Back on the Trail

My surgeon's advice is in: radiation, but not radiation to the extent that many practitioners would call for, plus Careful Watching. I will see the radiation oncologist in the next few days and get the details on his proposed zapping. Dr. Haughey, the surgeon, will do the Careful Watching, which initially means coming in every eight weeks or so for a ... careful watch.

The most interesting thing about the advice is that Dr. Haughey says his treatment involves significantly less radiation therapy than most practitioners would recommend. Since the primary cancer has not been found, many would recommend radiation that is all over the head and neck. One friend of mine compares it to shooting a blunderbuss in the air and hoping a flock of geese flies by.

We'll know more soon, because the unanimous advice is that I should hit the Second Opinion Trail, and go to one of the other national cancer centers: Johns Hopkins, M.D. Anderson, Sloan-Kettering, etc. Dr. Haughey confidently predicts they will disagree with him and advise more radiation. Why? Because it's the Standard of Care.

The term is both medical and legal:

M.D. Anderson's site (and these sites are amazing) helpfully posts a definition:

Standard of care. In medicine, treatment that experts agree is appropriate, accepted and widely used. Health care providers are obligated to provide patients with the standard of care. Also called standard therapy or best practice.

In addition - I am a lawyer, after all - I know that Standard of Care is basically the medical malpractice benchmark. You look at the standard of care in the locality and that's what the doctor has to meet. Which means my surgeon is willingly taking a risk - and with a patient who he knows to be a lawyer.

You really have to like this guy.

And you have to like his advice, since it involves less radiation. Or, as one of his other patients put it, I can avoid microwaving my head.

The Second Opinion Trail will be a little unusual. Most of the people I have known who rode it were in search of better news - a way to cure themselves, or buy more time, or endure less pain. I am going out simply to confirm that the proposed treatment makes sense. As Dr. Haughey says, it boils down to a balance of mortality and quality of life. I like his balance, I like the deal, but I have to verify. This is Due Diligence, really, and this M&A lawyer has a whole lot of experience with DD. Time for a data room check.

(photo: old Route 66, somewhere in Arizona, 2006)

Cancer

I'm going back for a turn-the-page interview with my surgeon tomorrow, where he gives his opinion on how to go forward. I have a preview, which is that he will recommend only careful watching, not radiation. But more on that tomorrow, or the next day.

What has struck me throughout this process is the gonglike resonance of the word, cancer. Where does that come from? Nearly everyone knows it's not an automatic death sentence. But it seems to be uniquely scary, in its own dimension, different even from stroke. We fear it, I think, because it is alien. An invader.

The derivation sheds a little light. "Cancer" is the Latin word for crab, although the Roman physicians also used the term for the disease. Ditto the Greeks, with "carcinoma". An invading creature, with claws.

And unlike other invading creatures - germs, say -we don't really know where it comes from. It doesn't come from the outside. There aren't little cancers floating around that hop on board. This invader seems to appear on its own - we grow our own enemy.

So if that's the case, is it an alien? Or an evil version of ourselves?

In my case it's further compounded because we can't find it. It's an invisible evil-alien-doppelganger. Even more scary, I suppose.

But here's what I say: aliens don't scare me and neither do ghosts. They intrigue me. God help me, I think the whole thing is interesting. And I have never felt more alive.

Grey Matter

Surgery was 12 days ago and at last, an hour ago or so, the doctor reported in with the results of the pathologist. Still inconclusive. As we said in Hong Kong: ay-ya.

Maybe this will always be inconclusive, maybe there are no definite answers. We do know, more or less, that all the lymph node cancer in my neck is gone. We also think that all the suspect tissue in my mouth is gone. But what is still "grey" - my surgeon's term - is whether a radiation oncologist would recommend radiation of the neck. There is some more testing of the tissue that was taken originally that might shed further light, and they are going to proceed with this.

But it's pretty clear at this point that the answer will not be clear. So we are left with me, who has no desire to undergo radiation unless it's necessary, and my surgeon, who doesn't like it either. He likes what he calls Careful Watching (let's call that "CW"). I sure like CW too, as opposed to going in every morning for months and having some tech zap my head and neck with X-rays, and making food taste so crappy that they offer to feed you through a "peg" in your stomach.

To me the obvious question is why, if we are not sure there is anything left to worry about, do the radiation at all? If CW fails somehow, can there suddenly erupt a serious cancer that radiation would have stopped? The surgeon says he's never seen it. What's more, he says, radiation can impair CW; it can make it harder to detect the kinds of changes in cells that CW is looking for. And radiation has its own downsides - not just short-term effects - including, at the end of the spectrum, carcinogenic downsides.

