rause (2002) Why God Won't Go Away : Brain Science and the Biology of Belief.

In short,

• Christianity posits a union of the individual with a greater individual (egoic duality)

• The concept of a union of mankind with the rest of the universe is found in Hinduism and Buddhism (wegoic non-duality)


As you might infer from my earlier remarks about the “egoic” perspective, I have a problem with the former view. My problem is that it implies that God (presumably the greater individual) is out there somewhere; furthermore, that each individual’s relationship is with God alone – that my relationship with you – whether we are linked by love or hate – is irrelevant. (When I was writing this, I initially used the word immaterial, but that’s the whole point of this discourse, relationships are not material objects, so I had to change the word to irrelevant).

In contrast, the latter conception, which Cynthia Bourgeault refers to as a “wegoic” perspective, is consistent with the tenets of Contemplative Christianity, as well as Buddhism and Hinduism -- this non-dual union of mankind with the rest of the universe, is more appealing to me, because it suggests that you and I are, willy-nilly, part of a web of relationships, individual figures on a shared ground. The ground is the contextual “glue’ that holds us together.

This figure-ground relationship forms a pattern, the significance of which each of us perceives and interprets in his or her own way. This emergent pattern for each individual is unique, but sufficiently similar to the perceptions of others to allow us to find kindred souls and gather ourselves into communities, called many things, Truth, Being, the Tao, the Void, and yes, indeed, even God.

What this pattern is called does not matter – square, triangle, Tao, or God. Recognition that there is a pattern is sufficient, what you label it is irrelevant. If it makes you happy and you feel the need, give it a name. This process of pattern recognition is called Gestalt formation.

Research on the brain has recently determined that the brain functions in precisely the same way when visualizing an object as it does when viewing the actual object – i.e. to the brain there is no difference between the image it creates and the object “out there”

The implication that “God" is a gestalt is not meant to trivialize our experience of God, but to suggest that one does not literally have to see God as a “thing out there” to be a believer. Our interconnectedness with and through “God” guides the way in which we choose to interact with each other. And the good news is that God doesn’t go away no matter how well or how poorly we interact with each other.

The concept of interconnectedness as "the heart and soul of our everyday living" transcends labels, political boundaries, and religious dogma.

The representation of interconnectedness found in the doctrine of the Jewel Net of Indra is one which I find particularly appealing.

The doctrine of The Jewel Net of Indra is an ancient view of the universe from Hua-Yen Buddhism. It teaches that the cosmos is like an infinite net of glittering jewels, all-different and each located at the connecting points in the net. In each one, we can see the images of all the others reflected. Each image contains an image of all the other jewels; and also the image of the images of the images, and so ad infinitum. The myriad reflections within each glistening jewel are the essence of the jewel itself, without which it does not exist. Every jewel is a Centre of the universe. Organizing in this image is not a machine. It is more like a hologram. Each part is the whole. Indra's Net is a web of relationships that sparkle, nourish, and amplify. It is an ancient image of oneness and diversity. And it is amazingly consonant with the new story of the universe emerging today at the frontiers of science. (Appreciative Inquiry Consulting: An Invitation to Connect With People Around the World for Creating a Positive Revolution In Change, http://www.aiconsulting.org/charter.htm)

Whatever. No-things matter! The ties that bind us together cannot be seen. they are not of this world, but they cab be made manifest simply by the way each of us chooses to act out our part in the web of relationships, named or nameless, in which we are grounded and made a part of a larger whole.

Think about your web of relationships while you listen to Ellen Stapenhorst's The Gift, Taking Our Lives in Our Hands, or Part of My Heart

Please note: Because the the limitations of Blogger to host audio files, it is necessary to use a third-party host. To avoid copyright infringement issues, please do not download these songs to your computer. You may listen to them by choosing the "Play" option. (First, turn off any music players in use). If you wish to download a song for your own use, please use iTunes or the music source of your choice. Thank you.

Part 3. Intermezzo: Seeing the Unseen

Time for a break from the metaphysical musings. When something is "unseen," you have no visual image of it, right? Well, sort of'

Whilst part of what we perceive comes through our senses from the object before us, another part (and it may be the larger part) always comes out of our own mind."-- William James

Here are three "pictures." What do you see?


