Bilateral Pulmonary Resection: A Dialogue After Plato

OK, so I’ve spent the week reading the early Platonic dialogues (Apology, Euthyprho, Crito, Phaedo, Gorgias, and Phaedrus) and trying to decide whether or not I ought to have a bilateral pulmonary resection (i.e., a surgery to remove the masses on my lungs). This decision, and the week as a whole, has been fairly stressful, as I’ve struggled to find clear guidance on what the “correct” choice would be in this scenario. In any case, my waffling about this decision all week struck me as being very Platonic, at least insofar as Socrates’ impressionable interlocutors can be called “Platonic.” Like Phaedrus, Euthyphro, and all the rest of them, I’ve seemed to jump readily (and enthusiastically!) from the idea that I absolutely must get surgery to the idea that I absolutely must not get surgery, and then back again.

On the basis of this (and because it seems like a good way to distract myself), I’ve written you all a Platonic dialogue in which Socrates and I consider the ins and outs of having such a surgery. All the factual information here should be accurate, and most of it reflects things I have been told by various “experts”—my oncologist, my surgeon, Dr. Einhorn, an oncologist specializing in testicular cancer at Mayo, and a number of journal articles I found using PubMed and Google Scholar.

As of this moment, I’m currently leaning strongly toward not having the surgery, though I still have not broken this news to my oncologist (for some reason, the thought of doing so makes me very nervous). This means I won’t know for sure whether or not I am officially “in remission” for a while; however, it doesn’t mean much to my overall odds (basically, I have 10-20% chance of relapse within the first year, regardless of whether or not I have the surgery; I would just know sooner if I have the surgery compared to if I don’t).

The scene: Brendan is laying in his boxer shorts on the couch, eating baby carrots out of the bag and watching Camera Obscura videos (http://youtu.be/Who4OL08iR8) on YouTube. He dozes off, and suddenly finds himself sitting near a tree next to a small brook. Excitedly, he looks around for sad-looking (but fairly cute) Scottish girl-leader-singers-of-twee-bands, as he thinks this must be one of *those* dreams. Unfortunately, it isn’t, and he soon realizes that he has dreamt himself into a scene from the Phaedrus. He turns around and, sure enough, there sits Socrates, who looks sort of like a 70-year-old version of Matthew Kramer (i.e., short and sort of ugly).

 Socrates: Oh, good, Brendan, you’ve finally awoken. It looks like you dozed off in the middle of our dialogue. Can you remember what we talking about?

Brendan: Not really, though my bet is that it had something to with the terribleness of rhetoric and the awesomeness that is a life dedicated to philosophy. Actually, though, I was wondering if you could help me with a problem. I’ve been trying to decide all week whether or not I should have a bilateral pulmonary resection, and I’ve become very confused.

Socrates: I’ve never heard of that. Can you tell me more about it?

Brendan: Well, I just finished undergoing chemotherapy for metastatic testicular cancer, and my blood markers (LDH, AFP, and HCG) have all returned to normal levels. However, a CT scan of my lungs revealed two small (< 2 cm) masses on the outside of my left lung and one extremely small tumor on the right lung. These masses might be cancerous, or they might not be. The surgery would involve cutting me open, and taking all the masses out.

Socrates: What’s the point of doing the surgery?

Brendan: Well, my oncologist and surgeon told me that the only point was to check and see if the masses were cancerous. If they were cancerous, then I would need to get more chemotherapy. An oncologist from the Mayo Clinic told me that an additional goal of the surgery was to remove any teratoma (basically, nonmalignant tumor tissue which can grow and cause problems, or which can mutate back into active cancer), which is frequently found in residual masses.

Socrates: And how long would the surgery take?

Brendan: I think I would have to be in the hospital for about a week, give or take a few days. And then I’d have to spend another month or two recovering. I’d likely be fully recovered after three to four months.

Socrates: OK, I was just testing to see whether you knew what was going on. Obviously, I know all about bilateral pulmonary resections, have frequently observed them. Your description has jogged my memory, thought—it was only a matter of my recollecting.

Brendan: Hah hah, a joke about the theory of recollection. Was that really appropriate? Or funny?

Socrates: I thought so. So, what do you propose to do?

Brendan: I think I should get the surgery done, and have the masses resected.

Socrates: Why do you think that?

Brendan: My oncologist told me that this was the best plan.

Socrates: Did he give you any reason why?

Brendan: He said they might still be cancerous, and the only way of telling for sure was to completely take them out. His reasoning was as follows: (1) the masses are so small that a needle biopsy might miss them and (2) he wouldn’t want to start salvage (i.e., second-line) chemotherapy without ensuring that they were cancer.

Socrates: That reasoning seems a little suspicious to me, even though the conclusion might be right. I’ve never heard of anyone doing needle biopsies on any testicular cancer tumors, regardless of size. After all, such biopsies would risk spreading the cancer, and they would also leave any teratoma in your body, which would be one of the main reasons for doing the surgery. And since your blood markers are normal, I don’t think that any sane oncologist would think that you immediately need salvage chemotherapy (even in the absence of a biopsy), since it’s fairly unlikely that you actually have active cancer. Salvage chemotherapy would only be appropriate in the case that a recurrent cancer diagnosis was confirmed.

It sounds to me like your oncologist didn’t really understand what the point of doing this surgery really was and thus, didn’t explain it very well to you.

Brendan: Oh, OK. So maybe I shouldn’t have the surgery?

Socrates: I wouldn’t jump to that conclusion just yet. I think it’s likely that your oncologist got the conclusion (“complete resection of all remaining tumors”) from some sort of standard treatment protocol that was devised by a group of testicular cancer experts. The oncologist probably just didn’t know the reasons behind the protocol’s recommendations, and was trying to come up with his best guess when he was explaining it to you.

Brendan: Whew. So, I really can trust him. That’s good to hear.

Socrates: Well, the mere fact that your oncologist got his conclusion from some sort of standardized protocol doesn’t necessarily mean that it is correct. After all, standardized treatment protocols are designed to be used by knowledgeable experts capable of recognizing when the protocol’s recommendations don’t apply, or when they need to be modified. The fact that the oncologist didn’t seem to know the whys and wherefores makes me think that he might not know enough about testicular cancer (or its standard progression) to recognize cases in which the protocol might need to be modified.

Brendan: Socrates, I think you’re right about both things. My oncologist does seem to be following some sort of standardized treatment plan. However, he doesn’t seem especially knowledgeable about testicular cancer. Among other things, he has told me demonstrably incorrect things about (1) dosing schedules, (2) protocols for delaying doses based on white blood cells counts, (3) the evidence supporting BEP’s current dosing regimen, and lots of other stuff. Given all of this, I’m not really sure how seriously to take his advice any more, especially in cases where it seems like some interpretation of the treatment plan is required.