But he's a cutter, not a radiation guy, and he's has a bias. He really hates the blunderbuss approach to treatment. I am struggling for an analogy - something like killing back the whole lawn in order to be sure you get the spots of crabgrass.

So back again to waiting, but I've learned to stop expecting some kind of clear denouement. It will be a judgment call based on shades of grey.

In the meantime, 12 days on, I'm up and at 'em. The only real lingering problems are a sore neck and throat and a mouth that still feels like I went to a sadistic dentist. Still numb, and food is not right. Some things taste great, like milkshakes, hence:



which my buddy Steve took at the Steak 'N Shake last week. Many other things I usually love, however, just will not go down. A great friend and cook served me a gorgeous Sockeye Salmon the other night, and I knew in my head that normally I would wolf it. Instead I pushed it around the plate like a girlyman.

The palate will come back, sooner or later. In the meantime I will not let this crisis go unexploited - and will regain the Hong Kong silhouette. Ay-ya!



-

Best Reply So Far

I realized I had neglected to give the news to a crusty old associate, and wrote him saying I had cancer of the neck.

He wrote back with:

"Where you been stickin' your neck?"

Surgery


This will be long and detailed, and a little graphic, so maybe I should start with a headline. A million years or so ago I was a journalist and did headlines, and they are cool little puzzles. Capture the piece; make it sound interesting; don't split infinitives or prepositional phrases at the end of the line; try to fit it into the column but don't be slavish about it; try to use active voice. I suppose there are many more rules; I think I made these up. Didn't go to J-school. Anyway, for this one:


Morgan Out of Surgery and Back Home;
A Bunch of Stuff Out, But Some Aspects
Still Inconclusive and Await Pathology


And then you go into that inverted paragraph who-what-when-where-why motif and design the piece so the last graphs can be cut off. Not here; this isn't news, it's a blog.


Now. Assuming I haven't shaken you and you're still reading, here goes:


We got to Barnes around 11 am on Thursday after a lot of confusion about the starting time. It's kind of a moving target anyway; the surgeon doesn't really know how long the preceding one will take. By about 2 pm they were ready to go, explaining the drill. A short conversation with the surgeon, and a slightly longer one with the anesthesiologist. Expected to take about 5 hours, so I thought I'd come back up around 7 pm.


A friend with a great sense of the absurd suggested that I try to savor the buzz as I was going under. A good idea, had I been at Fillmore East. As it was, the last thing I remember was getting wheeled down a corridor.


Next thing I know I'm waking up and looking a clock. It says 7. But there is something odd about the light, and I feel like I have a log shoved down my throat. Turns out it was 7 am Friday morning. The surgery had gone longer and later than expected, and the doctor was worried about my breathing as I was sedated through the night. Hence the big-ass breathing tube. Believe me, they are to be avoided at all cost. I had my wrists tied to the bed to keep me from waking up and yanking it out.


Someone did come and take it out, mercifully, but then I realized I was still way tubed up. A drain from my neck - I had this before, not a big deal - and a feeding tube down my nose and into my stomach. Very unpleasant and only there because I might not be able to eat and it was better to put it in during surgery than later, through the lacerated throat. So it was, at that point, pointless. Plus a catheter. I was an ingress-egress machine.


The feeding tube became a real driver. I wanted that baby out of there, and they said it would only come out if I could demonstrate that I could get nutrition down. So I downed everything I could stand, which wasn't much. Eventually I focused on tepid milk. Twenty-four hours later it was pulled out by a pretty good-looking female doc.


The surgery had not gone exactly as planned. The concept was that (a) we would look around inside the oral cavity with a microscope, find the primary, laser it out, then (b) go and take out the remaining cancerous lymph nodes on and take them out in a neck resection. All the activity was to be on the left side of my head and neck. Turned out (a) was inconclusive, the primary cancer not seen; but the doc did spot a precancerous lesion, maybe, on the right side of the cavity and took it out. I have the feeling he wanted something to show for the effort. Apparently it was hard work, because I have a relatively small cavity, and he had navigational problems. And I always thought I had a big mouth.


So he removed a lot of vestigial tonsils (if for some reason you've been following this story, you'll remember I had my tonsils taken out, I thought, in the 1950's) and then went on to part (b) and took out a chunk of my neck on the left side. Uneventful. Now the whole mess goes to Dr. Pathology and he works his magic, looking to see if we did, in fact, find the primary. At this point, maybe. But maybe not, which will throw me back to the whole radiation/chemo possibility, which is the bad part.


