Tumor Board Results...

Jasmine and I traveled to Stanford today. Our appointment was 1 PM and we expected to be able to leave by 2 PM. However, the 1 PM time slot was for a "fellow" (a physician already trained in a specialty who is spending time learning more about a narrow field.) For example, in my field of psychiatry, one completes medical school, then four years of psychiatry residency, and then may do fellowships in forensic psychiatry, addiction psychiatry, geriatric psychiatry, etc. Fellowships generally last one to two years.

This "fellow" was a radiologist who was studying the use of radiation in the treatment of various cancers.

He reviewed my history and did a physical examination that was tailored to my lungs and lymph nodes. He also did a brief neurological examination that I found to be remarkably concise and reasonably complete.

Although my MRI of the brain done two weeks ago was read as normal, there are issues with "resolution."  The scan is not able to see clusters as small as twenty or thirty cells. The PET/CT scan revealed that I have what is almost certainly tumor in my L2 vertebrae. Given this evidence of spread, there is a high probability that there are many other implants from the primary in my lung.  A metastasis is the appearance of a tumor with an origin in a distant site. For example, my primary tumor is in my lung. My L2 vertebrae defect is almost certainly a piece of the lung tumor that has travelled in my blood stream to bone. Lung tumors commonly spread to brain, bone, and adrenal glands. Very small metastases have just not grown to the point where they can be detected in scans.

After the fellow "worked me up" he went to the "tumor board" a collection of ten to twenty specialists in cancer from different medical disciplines, such as radiology, hematology, pulmonary medicine, thoracic surgery, medical oncology, etc. After reviewing my data, the board did not believe that it was necessary to biopsy my L2 vertebrae to prove it was tumor. The scan itself was suggestive enough in the face of a large lung tumor that fills the upper of the two lobes of the left lung.

After the tumor board discussed my case, the medical oncologist, Joel Neal MD PHD,  reported back to Jasmine and me. He laid out various options, including the entry into a study for Stage 4 Lung Cancer. It would involve a trip to Stanford once every three weeks for 8 hours of drug infusion. I would stay overnight after the medications were administered in case there were immediate side-effects. It would also involve having my imaging studies done at Stanford as well so that they could follow changes in tumor size in response to treatment.

I will take these recommendations from Stanford to my local oncologist, Dr. Palchak, who was so helpful to me last week and made me much more comfortable with a dose of steroids.

Some Reflections on Deaths


Throughout my medical career, I have had a special interest in my dying patients. From Kubler-Ross' work and other materials, I learned early on that most of us want to avoid the dying person. It reminds us of our own mortality and we are uncomfortable about how to act, what to say, what should to avoid mentioning, etc.

In my practices, I generally made a special effort to spend more time with the dying. Most of human conversation is ritualistic "fluff" not a bad thing at all, but seldom includes sharing stuff that comes from some place deep within. There is a much higher ratio of "real stuff" when we get to where the rubber hits the road and that is where the dying hang out much of the time.

As the imminence of my own death appeared in my X-Ray about a month ago, I've thought a lot about what is likely to occur to me in the next few months--believe me, I'm not looking forward to it. However, when I thought about the various other types of terminal illnesses, the one that I am facing looks much less daunting than many others I can imagine.

If you had asked me a few weeks ago -- before my awareness of my illness -- about my preferred methods of dying, I would have mentioned passing away while sleeping (Slip out the back, Jack!), being hit by a truck while bicycling on Route 1 between Morro Bay and San Luis...what a beautiful last scene! (no need to discuss much!). I would have chosen one of these. However, I have been amazed at how much I am enjoying simple pleasures that are wonderful moments (make a new plan, Stan).

I'm deeply appreciative for these moments and I'm reaching out greedily for more. My sense of gratitude is increased. This illness has bumped up my awareness a few notches.

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I'll be seeing a lawyer this morning and my local oncologist  this afternoon.