Socrates: OK, so let’s leave the oncologist aside for the moment. I heard you went to see the surgeon on Tuesday for a consult. What did he tell you?

Brendan: OK, so let’s leave the oncologist aside for the moment. When I went to see the surgeon on Tuesday, he told me that “it was a personal choice” whether to get the surgery, and that the statistical evidence couldn’t make this decision for me. He suggested that I could also wait until the results of my next CT scan.

Socrates: What do you think he meant when he said that the statistical evidence couldn’t make the decision for you?

Brendan: Well, at first I thought he was just talking nonsense—after all, surgeons and oncologists make almost of their treatment recommendations by applying statistical evidence to particular cases, and I’ve never heard them say that there was any issue with doing this. To make things more confusing, the surgeon also told me that, were the masses to have been much bigger than they were (e.g., if they were 1 cm, instead of 2 mm), surgery would definitely have been appropriate.

Socrates: So, the surgeon told you about a case in which he would have recommended surgery (presumably on the basis of statistical studies), and then quite noticeably failed to recommend it for your own case.

Brendan: Yes, that’s what’s seemed so weird to me. If he didn’t think the surgery was a good idea, why didn’t he just say so? And why all the weird talk about the importance of individual choice?

Socrates: Well, if the surgeon had directly told you that he thought the surgery was ill-advised, he would  have been directly contradicting the oncologist, which he (as a surgeon) really shouldn’t been doing, and might have gotten in trouble for.

Brendan: That makes sense. But then again, why trust a surgeon’s word on it? After all, isn’t the oncologist is supposed to be the expert?

Socrates: Well, the surgeon did make a number of concrete, factual claims that you can verify. For example, he did say that (1) bilateral pulmonary resection is fairly risky and (2) very small masses aren’t all that likely to be cancerous. You can check these things by using Pubmed and Google Scholar.

Brendan: [Spends a few hours on the computer:] OK, it sounds like the surgeon was right. For masses of these sizes, there’s only ~15% chance that they are cancerous, a ~40% chance they have teratoma, and ~55% chance they are necrosis (or dead scar tissue). The chances are not independent—i.e., it’s likely that either all of the tumors are cancerous, or that none is. So, the chance of cancer doesn’t go up (too much) just because I have three small tumors instead of a single small tumor.

 The surgery also sounds like it is fairly dangerous—there is a 13% chance of complications, including a non-negligible chance (1-2% chance) of death. So maybe the surgeon was right.

Socrates: Well, let’s consider this in a little more detail. So, what would the dangers be of waiting?

Brendan: It sounds like there are two sorts of things that the surgery is meant to do: (1) to diagnose whether there is any remaining cancer so that chemotherapy can be given and (2) to remove any large chunks of teratoma, on the off chance they might start growing and screw things up. A three-month really wouldn’t make much difference to the teratoma thing, since these grow relatively slowly. If cancer was found, it would allow for chemotherapy to get started right away.

Socrates: OK, so it sounds like the three month wait probably wouldn’t make much difference. But why wait at all? After all, it’s perfectly possible that you’ll eventually have to do this surgery later on, especially if any of the masses increase in size. And doing it now would give you the best chance of catching any cancer early on.

Brendan: Yes, that’s right—it’s perfectly possible I’ll have to do this surgery later on, even though I’m choosing to do it now. However, it’s also possible that the masses will shrink away, and I won’t have to do it. Plus, I’m not sure I would want to do a surgery of this scale at Carle hospital; if I wait, I might be able to do this at Mayo, where they have specialists dedicated to doing this sort of surgery.

Socrates: OK, so you’ve talked to the surgeon. What is your feeling about getting the surgery?

Brendan: I think that I should definitely not have it.

Socrates: Given the gravity of the situation, I’m not sure that it is a good idea to stop here. So far, you’ve only talked to an oncologist of debatable competence and a surgeon, who doesn’t even claim to be competent at medical oncology, regardless of how much he might know about the surgery in question. Is there anyone else you can ask?

Brendan: I guess I can e-mail the people at Indiana University and Mayo Clinic, which are the two nearest cancer research centers. There’s no guarantee that they will e-mail me back, though. After all, MDs are notoriously wary of disagreeing with a colleague, especially when they don’t have all of the diagnostic information in front of them.

Socrates: Well, that’s true, but the question you are asking isn’t really of diagnosis, right? I bet Indiana and Mayo have policies regarding when to resect tumors and when not to resect them. The oncologists wouldn’t be braking any rules of professional ethics by telling you what these policies are.

Brendan: It turns out you were right, Socrates. Both Mayo and IU responded quickly to my emails. Mayo was pretty cagey, but they suggested that they (as a matter of policy), always resect remaining masses for nonseminatomous germ cell tumors (the type of cancer I have; if I had seminatomous germ cell tumors, Mayo would not resect the masses). Unlike my oncologist, it seems like part of the reason for this was to get rid of teratoma. They didn’t comment on the surgical risk, however, which makes me wonder whether they might occasionally wait to resect.

Indiana University (in the form of Dr. Einhorn) was much more direct: he stated that IU would NEVER (the capital letters are his)  do  surgery in a case like mine, but would instead for future CT scans to see how the masses changed over time.

Socrates: OK, so it sounds like different places have different treatment guidelines. What do you know about your particular case that might make a difference?

Brendan: Well, it sounds like the fact that the remaining masses are small is a good thing, as small masses are significantly less likely to be cancerous than large ones. The fact that the tumors shrunk quite a bit during chemotherapy is also a good sign, and this makes it more likely that what remains is dead tissue [this is another issue my oncologist got backwards; he thought that tumor shrinkage made the case for removal stronger.] However, certain aspects of my case make it somewhat likely that the remaining masses contain teratoma: for example, my original tumor was 50% teratoma, and my LDH was fairly normal (so far as I can tell, this is relevant because it means that the tumor was growing somewhat slowly, which means there was a decent proportion of teratoma in it).

In any case, it seems like there is a decent chance (say, over 50%) that the remaining masses are necrotic, which means they are perfectly harmless. And if they aren’t necrotic, they are probably teratoma, which might (or might not) be harmless, but which could certainly be removed later if they started to grow and cause problems. There’s really only a 10-20% they are cancerous and, if they are, this will show up pretty quickly when my blood markers start rising or my CT scans show masses start increasing in size.

Socrates: OK, so it sounds like you have a relatively low risk of having cancer, when compared to the average person for whom these guidelines were formulated?  What do you know about  the surgery?

Brendan: The surgery is fairly high risk, especially when compared to the "typical" post-testicular-cancer surgeries, which often involve either (1) only the abdomen or (2) only a single lung. There's a fairly high risk of complications with the bilateral lung surgery, to the point where even the advocates of "cut out of everything" have been considering special protocols for this kind of surgery--i.e., there are recent studies on the possibility of doing one lung at a time, to minimize the risks involved with doing both lungs. I'm not sure any of these have caught on, but it definitely looks like this has been on peoples' minds.