1.Do you see a white square on top of 4 purple discs?


2.Do you see the solid white triangle superimposed over the triangle bounded in red to form a "Star of David"?


3.Do you see the outline of the white cube in front of the green circles?

If you said, "Yes," to any of these questions, you're wrong.

What you have “seen” – the square, the triangle that completes the Star of David, and the cube, -- do not exist any place other than in your own mind.

What is there to seen are colored figures (shapes) on a white ground. It is your mind, and your mind alone, that creates and labels the white shapes. The white "shapes" are the result of the mental process of Gestalt formation - examples of how, without conscious effort, the egoic mind "thingifies" the unseen.


The image above has circulated in Britain since the late 1950s. It contains a face of Christ, but not everyone can see it straight away. The story that goes with it says it was taken by a Chinese photographer who was riding home one day through the snow. According to the story...

His soul was troubled. He had been witnessing a great movement towards Christianity among his friends since the Japanese invasion. He longed to know the truth of what he had been hearing from Christian missionaries.

As he rode along he said, "Lord, if I could only see your face, I would believe." Instantly a voice spoke to his heart, "Take a picture. Take a picture."

He looked out at the melting snow forming pools of water and revealing here and there the black earth. It was an unattractive scene. Nevertheless, being thus strangely compelled, the man descended and focused his camera on the snowy roadway.

Curious to know the outcome of the incident, he developed the film at once upon returning to his home. Out from the black and white areas of the snow scene a face looked at him, full of tenderness and love - the face of Christ. He became a Christian as a result of this experience.

Provocative thought - "God as Gestalt."

Part 2. "The heart and soul of our everyday living" (continued)

In traditional Christian theology, there are two worlds – visible and invisible, the seen and the unseen. I have this on reasonably good authority:
(Pope John Paul II, Catechesis on God, Creator of the World, session 19)] [Nicene-Constantinopolitan Creed]:

"I believe in one God, the Father Almighty, Creator of heaven and earth, of all things (that is, entia or beings) seen and unseen".

"We know that man enjoys a unique position within the sphere of creation: by his body he belongs to the visible world, while by his spiritual soul which vivifies the body, he is as it were on the boundary between the visible and invisible creation. To the latter, according to the Creed which the Church professes in the light of Revelation, belong other beings, purely spiritual, therefore not proper to the visible world, even though present and working therein. They constitute a world apart."

This viewpoint is uniquely Western. According to Cynthia Borgeault, it arises out of an “egoic” perspective based on a subject-object duality under which we implicitly accept the need for a viewer separated from the thing to be viewed. Cynthia then proposes an alternative, a “wegoic” non-dual perspective.

Things seen are tangible, verifiable by touch, sight, or smell. They are accepted as “scientific evidence.”

“Contrariwise,” continued Tweedledee, "If it was so, it might be; and if it were so, it would be; but as it isn't, it ain't. That's logic."

Things unseen, intangible, and un-seeable cannot be verified from the “egoic” perspective;” the unseen cannot be touched, seen, or smelled. When we view the world from an “egoic” perspective, based on a subject-object duality, we are implicitly accepting the existence of a viewer separated from the thing to be viewed. We see only “things” out there; after all, "seeing is believing.”

Hence, as John Paul II said, things unseen are not of this world. For me, this creates a cognitive dissonance – people of faith do not accept that God does not exist simply because God cannot be seen – which is driven by our innate urge to “thingify” our beliefs into objects that can be seen, through the use of familiar symbols, images, and metaphors. Pope John Paul II alludes to entities in the realm of the unseen as ”angels,” so, of course, we know angels must look just like Roma Downey.

The mind can only see what it is prepared to see.
(Edward de Bono, (1990) I Am Right, You Are Wrong)

We see the world in terms of our cultural heritage and the capacity of our perceptual organs to deliver culturally predetermined messages to us.
(Jamake Highwater, Blackfeet/Cherokee, (1981): The Primal Mind: Vision and Reality in Indian America.)