Two more nights in the hospital, and nights in a hospital are just lousy. The technique seems to be not to care about uninterrupted sleep, but rather to show up every couple of hours, turn on bright lights, wheel in a device, and inject something into your veins or take blood out or take your temp or check your blood pressure, and the people who are doing it although really nice look increasing like denizens of the Star Wars Cantina as the hours go by. Which they do slowly.


Plus it was a double room, and my roommate was a very sick dude. He was five feet away, on the other side of a curtain.


I lobbied for an early release on Saturday and lost. So I became Mr. Positive, eating as much as I could, strolling around, chatting up the staff, bucking up my roommate, in order to establish my creds and get the hell out of the place. Sorry. Even though they are staffed by really nice people, I do not like hospitals. I can't shake the notions that they are giant petrie dishes and people go there to die.


This morning the docs said I was "extraordinary." So Mr. Positive got sprung.


I'm now home with just the neck drain, which is not pretty, and a Frankenstein's monster scar along the jawline, and a swelled neck, but everyone is saying I look great. Which may mean I am surrounded by flatterers, but I'll take it.


From here, taking a lot of pills, can't lift over 10 pounds, and back to waiting.

Lucky

(The photo: moonrise over the Grand Canyon.)

You bet I'm lucky. No matter where this goes.

My whole thing about the Big Guy is that that he's the one I say thanks to. That's my belief system, such as it is.

Family, friends, clients, the firm, the band, a pretty active imagination and about to enter my 60th year on the planet. Lucky man I am, and grateful.

Countdown

I'm sure there are many very bad things about dealing with cancer, practically none of which I have yet encountered. The only one I seem to be struggling with so far is... waiting.

Waiting in waiting rooms (well, that's what they are for, I guess.) Waiting in examination rooms (Mrs. Strays and I spent two hours in one - I was reduced to Hulu on the laptop.) And mostly waiting all day long, every day, for the next big step, which at this point is surgery. Thursday June 4, less than a week away. The only interesting thing in the meantime is that I go in around noon and will have had to fast since the midnight before. An opportunity to shed a few, but I will be powerful hongry.

One really does think about it most of the time. Wake up: oh yeah, I've got cancer. Get a headache: is it because I've got cancer? People who don't know ask: "How ya doin'?" "Great." (Thinking, kind of ironic.) People who do know, serious face: "So, how are you?" "Great, x days to surgery". (Thinking, amazing how great everyone is, but also does this person want to hear a longer version? Hope not.)

And you see references to cancer and terminal illness all over the place, and they certainly take on a new resonance. Is there a mini-economy, apart from medicine, based on all this?

So, the countdown. Five days to go.

More Labels

One my better (well, I think so) posts dealt with labels, and how they raise questions, but here I have another type of label in mind: the unfamiliar terms that professions use to describe what they do, and in particular the terms my surgeon is using to describe what he's planning to do:

Microlaryngoscopy with transoral C02 laser survery of the primary, left palatine tonsillectomy, left lingual tonsillectomy, and completion left neck dissection.

Taken from his assistant's email. OK, let's break it down.

Microlaryngoscopy

This is what he's planning to do with the microscope, that is, going down my throat and looking for the elusive primary cancer

with transoral C02 laser

and if he finds it, with a laser, conducting a

survery of the primary

What in the world is survery? A typo, probably, "v" and "g" aren't that far apart... so it certainly could be surgery. Or survey, which Google favors. As with most misspelled words, there are dozens of "survery" examples out there but they seem to mean survey.

left palatine tonsillectomy, left lingual tonsillectomy,

And I thought I'd done with my tonsils back in 1955. There are evidently little residual flaps of tonsil (OK, that's not for the squeamish) that he finds candidates for complete, 50+ year-later elimination

and completion left neck dissection.

Which is the part that was always going to happen. Taking out the lymph nodes and surrounding tissue. There is a history here, I heard about it a little from Doctor No. 1. This procedure was once pretty massive - they took out a whole lotta neck - and has since been scaled back so I get to keep things like nerves and arteries. It was developed in the early 20th century by a well-known Clevelander, Dr. Crile, who started the Cleveland Clinic. (And whose grandson was a terrific but controversial journalist.) They had a place out in Painesville, I think, called Little Mountain. Always thought it was a great name... or better yet, a great label.

Nuclear Family

It's flooded at Pere Marquette but this group has it under control.

Different Deal

And a better one. So here's the reason why you go the best hospital in town: they come up with better treatment.