Socrates: So, the surgery is fairly risky. Still, Mayo would probably recommend you do this surgery, even given the risks. Is there anything you can say in defense of you desire not to do the surgery right now?

Brendan: Hmm. I don't know. Carle's not Mayo?

Socrates: And why would that make a difference?

Brendan: There's lot of data showing the risk of surgical complications for a given procedure at a given hospital is inversely related to the frequency with which that procedure is performed at that hospital. So, Mayo (which performs a lot of these procedures) would likely have better success with them than Carle (which doesn't do a lot of these procedures). So, it's likely that doing this surgery at Carle might be more risky than the general statistics let on, and doing the surgery at Mayo would be less risky than the general statistics suggest.

Socrates: That's right. And from what we've established so far, it seems like the risks of undergoing this surgery at a place like IU or Mayo (which do lots of the surgeries) are, at best, evenly balanced with the benefits. When we factor in the fact that this surgery would be performed at a relatively small regional hospital, what does this do to the risk calculus?

Brendan: Since it's more risky to do the surgery than normal, it suggests that, in my particular case, it might be better to wait to do the surgery, at least until I have some indication of whether it is really needed. For example, I should certainly do the surgery if the masses started to increase in size. Until then, though, it might be best to wait and see.

Socrates: That seems like a reasonable conclusion, given everything we've said here. However, you do realize that you could be wrong, and that failing to do the surgery now might come back and bite you later. And, if this happens, it's likely that you oncologist will (perhaps nicely, perhaps not) remind you that he had recommended that you undergo this surgery.

Brendan: Yes, I know. That's part of what makes me so nervous about the whole thing. For some reason, I don't like the idea of a (1) having my cancer recur and (2) thinking that there is something I could have done to prevent this from happening.

Socrates: I can see how that would be a stressful experience, and it's certainly a possibility. However, you also need to remember that choosing to do surgery would carry similar risks. For example, it's perfectly possible that they could do the surgery, find nothing but necrosis, and that you nevertheless experience severe surgical complications. You'd probably feel pretty similarly in this case--you'd think "if only I'd chosen not to do the surgery." Of course, your oncologist would tell you that you did the right thing, but I'm not sure how much that sort of thing should really count for, given the sort of thing we are talking about. And it's not as if you are choosing contrary to what the evidence says--this really does seem to be a case in which the experts genuinely disagree on what ought to be done.

Brendan: I guess that's worth something, and I'll try to keep that in mind. I think it's getting a little cold out, though, and I'm getting a little tired. Should we head back to Athens?

Socrates: I think there's probably more to be said about this issue, but I agree that it's getting a little late in the afternoon, so maybe it's best to wrap and head home. I hear Camera Obscura is performing near the Parthenon tonight, and that there will be an aftershow party restricted to card-carrying philosophers. Maybe we can still get there in time if we leave now.

At this point, Brendan wakes up. He never does get to attend the afterparty, though he is fairly sure that it rocked.

(Some of the) Test Results

AN UPDATE: The HCG-testing-machine got fixed, and I got my results: <0.5, which is what I'd hoped to see. This doesn't necessarily mean that the lumps near my lungs are not cancerous, but it's a big step in the right direction. In any case, I think there is still reason for (cautious) optimism: it's more likely than not that the lumps are not cancerous (and thus, I wouldn't need any more chemotherapy) and, even if they are cancerous, the salvage chemotherapy would be likely to work. Bad HCG levels would have made both of these propositions more doubtful.

I just wanted to post a quick update about my test results, which were a mix of the (1) good, (2) bad, and (3) indeterminate.  Here goes:

• The good--the tumors in my abdomen are gone, and the tumors in my lungs are either reduced in size or gone. The CT scan showed no sign of disease progression and would be consistent with remission.
• The bad--there are three small residual masses on my lungs, which may be either scar tissue or residual cancer. Provided my HCG levels are not rising (see next point), this will most likely mean major surgery to resect these remaining masses, and test them for residual cancer. If there is residual cancer, I would undergo an additional two rounds of "salvage" chemotherapy. The surgery would likely be at Carle, and would likely take place sometime in the next two weeks or so. My guess is that I would be in the hospital for around a week, depending on how things go.
• The indeterminate--The HCG testing machine at Carle is broke, which means that I may not get these results until sometime Tuesday (because of the holiday weekend). If my levels are stable, there is a decent chance (I would guess over 60%, though its tough to find exact statistics) that the lung masses are not cancerous; if my HCG levels are rising, this would almost certainly be indicative of active cancer.

In any case, that's all I know for now. I'm doing OK, though am obviously a bit frustrated about the possibility of having to wait another four days to know anything more definite. I think Anne and I may head to the new YMCA to work out for a bit, but we should be around for most of the day. I hope everyone is doing well (and thanks so much for all the wonderful birthday cards and gifts!).

The Third Time is the Charm, Right?

..and this is the promised follow-up in which I describe my third  (and hopefully final) cycle of chemotherapy. There's nothing super-exciting to report since my last post, really, and you can scroll to the end if you just want to know the plan for what's to come. Here goes:

Some awesome embroidery by Becky O'Donoghue. 

Anne and Kramer Have a Birthday (Week 1)

Cycle 3 begins on Friday, April 20. Just as was the case with the last cycle, I get to spend Friday in the Cancer Center, the weekend in the hospital, and then head back to the Cancer Center for Monday and Tuesday. Friday  is more or less routine: I go early for tests, eat breakfast in the cafeteria, meet with the oncologist, and then spend around six hours getting chemo (day 1 is the only day when I get all three chemotherapy drugs, and is thus the longest day).

My meeting with the oncologist is more or less routine. My blood chemistry (e.g., iron and hemoglobin levels, white cell counts, etc.) is pretty much OK, and there's nothing particularly alarming about my cancer markers, although I find myself worrying a bit about them anyways. My HCG levels are up to 2 (from 0), but this isn't statistically significant, and anything under 5 is considered perfectly normal. My LDH levels are 260, which is not normal, but this could be (and probably is) due to the fact that Neulasta shot I got made my bone marrow go a bit crazy with the whole making-new-blood-cells thing, and the elevated LDH levels are reflecting this (I've read somewhere that, if they are really concerned, there's some way of doing a cell-specific-LDH test, but I'm guessing this is fairly costly).

Chemotherapy is also more-or-less routine: they hook me up to a bag of saline, give me my pre-meds (steroids, Tylenol, antinausea drugs, Benadryl), then give bleomycin, cisplatin, and etoposide. I talk to the nurses some, who I've gotten to know fairly well (Mary just got back from Italy and Leslie has gotten accepted to the Nurse Practitioner program at the U of I). The stronger steroid I get with cisplatin keeps from sleeping all afternoon, though, which is nice, because Friday, April 20, is Anne's and Kramer's (and also Hitler's) birthday!