Which is to say that each of us sees the world from our own viewpoint; however, I know there is more to the world than that which I can see, touch, taste or smell. How many of you share that belief?

How do you and I know this in the absence of verifiable scientific evidence?

Because we have experienced emotions – love, hate, sorrow. We have and hold insights, revelations, epiphanies, ideas, and concepts and, because we believe they are important, we struggle to communicate them to others. This struggle is at the heart of creativity as we seek to find a means to re-present our insights and feelings. But the best we can do in this “thingification” process is to create a “mind map” in the form of a painting, a poem, a piece of music, sermon or some other form of intellectualized experience.

But my re-presentation is not the real thing --- Alford Korzybski's dictum, "the map is not the territory." Furthermore, because this re-presentation is grounded in my own unique cultural heritage and experiences, it is even more difficult for anyone else to see and to accept it as reality.

[View my self-description, "What Language Do You Speak," in the sidebar]

(To be continued)

Tuesday, May 26, 2009

Part 1. "The heart and soul of our everyday living"

[WARNING: You my find this "heavy" going - metaphysical musings on live and death, the seen and unseen, the "...spiritual and emotional dimensions of human existence – in other words the heart and soul of our everyday living." (Sabina Spencer (2004) Heart of Leadership. I plan to take this theme and push it along paths that I have been exploring for the past 40 years. Some of you may feel I’m pushing it right over the top. Take heart, I am not trying to sell you anything. No-thing ventured, No-thing gained.]

While we lived in Redstone, Colorado, my wife and I attended the Aspen Chapel, a non-denominational, and some would say, liberal, progressive congregation with spiritual leanings in more than one direction, tho' principally Lutheran/Methodist/Episcopalian and a soupçon of Buddhism. I occasionally served as a lay "message-sharer," no preachers here. What follows is a mash-up of ideas taken from some of my "messages."

----------------------------

Good Morning, rationalists, atheists, Christians, Jews, Buddhists, Hindus, Muslims, pagans, and miscellaneous others. Did I miss anybody?

No? OK, good. I will leave it to you to decide to which group I belong after hearing what I am going to say.

On becoming aware that I was recently diagnosed and am being treated for a particularly nasty form of cancer, several people have asked me, “Has this experience changed your attitude about life.”

The first time I was asked, I realized that I didn’t have a ready answer, so I responded with the first thing that popped into my head. “Well, “I said, “it’s a relief that I no longer have to worry about eating hamburgers anymore, as it is highly unlikely that I’ll die from heart disease.”

From the expression on the questioners’ faces, it was apparent that this was not the expected nor the desired answer.

Gray-haired folks may remember the 1983 Monte Python movie, "The Meaning of Life." On reflection, after seeing it, I thought, "Well that was a meaningless movie."

Over time, I came to the realization that, "Yes, "life" per se is meaningless, it simply is, an existential reality, a "vessel without content." It is the act of living that fills the vessel with substance and gives meaning to our lives. Life is no big deal. We are given the opportunity to live without having to ask for it.

Like "life," death simply is, an existential form without substance. Dying, on the other hand, seems to be a very big deal in people’s minds. Why is that?

Death is no big deal – given our fragile bodies, it’s easy to achieve and inevitable. Is death from disease any worse than death from aging? Sooner maybe, but no worse or better. The big deal is that, in our minds, death is a scary proposition – it is the fear of dying and its attendant trauma that is the big deal. Death, like life, is meaningless, the big deal is the way we give it form and meaning through action.

[Please note that although fear of death looms large among those of us of the Western, Christian persuasion, it is by no means universal among the groups I greeted this morning.]

Being able to overcome the fear of death by focusing on the quality of living is a very big step on the way to better living.

Must Reads ...

When I experienced my first metastatic melanoma four years ago, I struggled a bit over the choice of treatments (cf. "Evaluating Options,"May 21, 2009). While visiting our son in Arlington, VA, my wife bought me Jerome Groopman's, The Anatomy of Hope. Groopman is a Harvard Medical School professor and New Yorker staff writer; as you would expect, both knowledgeable and a gifted writer.

