The fault in MY stars.

Post-transplant day #1073.  The fault in MY stars.

"The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings" Cassius says in Julius Ceasar.  He is explaining that if there are any obstacles to realigning Rome's leadership to something more equal, the impetus must come from within.  Food for thought. Especially in relation to cancer, where a person may wonder if at some point they had enough control to avert this.

These last six months.  It isn't that I have nothing to say, it's that I'm not sure how to say it.  How to fashion the murder of crows that passes for thoughts in my brain these days into something rather more beautiful and coordinated.  As John Greene put it, "my thoughts are stars I can't fathom into constellations"; a saying I find very apropos these days.

I have not written much about my cancer as these last seven months have passed.  I start to write, then stop, and it suddenly feels very, very meaningless. I'm a newcomer to this corner of medicine and anything I may have to say has been said a thousand times by a thousand other voices more thoughtful than mine.  And what could I say, but over and over "I'm tired, I'm tired, I'm really very tired."  Even the most patient of caregivers would get tired of that refrain.

And yet, if you want a concrete detail, that is how my cancer stands in my mind: constant weariness, regular exhaustion, severe anemia.  There are also bowel irregularities as my body takes its sweet fucking time adjusting to the new plumbing.  It can ruin my day - I'll leave it at that.

Cancer forces profound realizations upon its victims and their families, in ways similar to transplant. That the cure is sometimes worse than the disease, for instance.  Individual rounds of chemo could be planned for and dealt with and seem somewhat easy, but the long course of it ground me down, exhaustion settling into my bones in a way that felt irreversible (though right now, a month out from my last dose, I'm feeling much better!)

The immediate fatigue 5FU caused me ranged from mild to severe, but it always meant the next week would be a bad week.  April and I began to plan around these weeks and April didn't push me to get much more done than work, eat, take meds, and sleep.  The surgery hurt, the chemo wore me down, but the worst effect, I think, is what this has done to April.

April is the one who has most directly borne the reality of my cancer, outside myself.  She watched me sleep through leaden weekends, took me to the hospital, sat with me throughout.  She double-checked everything the doctors and nurses said against her medical experience and did her own research on colorectal cancer.  And if she was short with me now and then, it just shows she's human.  Her frustrations boil over and I think one of those frustrations is my refusal to panic over the cancer or its treatment.

Now that...THAT is a subject for a whole post of its own: Stoicism as a primary coping strategy.  Not doctor approved, I'm sure.

I got through it.  That's all.  I did not shine, I did nothing exceptional.  I kept my nose to the grindstone at work and limited my extracurricular activities.  I tried not to bitch and complain, even as chemo brain set in and I found myself with a spotty memory.  Very spotty.  On top of the exhaustion and bowel troubles. The memory loss bothered me more than anything, because it means that my cancer has managed (via its own treatment) to get to my brain.  When you find yourself forgetting, you wonder WHAT you forgot, and when.  You wonder how much of yourself might be slipping away, without knowing it.  Blissful...and terrifying.

Now let's face the future:  Last week I had PET and MRI scans.  And Tuesday, my oncologist sat me down and let me know that the spot the PET scan had found had been confirmed by MRI. I have liver cancer.

Once again, I head into unknown territory.  My immediate future involves getting cut open from sternum to belly button, to be able to get at that spot and cut it out.  There will be significantly longer initial recovery than with my sigmoidectomy, the doctors tell me.  (Of course, I hope to prove them wrong.)  And after that, more chemo.  This time oxalyplaten will be added to the treatment, alongside 5FU.  April is understandably upset and has expressed that she's afraid chemo will tip my kidneys into outright failure.  I talked to the liver surgical oncologist today about that issue and he noted that they've had plenty of patients in kidney failure and they will carefully set doses and timing so as to be as easy on my kidneys as possible.

And that...is that.  It's all I know right now.  Tonight I'm reminded that the fault is NOT in our stars, but in ourselves. If I wish to conquer, then I must BE a conquerer. I must work hard at this next phase, particularly recovery, and not allow chemo to control my life so much.  Though...really.... I don't give much chance of that.

Okay?

Okay.

Destination Unknown

Post-transplant day 865.  --Destination unknown.--

For the first time in my life, I have no idea where I’m going.

Duke Admissions February-March 2016.  February 18th thru 23rd for 1) high creatinine detected by both UNC [4.7] and Duke [4.9] on the 16th and 17th, respectively; 2) high blood pressure, noted on admission; 3) blood in stool.  Late night admission; immediately given IV fluids.  Creatinine drops over a few days until 2.5 at discharge.  Consults, medicine changes throughout stay.  Attempts to control blood pressure w/ medication changes complicated by changes to meds prompted by advanced kidney damage.  Finally settle on DCing metoprolol, re-starting amlodipine at half strength, and added carvedilol and hydralazine 3x day.  Fosamax DC.  Calcium cut to half. 