At Eric's behest, Kate and Graham host a party for Anne and Kramer, and I manage to make it until around 10:00, which I'm pretty impressed with. We have some pinto beans and corn bread along with some brownies and chocolate cake (vegan and otherwise) and various other accoutrements (can you believe that I spelled accoutrements on only the second try?). Around 8:00, a group walks downtown to see a friend's art opening, but I'm a bit too tired to walk the half-mile, and some people hang out with me and watch YouTube videos.

Anne and I spend the weekend days in the hospital, where I get chemotherapy. There's a new (well, new to me) nurse who I am a bit leery of--she doesn't seem to know how to use the anesthetic spray that they often use before sticking a needle in my sport, and she only gives me half as much saline with my cisplatin as is normal. Nothing horrible happens, though, and we (along with my parents, who come down to visit) are back to the Cancer Center on Monday and Tuesday.

I spend the rest of the week laying around the house and feeling icky, mostly. Along with my traditional symptoms (insomnia at night from steroids,  fatigue during the days, and a continual feeling of not-quite-nausea), I have two new ones: planter fasciitis in my left foot, and pain in two of my teeth (one of the right of my mouth and one of the left side) whenever I chew. This makes walking and eating more unpleasant than normal, and I am a bit cranky for the rest of the week.

Illinois Marathon! Ebertfest! Philosophy Grad Conference! (Week 2)

OK, so the title of this section is a little misleading. I watch Anne and Kate run the 10K on Saturday morning, I walk by the Ebertfest (for those who don't know, Roger Ebert grew up in CU and hosts a film festival at the Virginia Theater every April) on Saturday and Sunday afternoon, and I am just too damn tired to go to the philosophy graduate conference happening this weekend. And while the week is mostly notable for all the things that I'd rather be doing, it really isn't that bad, all things considered.

When I go in to get bleomycin on Friday, I get to meet with a different oncologist than normal -- a mid-50s-ish, very talkative German American. I tell him about my lower extremity problems (by now, my achilles is acting up as well), and he makes me walk around on my toes and heels, checking for signs of peripheral neuropathy (cisplatin can damage your nervous system, though it's fairly uncommon when it's not given in super-high doses). In 15 minutes, I think he tells me more about testicular cancer than my normal oncologist has in the last three months: (1) how Dr. Einhorn developed the BEP regimen in the late 1970S, (2) what the relapse rate is (around 10% the first year,  5% the second year, and then really low after that), and (3) what sort of long-term side effects I can expect (e.g., bleomycin-induced lung scarring often takes a few months post-chemotherapy to clear up).

After chemotherapy, I go home and sleep for most of the day, then get up on Saturday morning to watch Anne and Kate run by at around 7:30 with a group of friends. (If I remember right, Anne runs a 1:07 and Kate runs 1:10). We eat doughnuts in the morning, then go to the Esquire for a  postrace lunch, and then home for a nap. I take my first bike ride in the afternoon (and even wear a helmet!) and Anne and I have pizza and watch Waiting for Superman in the evening. I actually thought the movie was actually OK, given what I'd heard about it, though the stuff on teacher's unions was a bit over the top.

The rest of the week is a bit of a blur; I'm back at work from Monday through Thursday, but I'm still feeling a bit beat up. My workload is very light: I look at a few ebooks to make sure they match the print books, run some word counts on manuscripts that are about to be transmitted to editorial, and check the accuracy of some simple math in a biomechanics textbook By now, I've taken to kinesiotaping both my plantar fascia and my Achilles tendon, on the grounds that every tendon in my left foot feels like its about to tear. I go for a few short bike rides around the neighborhood (just to be able to keep moving), but don't do too much else.

I Drink Beer, Watch TV, and Call People from MetLife (Week 3)

On Friday, May 4, I get bleomycin, and for some reason can't quite bring myself to tell my fellow chemo ward patients "This is my last dose!" I think I'm afraid that I'll jinx if I say anything out loud, though. The bleomycin session itself goes pretty much as normal (i.e., I'm half asleep through most of it), though I over one of the older patients talking to his wife about his now-terminal diagnosis, and I'm not sure what to say (we've occasionally chatted, though I find that I can't remember his name). We talk a little before I leave, and I wish him good luck, but I wish that there were something kinder and more empathetic I could have said (and the bleomycin-brain fog was certainly not helping).

On Saturday, I go to the hospital in the afternoon for my Neulasta shot and am pleasantly surprised when my insurance picks up the whole tab (apparently, I have now hit my annual $2,600 max, and won't need to pay any more for in-network services). Afterwards, Anne and I go out to Seven Saints for dinner, and I have the "Seven Saints Platter," which is basically a big bruschetta type appetizer, with toasts and pitas accompanied by little bowls of olive tapenade, hummus, and a traditional tomato topping. Afterwards, we go to Boltini so Anne and Kate can have girly drinks. I have my first full beer since chemo started, but it's quite as great as I expected (the beer's some sort of underhopped summer beer, and I'm still a bit nauseous). It feels like a milestone nevertheless.

I feel pretty beat during the week that follows--the tendons in my left foot are still sore, my teeth still hurt, and I feel generally sore and wiped out. My guess is that this is a combination of (1) the cumulative effects of three months of chemotherapy and (2) the Neulasta shot, which has a half-life of well over a day, and which always makes me feel a bit crappy. In any case, I'm glad that I don't have to start cycle 4 at the end of the week (if I'd had a "poor" or "fair" prognosis, instead of a "good" one, I would have been given 4 cycles of BEP instead of only 3).


On Wednesday morning, Anne takes the train to Minnesota, where she'll be hanging out and having fun with her family (and Liz and Joe, too!) until the next Tuesday. I spend the remainder of the week working, biking, and watching the second series of the BBC show Sherlock. Oh, and I also get to call MetLife nearly every day, since I've discovered its just about impossible to get my claim for long-term disability filed. When I fax them paperwork, they lose it; when they fax the hospital, the hospital loses it; when I try to return their calls, no one ever answers, and then they e-mail human resources at HK saying things like "we tried to get a hold of him but couldn't." (As of this moment, I still haven't gotten any money from them, even though I filed my claim on April 2, which is the day I was eligible). It's a bit frustrating, to say the least.

One Week Out

Cycle 3 officially ends on Friday, May 11, and (barring bad test results) I have completed all of the chemotherapy I will need. By Monday, I'm feeling well enough to use elliptical machine at work, and to go for 5-6 miles outside on my bike. (I'd tried on the elliptical machine a few times last week, too, but was not terribly successful in these attempts). Anne gets back from Minnesota on Tuesday night, and we hang out with Kramer (on Wednesday) and Kate and Graham (on Thursday). I'm feeling fairly social, and find that I'm to the point where food (and even beer) have begun to seem appetizing again. 