Based on the same facts, the new doctor on the scene - his name is Bruce Haughey - has a different, and much less burdensome, treatment. The old plan was to (a) remove the cancerous nodes and surrounding tissue from the neck (b) do some "random biopsies" to try to find the primary cancer, and (c) follow up with radiation and, maybe, chemotherapy. The new guy will stick with (a), has a different approach to (b), and thereby will probably eliminate the need for (c).

Dr. Haughey is a self-confident New Zealander and the Director of Head and Neck Surgical Oncology at Barnes*. He said that what I have is quite common, and they have developed a process for it that has been very successful. His approach is to use a microscope to look for the primary cancer during the surgery and if he finds it, which he usually does, excise it with a laser. It is usually identified during that process and a followup biopsy of the removed tissue. Then, no need for radiation or chemo. Mrs. Strays asked the logical question why we hadn't heard about this procedure before. He said probably because he hadn't published it yet.

Well, yahoo. The surgery never bothered me. In fact I can't wait - it is strange to wake up every morning knowing you have cancer in your neck, and I'd like to get past it. But I was not looking forward to radiation, which was certain, or chemo, which was possible.

Dr. Haughey gave me the standard disclaimers, and can't guarantee no radiation. But it is a very different future. With this, I may well be back up and getting on with the rest of my life by mid-June. Yippee kai-yay.



* The name of the place is kind of a mess. So far I have about six: Barnes, Barnes-Jewish, BJC, Washington University School of Medicine, Center for Advanced Medicine, Siteman Cancer Center. I know there are some real distinctions between the hospital and the university; but the rest, I guess, is a mash of history and marketing.

Picking the Joint

So, here's where it comes out on the Teaching Hospital v. Other Good Hospital debate.

If you are dealing with something where you have a life expectancy statistic:

• do the homework
• go with the best hospital for that area of disease
• to which you can have reasonable access.

On the other hand, if life expectancy isn't really an issue:

• do the homework
• go with the hospital that has an established practice in that area of disease
• to which you can have comfortable access.

Teaching v. non-teaching is not necessarily the driver. A very smart doctor I was with the other night had several examples where the teaching hospital was not necessarily the best in town.

Lessons learned so far.

At times like this the good people surface.

The Big C

Well, the Republic of Equity is going to have to wait a bit. The Dictators of Debt can continue their evil ways without my stuff, and I'm sure they're relieved. I have a bigger, more personal, and much easier-to-write-about thing going on.

I have cancer.

The road here:

A soft-spoken well-dressed guy I have known a little for years was taking over as my dentist. Our first visit was mid-March, and he does this macro head exam, taking casts, making models, shooting x-rays and photos and generally poking around. Plus he felt my neck, and, with his fingers on the left side, said "What's that?" I said, "Dunno." He said, "Get it checked out." He was quite insistent. "Get it checked out right away."

I had noticed it before, while shaving. I thought it was a sort of muscle, kind of buff. That's it.

So for the next six weeks I went through appointments broken and met, no big sense of urgency. First my regular doc, who sent me to an ENT, who did what's called a needle biopsy, and that didn't show him enough, so I went in for a real cut, under general anesthesia for the first time since I was five. (That was for a tonsillectomy.) He said the results would usually be - I like this term, it has a certain hauteur - "unimportant."

They put a drain, not a lot of fun, in the neck for the next couple of days, and upon my going in to have it dismantled and removed it fell to the nurse practitioner to reveal that the results were, well, important. Cancer in the lymph node.

I wish none of this were happening to me, obviously, but it's pretty interesting. The lymphatic system acts like a little storm sewer system in the body, separately from but in coordination with the blood circulatory system. Cancer cells travel to lymph nodes, and accumulate there. That's what they found. The cancer is metastatic, which means the cells are coming from a primary cancer somewhere else.

So the next step, of which I'm in the middle,* is to find the primary cancer. The first step was a PET scan.

PET scans are one of these jobs where you lie down on a tray and they move your body in and out of a tube. Fine, but they take a while and I was desperate for reading material. I resolved to memorize great speeches or great poetry so I can reel them out at future such times. As it was, I tried making lists, the first being a list of old girlfriends. I told this to the techies who run the machine and they loved it. (I wish their lives, by the way, on nobody.)

Yesterday we** met with a radiation oncologist, who tells you what to expect, generally, from the radiation treatments that are almost surely ahead. He gave us a first report on the PET scan and it sounded good. No evident cancer outside the head and neck. Something may going on with the right side, in an epiglottic fold***, but it may not be what they are looking for. All of this is pretty consistent with the better-case predictions I had heard.