  -- from my notes

Throughout my life, I’ve been able to hazily foresee my future, or possible futures.  I could tell where I was going to go to college, where to grad school, what occupations I’d make a life of.  I could predict the course of my disease to a great degree up to and including transplant.  A life of a transplant has its own divergences, beyond the infections, sinusitis, lung collapses, hemoptysis, liver disease, kidney disease, pancreatic insufficiency, malabsorption, and diabetes I’m already familiar with.  New maps have had to be called up - new skills learned, new possibilities considered.  Many are mentioned, but the big one we all mentally prep for is rejection.  As yet, I have no experience with that.  I have, however, experienced multiple lung infections, a marked increase in my kidney disease, and the onset of hypertension and anemia.  Still - I can handle these.  They were on my map as possible parts of the journey.

What has taken me by surprise, though, is a diagnosis of cancer.

Felt pretty wiped out upon discharge.  Still having bloody stool and headache.  But blood pressure and creatinine under control.  Spent February 24 at April’s.  We talked and decided that the bloody stool hadn’t been addressed with seriousness - plus it was getting worse.  Back to ER in the morning of 25th.  Spent all day there; started Miralax prep 8pm finished by midnight.  Moved to 9327.  Colonoscopy the afternoon of the 26th.  Preliminary results back by 6pm.  

A 5 cm mass has been found in my rectum.  Biopsies were taken and will be studied…soon.  April spent the night with me - tearful, angry, frustrated with me (partly) and the system (mostly).  She’s smart as a whip but she doesn’t know how to redirect her emotions well.  Probably best night I’ve ever slept with her, though, even on that twin-sized hospital mattress.

I just have very few reference points to help me navigate this.  I am depending more on the doctors now than at any time before, as my close friends and family also have little experience with cancer or modern treatments for it.  To keep up with the journey metaphor, the atmosphere has become rather hazy, yet I have no choice but to keep moving forward - blindly.  Even the doctors have been very careful as they move forward.

Spoke to Dr. Thacker, surgical oncologist.  She said biopsy and CT results in full are still pending, but the first look at the CT gives enough information that they need MORE information before proceeding with treatment.  She says the mass is “rectosigmoid”, meaning it appears to be right at the junction of the sigmoid colon and the rectum.  Her diagram on the whiteboard was very simple and very dismaying.  This means more testing - probing really - is necessary to determine exact location, etc.  Because if the tumor is located beyond 15 cm in, we go directly to surgery.  If it is located before 15cm, and encroaches on rectal tissue, then oral chemo and radiation.  The oral chemo is designed to make the tumor susceptible to radiation, which is to shrink the tumor.  And THEN surgery.

The surgery went well.  I have a few new scars for it and some lingering problems with bowel movements that I won’t go into here.  Trust me, you don’t want anybody cutting parts of your colon out.  

Fortunately, I’m not alone.  I have April and my family.  I have excellent doctors.  I have my belief I can overcome anything.  And cancer is a very different beast than lung disease or transplant status. Different enough that everybody knows what cancer is, the seriousness of it, and entire hospitals are built to fight it. 

If there’s one observation I can make so far, it’s that while “I need a transplant” or “I’m immunosuppressed” draws a blank with some people or elicits a confused reaction, “I have cancer” immediately meets with sympathy and understanding.  EVERYBODY has dealt with cancer, if not in themselves then in a close relative.  So I’m not surprised I’m getting good support from FB.  

But what does surprise me is the change in how I’m treated by medical professionals.  Until last Friday, I had the impression my “little” problems - hypertension and kidney disease - were boring, run-of-the-mill, and slightly annoying for the medical professionals taking care of me.  But a diagnosis of cancer? That changes things.  Tanya the PA on 7800, for instance, did a 180 from stony-faced, hella-competent professional, to compassionate, hella-competent, personable medical ally.  She told me a bit about her sister’s permanent colostomy and her own fight against breast cancer and mothers who are more of a complication than a help (in these situations).  We had a couple long, good conversations before my last discharge.  I hope I can count on her this weekend to help keep all teams coordinated.  I’m not going to have the humour or patience to deal with people who won’t listen to me or to each other.

Cancer has already changed me permanently - physically, chemically, mentally, socially. Cancer is a veneer that changes how people see you.  And, I suspect, changes it just as permanently.  I know I view my acquaintances who have survived cancer with more awe than I did before, like Susan Hilferty.  So now I’ll be “that” guy - all over again.  If it's pity, my friends can save it.  I only need their understanding that I have a new normal, even farther from center than before. 

This post has been extremely difficult to write.  I’ve been mulling over what I wanted to say for over two months.  But tomorrow begins a new phase of treatment - chemotherapy - and I felt I needed to get down on paper what has been stewing in my brain so far.  I realize that I have dodged bullets at every turn.  The tumor was located just far enough in to treat primarily with surgery, immediately.  Chemo is up to bat as cleanup; primarily because the tumor was Stage III, I had a small amount of metastasis, and I am, after all, immunosuppressed.  Things could have been a whole lot worse and for that I am thankful. 

 Things may still go sideways, but for now, I’m OK. What I keep coming back to is my ability to cope.  These last two months, I have repeatedly reminded MYSELF that I’ll handle this thing like I always have: calmly, with deliberation, and with dignity.