I'm still coughing a bit, but mostly in the morning and evening; I don't notice that I have any real difficulty breathing. Likewise, my teeth and left foot are still somewhat bothersome, but are nowhere near as annoying as they were during the previous two weeks. I even have some fuzz developing on top of my head, though I still haven't needed to shave (I haven't shaved since chemotherapy started).

A week from today, on Friday, May 25, I will find out the results of the chemotherapy (based on a CT scan on Tuesday and tests of blood markers on Friday morning). As I've written before, there are three possible outcomes, in decreasing order of probability and desirability: (1) complete remission; (2) blood markers are fine but CT scan shows partial remnants of tumor (this would mean major surgery, but would still be more likely to indicate remission than active cancer);or (3) either blood markers are not fine, CT scan shows tumors of increasing size; or both. I don't know what would happen in the third case, but I'd be likely to undergo additional chemotherapy.

(April was not) The Cruelest Month

OK, so I haven't blogged for quite a while, and I thought it was a time for a "Here's what's going on with Brendan"-type post. The (very) short version of the story is as follows: (a) I'm all done with chemo (woo-hoo!) but (b) I won't know if the chemo worked until May 25. I've been a little under the weather (even compared to what's been normal), but I'm looking forward to starting to feel better soon.

In any case, here's the story of cycle 2 (which covers basically the first two-thirds of April). I'll try to get the stuff on cycle 3 up in a few days.

Cycle 1: A Recap

I started my first cycle of chemotherapy on Monday, February 27th. My chemotherapy regimen consisted of bleomycin (B), etoposide (E), and cisplatin (P for "platinum") Each cycle was supposed to last 21 days—5 days on (BEP day 1, then EP days 1-4), 2 days off,1 day on (B only), 6 days off, 1 day on (B only), 6 days of—and then the next cycle was going to start on day 22. It didn’t quite work out the way, which I’ve written a bit about earlier. I made it through the first two weeks fine, but ended up having to wait ten days for the final dose of bleomycin, on account of my white cell counts being super low. In cycles two and three, I received the Neulasta (a longer lasting and much more expensive version of Neupogen, which is what I was given toward the end of cycle 1).

As far as setbacks go, a 10 day delay really wasn’t too bad, and it’s certainly was something I was willing to live with. If I could go back and do it over again, though, I’d be a bit more assertive with my physician (in asking for Neupogen, or in directing him to give my bleomycin even when my white counts were low). Live and learn, I guess. So far as I can tell, tinkering with the dosing regimens on BEP therapy has some effects on its effectiveness, but not overwhelmingly huge ones—for example, studies have found that doing things like deleting bleomycin or stopping after two cycles lowered cure rates by 5-10%. So, while I don’t think the ten day delay was optimal, I don’t think was a disaster, since I’m at least still receiving all the drugs. In any case, my HCG level dropped to 0 by the end of cycle 1, which means that there has been at least partial response to the chemotherapy.

When I started chemotherapy in February, I had two symptoms—sore nipples and a productive cough. The nipple soreness (which was due to elevated HCG levels) went away toward the end of cycle 1, while the coughing has stayed with me, though it has gotten quite a bit better (and for all I know, might be caused by something entirely different than my pre-chemotherapy coughing).  I’m still not quite sure what to think about the cough—it could be caused by active cancer cells, by dead cancer cells, by bleomycin-induced lung scarring, or by some infection (perhaps initially caused by the cancer) that my weakened immune system just  can’t get rid of. Whatever it is, I’ll have to wait for the CT scan to know for sure, and even then they’ll probably have to do a biopsy if they see anything in my lungs. CT scans, unfortunately, can’t tell the difference between dead tumors, live tumors, and certain types of pneumonia.

Cycle 2: Week One

 I start cycle 2 of chemotherapy on Friday, Mar 30th, and ended up going Fri-Tues (instead of Mon-Fri). This requires that I be admitted as an outpatient to the hospital oncology ward for Saturday and Sunday. The ward is small, windowless, and a bit gloomy looking. If you imagine a typical regional hospital ward built in the mid-60s, you’ve probably got the right idea. The nurse who administers chemo is very friendly and talkative, though, and she doesn't even mind when we filled up the ward to capacity with visitors (thanks to Anne S, Anne R, Kate, Graham, Liz, Rachel, and Steve!).

I don’t  accomplish much over the weekend, with the possible exception of watching a lot of college basketball. I’ve entered in two tournament pools and am poised to win money if either Ohio State ($150) or Kansas ($50) win the tournament. Obviously, things don't work out too well for me, and every team I root for loses: Louisville against Kentucky, Ohio State against Kansas, and Kansas against Kentucky. Oh well. Anne and I go to see The Hunger Games on Sunday, which I think was pretty good, though not outstanding. I imagine just about everyone on earth has seen this movie by now, so I’m not sure what else to say about the movie. I didn’t think books two and three quite lived up to the promise of book one, so I’ll be interested to see how those work as movies. Oh, and Jennifer Lawrence (the lead actress) is absolutely phenomenal in Winter’s Bone. So, you should all see that, if you haven’t already.

On Monday and Tuesday, I am back in the Cancer Center in the south clinic. My mom comes to visit for Monday and Tuesday, and we have a good time.  Chemotherapy (which runs Fri-Tues during the first week of each cycle) goes fairly well. On Wednesday, I get my first white-blood-cell-boosting Neulasta shot, which costs  $738 (well, it actually costs five times this much, but my insurance covers 80%). The shots end up doing their job, though, and I don't have to delay chemotherapy again.

I take Wednesday and Thursday off from work, and spend most of my time watching Ken Burn’s Civil War, which I really like. I sometimes find Shelby Foote (a nonacademic historian who features prominently in the series) a bit annoying, though. For example, he likes to say things like “Abraham Lincoln and Nathan Bedford Forrest were the two great geniuses of the Civil War.” Really? I guess Forrest was good at strategy, but so were lots of other people—Grant, Sherman, Lee, and Stonewall Jackson, just to name a few. And Forrest was an absolutely terrible human being, even when judged against his contemporaries—he had a policy of executing black soldiers after they surrendered and helped found the Ku Klux Klan, among other things. I know they still think he’s a hero in Tennessee, but he seems to me like he’s a whole lot closer to Joseph Goebells  than to Erwin Rommel. The postwar U.S. government would have been perfectly justified in having him tried and executed as a war criminal, had they decided to do so. And Shelby Foote doesn’t help things by comparing him to Lincoln. Just sayin.

Cycle 2: Week 2

On Friday, I go in for my bleomycin dose, which is fairly uneventful (basically, I just sit around and then go to sleep--see the next section for more details). I find out that the Neulasta is doing its job, and that I have approximately 10 times as many neutrophils as an ordinary person has (and, therefore, around 500 times as many as I'd had toward the middle of cycle 1, when my white cell counts were in the toilet.)