Now on to the decision to move from the suburban hospital where all this has taken place so far, to a city teaching hospital, which is what practically everyone says to do. In particular, move to the Siteman Cancer Center at Barnes, which does indeed sound like a first-class place. I don't know the pros and cons. Why wouldn't everyone do this? Cost? Doubtful, I don't think the teaching hospitals are any more expensive for those of us who are insured. (And they are more likely to take on the uninsured.) Suburbitis? (You know, too many black folks in the waiting rooms at those big downtown hospitals...) Maybe, but that's not me. The doctors? My guy at Suburb Hospital, which itself has a terrific reputation, said it is comprised mainly of docs from Barnes (Washington University, actually) who don't want to teach. So they play more golf? OK, fine, but to me... unimportant.

********************************************************************************

* Up with this I will not put! - WC

** "We" ain't royal. We is me and Mrs. Strays.

*** The Epliglottic Fold sounds, to me, like a place where Jabba the Hutt might hang out.

On the Road from Kansas City to St. Louis

The winter of 2008-2009. What a trip.

I Am Starting to Get It

There was a book or a blog or something that was pushed at me for years called Empire of Debt. It predicted pretty much what is happening now.

They were obviously right but I think they got the metaphor wrong - at least if it's trying to describe the problem. The problem is not that it's an empire - it may be, but that's more of a descriptor than a critique - the problem is that it is a Dictatorship of Debt.

Hence AIG. Hence the US government, the ultimate debt junkie. Hence Goldman Sachs, which I am sure is well on its way to becoming the next Trilateral Commission in the eyes of the conspiracy theorists.

Their solutions are all based on the idea of reinflation through debt. Defer the problem to the next generation and the next and the next; stand at the arterial money flows and siphon off small percentages of huge torrents of cash; shrink the number of players at the top. (Bye-bye Lehman - too bad you didn't have enough friends on the way down.)

The answer for the revolutionaries: convert the Dictatorship of Debt into the Republic of Equity.

More later. Back to work. Keep the day job.

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No. 2: Baskets O' Loans

Is our ability to deal with the downward drop in residential real estate impaired by the fact that economic ownership of the mortgages is scattered - held "out there" in the market? How do you administer that?

Well, wait. There is someone - let's call him the Collection Agent - who is in the chain and has a list of debtors. When they make a payment, the CA checks it off, takes a little piece, and sends the balance along. At the other end there is someone - let's call him the Distribution Agent. When money rolls in the DA looks at his list of holders, checks them off, takes a little piece, and sends them their share.

So the CA knows who is going into foreclosure and the DA knows who is going to have to take less than expected.

So this time, in contrast to No. 1 below:

When it's time for the debtor to give up, he surrenders ownership of the house to the CA (which holds for the ultimate owners) but the debtor can continue to live there as a tenant. Rent is enough to cover major maintenance, insurance, taxes, and costs of administration of the arrangment by the CA and the DA, but zero is applied to debt service. The tenant has to keep the place up. The ultimate owners keep the loan for, let's say, 10 years. At the end, or if the property can't keep a tenant on those terms in the meantime, it's sold and then the CA, the DA, and the ultimately owners divvy up any proceeds.

Solving the Crisis, One Issue at a Time
No. 1: Foreclosed Homes

I'm starting to get it. The torrent of words that is roaring past on the economic crisis is at levels of 5000, 10,000, 25,000 feet. Way over the head of the problems. Leaving us with: put new money in giant institutions at the top of the pyramid and eventually we can all borrow our way back to health. And now add this: let's couple it with WPA 2009.

Nah. Break it into pieces and fix each piece.

Today: the huge inventory of foreclosed homes, which is expected to grow even larger.

Our traditional approach - throw out the debtor and auction off the property - is a fair way to get back to true value but on a massive scale it is just going to dig a massive short-term hole.

Instead: when it's time for the debtor to give up, he surrenders ownership of the house to the bank but can continue to live there as a tenant. Rent is enough to cover major maintenance, insurance, taxes, and costs of administration of the arrangment by the bank, but zero is applied to debt service. The tenant has to keep the place up. The bank does not have to write down the asset - so long as it can keep a tenant in there on that basis, it can keep the loan on its books in full. For, let's say, 10 years. At the end, or if the bank can't find a tenant on those terms in the meantime, it's sold and then the bank takes the loss. Or keeps the gain.

Takes no new cash, stablizes the residential market.

Next: homes where the debt is parcelled out and held in securitized pools.

River Bottoms - St. Charles County

There are broad vistas right up close to cities on rivers - people won't build there, it can flood, we know it well in this confluence of the Mississippi, the Missouri, and the Illinois.

So we have this, 20 minutes from downtown.

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2009 just cannot be more troubling than 2008, can it?