I highly recommend this book for anyone in need of help or wishing to help a friend suffering from cancer. It brightened my days and strengthened my resolve to live. I think you will find that it will do the same for you.

P.S. If you have not read it recently, add Vicktor E. Frankl's Man's Search for Meaning (1946) to your must read list. Although more philosophical and metaphysical in tone, it dovetails very effectively with Groopman's work and offers a more complete vision of the importance and power of a positive vision of the future.

Saturday, May 23, 2009

Afterthought...

The images in my last post are kind of blobby and might not mean much unless you're a student of anatomy. So, in the interest of clarity I'm posting this graphic to show you the source of the problem.


(Sourced from Wikipedia)

Friday, May 22, 2009

Cyberknife Strikes Again

Today was my third and last Cyberknife treatment. Now, I' ll wait four weeks to see what's next - did it work? The only know prior instance of the use of Cyberknife for a heart lesion was for a sarcoma, so I am the only instance of treatment for melanoma. Here's what happened. The first image shows where the 270 radiation beams entered my body.


The second image shows the area of convergence. The oblong gray blob is my heart. The small bright orange spots indicate the area of maximum convergence (highest dosage); the larger orange boundaries indicates the areas where 72% convergence occurred (Since a lesion on the heart is a moving target it is necessary to set a larger perimeter for the target area to increase the probability of attaining a "hit").

The last image is a chart of the actual dosages received, color-coded to Image 2.

With a maximum dosage of 3740.33 cGy, the chart indicates the primary target area received a mean dosage of 3241.68 CGy (86.62%). With a maximum dosage of of 3439,69 cGy, the larger light orange secondary containing target area received a mean dosage of 3146.36 cGy (91.47%). Radiation exposure to the adjoining areas (lungs, heart, esophagus) was significantly lower, well below the threshold of damage danger.

What does this mean? First and most important, Cyberknife was able to deliver a therapeutic dosage to the target area without significant impact on the surrounding areas. Second, because the treatment dosage levels were based on 1985 experience for safe broad area radiation to the heart, the effect of focused multiple dosages is unknown. Thirdly, since I am the first melanoma patient to receive this treatment, nothing further can be inferred or verified about the result for 4 - 6 weeks, after follow-up studies are completed.

Sorry about that! Trust me, no one's more anxious to know than I am. In the meantime, I'm pushing for a resolution of the small, untreated mets in my right lung and enjoying the extra 20 yards I'm producing within my new Callaway FT-iQ driver.

When You Need a Friend...

When you have lived in the Washington, D.C. area, you are familiar with the saying, "If you're a politician and need a friend, get a dog!"

Everyone in need should have a dog (or a pet). Why? First, "Dog" is "God" spelled backward, so you got things covered coming and going, "Dog is my co-pilot."

Most importantly dogs offer unconditional love, are forgiving, and demand very little of their owners and soul mates - a little food and water, walks, hugs, and a measure of love returned. They also provide spontaneous moments of joy and reward.


I'm scheduled for my third Cyberknife radiation treatment today. Cookie, our 6-year old Cairn Terrier, came into the bedroom,
and did her best puppy bow with the obvious intention of inviting me to play. In this case, play consisted of me standing in the middle of the living room clapping my hands and yelling, "I'm going to get you!," while she races madly around the house, through my legs, under, and over the furniture, stopping only when she heard the toaster pop in the kitchen where my wife was making breakfast. "Toasties" are very high on Cookie's list of needs.

This was followed by some "training." This means she performs for treats. This morning with a chicken chip for motivation, I put her in a Sit-Stay and walked about 30' away and faced her. At this point, I'll usually use voice command and gesture for "Come," then "Stop" en route, followed by a final "Come" and reward. Today, I tried something new. She knows "Down" and "Stay", but I had never tried a Down-Stay from a distance. I was dubious about it working because the gestures for "Down" and "Come" are very similar, open palm toward dog moved vertically for "Down," horizontally for "Come."

So, starting her from a Sit-stay, I walked away, turned and gave the command for "Down." Sonnova gun, she dropped like a log and waited expectantly for the next command. Surviving cancer is a series of small victories - Cookie's my role model for success.