The rest of the week is really a high point, at least in terms of how I feel. Greg and Laura are in town with their baby boy, Nathan, for the weekend, and we get together with them both Saturday and Sunday. On Saturday, we have lunch at the Esquire; on Sunday, we have Easter lunch with a group of friends at Adriana and Eduardo's house (being the weirdo that I am, I bring Boca spicy chicken patties, and focus my energy on eating the vegan-friendly side dishes, which are all wonderful.)

I go back to work from Mon-Thurs, and think that I am fairly productive, all things considered. Anne and I have a pretty fun week, too. We watch Your Highness with Kramer (which is absolutely terrible), go to eat with Kate and Graham at Dublin O'Neil's with Kate and Graham (which has the best "English-style" fish and chips in town, even if it can't compete with the Seaboat) and go shopping and out to Fazoli's on Wednesday.

The discouraging aspect of this week is that it marks the beginning of an absolutely terrible 2012 baseball season. The Twins lose 4 of their first 6, which turns out to be a pretty accurate prediction for how the succeeding weeks will go (they are currently 8-22, and behind by 5 runs to Toronto at home). The Brewers win 4 of their first 6, but 3 of these wins are against the Cubs, so it's tough to know what to think (they are current 13-18). At this point, I'm still holding out hope. (By the time of this writing, I'm mentally preparing myself for another postseason of rooting for the Cardinals, if for no other reason than that it annoys the Cub fans to no end.)

Cycle 2: Week 3

Just like week 2, week 3 starts on a bleomycin day, which means that it basically consists of the following routine: 

• Check in at 7:00. Sit around for a half hour. 
• Blood test from 7:30-7:35. They leave an IV line dangling from the port in my chest. (On occasion, I've forgotten it was there and have gotten some strange looks in coffee shops...)
• Waste time from 7:35-9:00. I always spend this time having a "second breakfast" in the hospital cafeteria, which is actually pretty good.
• Meet with my oncologist from 9:00-9:15. In these sorts of meetings, we basically just look at my blood counts, which I've learned to interpret fairly well. On this particular day, my white blood cell counts sort of sucks, and we decide I should get a Neulasta shot in the hospital on Saturday.
• Sit around in the chemo area from 9:15-9:45.
• Get hooked up to "pre-meds" at around 9:45. For bleo days, this includes saline, a steroid, Benadryl, and Tylenol.
• The Benadryl always puts me immediately to sleep, and I usually am not fully awake until six hours later.At around 10:30, a nurse pushes bleomycin through a syringe into my IV. This takes around 10 minutes. 
• Go home at 11:00 and sleep until 4:00.

When I get up at 4:00, I help Anne clean the house in preparation for her parents' arrival. (Actually, I might be making up the part about me helping with the cleaning. I mostly remember that cleaning was being done, and that I was awake...)  They arrive around 6:00, and brought us all sorts of goodies from Trader Joe's. We decide to have Seaboat for dinner, which (as I've noted in a previous post) is pretty awesome.

On Saturday, Anne and I get up and go for a run in the rain, and then meet up with her parents. The four of us go to the hospital to get my Neulasta shot administered. Due to a whacky provision in my health insurance (which won't cover the use of the exact same shot when it is provided by the hospital pharmacy), we have to stop at Walgreens along the way to purchase the shot. Everything goes fine, though, and we're in and out in less than 30 minutes.  We have a good time hanging out for the rest of the day, and went downtown to celebrate Anne's birthday. I'm feeling a little queasy in the evening, though, so I have to duck out on Anne's birthday meal at Boltini.

The rest of the week is pretty quiet, at least as far as cancer related-stuff is concerned. While I don't feel absolutely terrible (which I will by next week), I also don't feel nearly as well as I did during week 2. I'm at work Mon-Thurs, though I usually only make it through about half the day before going home. On Wednesday, Anne, Rachel, Kramer, and I go out for Anne's birthday dinner at Red Lobster (courtesy of Grandma Feck); on Thursday (Anne's actual birthday), I stay home while the girls go out dancing until late.
On Friday morning, cycle 3 starts.

Opinions Like Kittens: Philosopical Thoughts on Cancer Treatment

Like most cancer patients, I’ve found that treatment has definitely been a learning process. While most of these learning experiences have been on a personal level, I think this whole experience has also made me take a lot of issues in health care ethics (and philosophy more generally) more seriously than I had before (which is somewhat ironic, because I used to teach health care ethics). In any case, here’s ten things I think I think about philosophy, science, health care ethics, and cancer. I promise this will be my only “traditional” blog post, in which I make unsupported arguments about substantive matters of fact supported by nothing but my own intuition (no sources here, because I’m just too lazy :)). Many of you probably know more about these things than I do, but I just thought I’d give my two cents (and, as a semi-professional philosopher, I’m pretty OK with being told that I’m wrong):

1. The treatment of TC was a success story in the history of medicine, and this has implications for philosophy of science. In 1975, metastatic testicular cancer had a 5-year survival rate of around 10%; these days, it’s closer to 90%. The pioneering work was all done by Dr. Einhorn at Indiana University, who has continued to be the world’s leading expert on testicular cancer (he treated Lance Armstrong, and is still the head of the testes cancer group at IU). Plus, he responded to a question I e-mailed him within two hours! A little more on that question later, though. Even since the early 80s (when the current treatment regimen was more or less fixed) things have really improved—e.g., the combination of steroids and antinausea drugs (e.g., Zofran) have decreased the average frequency of vomiting from 12/day to 0/day. In most cases, BEP patients actually gain weight, though that hasn’t been the experience in my case. So, the success of BEP chemotheraphy is evidence of favor of what I might call “who cares about the mechanism?” view of scientific methodology—we do science by throwing random chemicals in vats (or grow bacteria, etc.), throw the resulting mixtures at malignant tumors, and hope like hell something works.
2. The attempt to extend the “principles” behind the treatment of TC to the treatment of other solid tumors was not a success story in the history of medicine, and this has lessons for philosophy of science, too. The 1980s were filled with thousands of trials of various combinations of chemotoxic drugs for every imaginable type of solid tumor (breast, lung, colon). At best, these trials led to treatments that were moderately more successful than what had been the case; at worst, the trials subjected patients to fairly terrible side effects for little or no benefit. It turns out that TC is simply a bad analogue for most other cancers, for the same reason that it’s so reason that it’s (relatively) easy to treat – cells from the testicles are pretty easy to kill when compared to just about every type of cell. Radiation kills them; so do the three drugs used in BEP (bleomycin, etoposide, cisplatin). Independently, each method is capable of killing a large proportion of TC cells, though not enough to prevent a quick relapse. Together, though, they kill enough to sustain a cure in a majority of cases. If nothing else, I think TC is a good reminder that cancer isn’t a monolithic entity, and that research done on individual treatments on individual cancers may have little or no applicability to the treatment of other cancers. So, maybe the treatment of TC (which didn’t require much focus on the underlying mechanisms of the cancer) is more of anomaly than a paradigm-shifting case.
3. There is a big disconnect between actual cancer research and the public perception of cancer research, particularly concerning the relationship between cancer and particular food choices. After spending much of the last month of Google Scholar, PubMed, and NCI website, it looks to me like we have some evidence that various foods—fruit juices, refined sugars, red meats, green tea, soy products, coffee, chocolate,  etc.—do something to the evolution and growth of specific types of cancer cells during specific stages of growth, but it looks we don’t have any great evidence concerning what they do, to which types of cancer cells, or about how these things might interact with things like chemotherapy. For example, it seems plausible that antioxidants might prevent the sort of cell damage that leads to the development of cancerous cells; however, it also seems plausible that these things might serve to protect cells from cytotoxic chemotherapy and/or accelerate the growth of malignant tumors (even in the absence of chemotherapy). In general, it looks to me like all of this research is pretty equivocal, and that there’s actually very little to be said beside “eat a balanced diet” or something similarly innocuous. In general, I think it’s unfortunate that so many talk shows and cancer books make it seem like there is some magical bullet cancer cure figure-out-able out through common sense and ordinary observation, and that research oncologists are somehow overlooking these potential treatments. I think there’s a lesson for philosophy of science buried here somewhere. Way too often, introductory courses in philosophy tend to focus on theories that obviously aren’t scientific (like astrology), rather than on theories that overreach their scientific underpinnings (cancer diets, the autism vaccine hullaballoo, and so on).
4.  We do know at least two magical bullets when it comes to cancer prevention: don’t smoke and exercise at least 150/minutes weekly. Also, political libertarians are wrong. The studies concerning both smoking and exercise are pretty unequivocal, and the effect size is massive. Again, I’m not sure what the general lesson is here, but I think that policy-making entities need to start thinking of physical inactivity in the same way they started thinking about smoking during the 1980s—as a massive public health problem that needs to be primarily addressed at a policy level, and not at a personal level. (I feel like I’m reciting the intro to about a dozen Human Kinetics books here…). These sorts of issues always seem to me like case studies in why undiluted political libertarianism (of the Ron Paul variety) makes no sense, at least from a results-matter point of view. After all, if libertarians had gotten their way on smoking (and the government hadn’t “interfered” through various taxes and punitive measure against smoking), people in the U.S. would, on average, have lost something 2-3 years of life expectancy (and probably considerably more in terms of disability-free-life-years). Smoking and physical inactivity are good examples of the sorts of behaviors that (1) we have very good evidence are massively harmful and (2) we have equally good evidence that lots of people will continue to engage in these behaviors if left to their own devices.
5.  I think cancer and chemotherapy provide a good model of evolution via natural selection. Sixty years of clinical trials have shown that relapsed cancers show a much higher resistance to the cytotoxic drugs with which they were initially treated. The explanation for this is that these cells are the direct descendants of a very select group of the initial cancer cells—i.e., the cells that had mutations allowing them to survive first-round chemotherapy. Cancer cells, in general, show very high genetic variability, and they also mutate and reproduce very quickly. In this sense, they provide a succinct model for the evolutionary process, including parts of the story that are often overlooked. So, for example, I think cancer cells nicely illustrate Darwin’s point about the success of invasive species. If organisms (or cells, in this case) were designed to flourish in their chosen environments (as Darwin’s creationist opponents held), we shouldn’t see them being beaten out by invasive species that weren’t designed for these environments. But in cancer (as in many other places in nature), this is precisely what happens—cells from another part of the body end up being much, much more successful than the cells that were “supposed” to live there. This isn’t good for the person with cancer (or for the containing ecosystem, in the case of invasive species), of course, but that’s something worth emphasizing, too—evolution isn’t “directed” toward any specific end, even if it sometimes useful to talk about it as if it were.
6.  There is something worrisome about the whole “general practitioner as gatekeeper to people who actually know what they are talking about” model of health care. This is one thing U.S.-style HMOs and European-style centralized systems share, and my medical history has left me with mixed feelings about it (though I’ve no idea what the alternative would be). I could go into a ton of horror stories from my past regarding bad recommendations I’ve received from MDs about cardiac arrhythmias, insomnia, lower-extremity tendonapathies, and so on. My most recent complaint is that my (general-purpose, though very friendly) oncologist seems to be only vaguely aware of the specifics of the BEP protocol—he consistently misdescribes the timings of various doses, forgets to prescribe secondary drugs unless I repeatedly ask, and so on. More seriously, he recently delayed treatment for 11 days (and suggested delaying 14 days) on account of low neutrophils, which I am now convinced is a significant misunderstanding of the BEP protocol (I e-mailed Dr. Einhorn to ask about this, and he confirmed my suspicion). I understand that, as a matter of practicality and cost, specialists cannot direct the treatment of every individual patient. However, I do think there is a role for a significantly increased use of computer systems that would guide general practitioners on what the current, evidence-based treatment recommendations are for various conditions. I also think that GPs should be required to consult with relevant subject-matter experts within their research group, in any case where they are dealing with conditions with which they are unfamiliar. I know that some of these things probably *are* requirements, but I never seem to see used effectively in action. In any case, given the technological resources available to us, I think that relying even a moderate amount on MDs’ quickly outdated medical-school education is a poor way of determining proper treatment for uncommon conditions. The fact that cures rates for solid tumors are significantly higher at research centers than at smaller, regional hospitals is a personal concern of mine, and I don’t entirely buy the explanation that this difference is due to different sorts of patients seen at these locations.
7. There are lots of reasons, good and bad, that health care in the U.S. is so expensive. Carle has billed my insurance company around $60,000 so far, and I expect the 5-year total (the length of cancer surveillance, should I make it all the way through) will be close to $150,000. So why is all of this so expensive? Here’s a list of five things that I (perhaps somewhat unjustifiably) blame my health care costs on, in order from least to most annoying:
1.  We’re getting better at treating certain sorts of illness, and treating these sorts of conditions costs a ton of money. Treating solid tumor cancers and chronic heart conditions in particular requires lots of technology, lots of hours from medical staff, and so on. I don’t really think there is any great solution to this, though, and this is a problem for any health care system (and not just the U.S. one). From my point of view, of course, this is a perfectly worthwhile use of health care dollars J.
2.  U.S. physicians earn a lot more than their international peers do, and a lot more than people with similar educational backgrounds in the U.S. do. This is true even when one accounts for the high price of medical school, the underpaid internships, the long hours worked, and the price of malpractice insurance. This doesn’t bother me a ton, since I think the added cost here is pretty negligible when compared to other factors (and it does help us attract a lot of talented foreign doctors, many of whom have been involved in my treatment), but it does bother me whenever I hear physicians trying to provide some sort of “moral” defense for their astronomical salaries. I accept that this is the way life is, but I don’t think this means it ought to be that way. I think centralized health-care system do somewhat better than the U.S. in this regard, since the government is in a better position to influence physicians’ salaries (whether or not it directly pays them).
3.  We don’t ration health care dollars effectively. There are all sorts of reasons for this—doctors who provide unnecessary treatments on a “pay per treatment” basis, insurance plans and/or HMOs willing to commit millions of dollars of treatment toward the care of patients with little hope of recovery, physicians who choose less effective, but more conservative treatments to avoid “blame” (or lawsuits!) for adopting more effective, but higher risk treatments, and so on. I think the U.K. is moving in the right direction on this, with a governmental standards board setting guidelines for treatment based on expected cost/life-year-saved. Like it or not, we have limited health care resources, and the current U.S. private/public system is not terribly effective at spending these dollars where they do the most good. (There are exceptions , of course: both the VA and Medicare achieve much better cost : outcome ratios than do private health plans. Mayo Clinic is a good example of a private institution that seems to do many of these things right.).  
4.  Insurance companies might only make 5% profits, but they’ve been spending 15% trying to decide whom to deny coverage to. This is obviously an inefficient way of spending of health care money, which everyone (right-wing politicians, left-wing politicians, insurance company executives, and so on) acknowledged from around 1972 until 2008, when it became the centerpiece of Obama’s health care plan. I have my suspicions about the specific form the individual mandate took (in that it requires payments to non-governmental, for-profit entities), but there’s no way of addressing this source of inefficiency without some sort of governmental mandate. If the current one ends up being ruled unconstitutional (while I hope that it is not, I do have some sympathy for those think it might be, since I don’t think political expediency implies constitutionality), I think there are other versions which could easily pass Constitutional, commerce-clause muster (e.g., national health insurance on the Canadian model) if we could somehow find the political will to make them happen. I’m already worried about what the insurance company will try to bill me for (my current worst-case scenario includes all the treatment I’ve gotten while admitted to the hospital over the weekend, which I’ve heard horror stories about). I don’t necessarily blame insurance companies for this; after all, they have absolutely no reason to want to spend 15% of their money denying coverage. The problem is almost entirely one of bad governmental policy, and it seems to be unique to the U.S. (since nearly every other developed nation has some sort of mandate, though none of them allow private insurers to profit off of it).
5. Pharmaceutical companies make nearly 20% profits, and they make them largely on the backs of U.S. consumers, since we pay way more for drugs than nearly everyone else in the world does. The money these companies do spend on research tends to be on “me-too” drugs of marginal efficacy (second-generation anti-depressants, statins, etc.), and even this research is (in effect) heavily subsidized by public research universities and teaching hospitals, who pay to train the staff, employ the researchers when they are not doing drug-company research, and so on. Unlike all the other categories above, I don’t really have much nice to say here (especially given the amount of money I’ve paid for drugs like Neupogen). The U.S. model of health care encourages this sort of bad behavior by (1) refusing to allow the government (by far the largest purchaser of drugs) to bargain for lower drug prices, (2) granting large numbers of patents to drugs of debatable utility (e.g., if there is already a drug on the market that does the same thing, or if the research supporting the drug’s effectiveness is equivocal), and (3) allowing drug patents to last too long. Again, I don’t see this as a problem of “those greedy drug companies"; the problem is largely one of ineffective government policies.
8. It’s surprisingly difficult to adjust beliefs to the actual evidence—it’s much easier to be too optimistic or too pessimistic. I think I said and/or wrote this before, but I’ve found it very difficult to adapt myself to the idea of having a 85% chance (or 90% chance, or whatever) of being alive in 5 years. Instead, I spend about 85-90% of the time assuming I will be fine, and then am convinced 10-15% something will go terribly wrong. As far as I can tell, this is pretty typical for cancer patients, but I still wish I could do a bit better. It seems like there were certain things I would make it a point to do (Write a memoir? Prepare a living will? Take up playing the piano? Learn to hit a decent two-handed backhand?) if I could just convince myself that there was a realistic, though fairly improbable, chance that something bad could happen. Constantly believing that either the best will happen or the worst will doesn’t really goad one on to useful action, though. The formal epistemologist in me (who likes to represent degrees of beliefs with numbers from 0 to 1) wonders how to represent these sorts of whacky belief states.
9.  So far, I’ve found that cancer has served to reinforce most of my most deeply held beliefs, instead of causing me to revise them. Before this whole thing started, I’d spent a fair amount of time writing and teaching about issues in health care ethics, the philosophy of science, the philosophy of religion, and so on. So far, I’ve found that my personal experience with cancer has tended to reinforce things I already thought, with the biggest difference being that I’m much more cranky when I assert them (though this might be a product of the nausea and fatigue). I have no idea of this is typical, but my guess is that it can’t be too uncommon, even though deathbead conversion stories are undoubtedly make for better TV. Confirmation bias (the tendency only notice the “evidence” that supports your pre-existing beliefs) is pretty universal among humans, and I think it’s especially common in stressful situations. This all being said, the whole experience has been valuable to me in terms of making me realize all the things I’ve really liked about my life so far (mostly the people, but the books, sports, and traveling weren’t too bad either) and the things I’d really like to do when I get done with all of this (have children, write a book, get back into teaching someday).
10. In general, I think people are pretty decent. I’d like to think I’ve always had a fairly positive view of other people, but I think having cancer has definitely reinforced for me how fundamentally decent most people are. All of my family and friends have been wonderful (thanks, everyone!), and so has just about everyone else with whom I’ve the opportunity to interact—medical staff, other cancer patients, coworkers, etc. In any case, this last point probably isn’t a terribly philosophical one, but it seemed worth saying.

Eating, Waiting

 So week two is finished, with some good things and not some not-so-good things. The good thing is that I weathered the first cisplatin dose pretty well in terms of nausea and fatigue, to the point where I almost feel healthy as I write this. The bad thing is that, according to my blood counts today, my white cell cell counts are too low for me to get cisplatin next week, so everything from here on out has to be pushed back a week. My absolute white cell count was about 1,320/ul (where it should be >4,000) and my absolute neutrophil count, which is the part of the white cell count that really matters for infection fighting, was 370/ul (where it should be >1,300). This last number puts me at a "very high" risk of infection, so it makes sense to delay the treatment. Some of my other counts (hemoglobin, red cells, platelets, protein) were marginal, but none of these would have delayed my treatment, since it looks like they could have recovered in time for next week. In any case, the counts as a whole make it clear that, however well I'm feeling, my bone marrow has taken a beating from the cisplatin and hasn't quite bounced back yet.

This isn't "oh my gosh, that's terrible news", since the protocol has been designed to account for it (it allows for either 21 or 28 day cycles), but it's not what I wanted to hear, either, since (1) the optimal cycle is 21 days and not 28 and (2) this means I'm at an elevated risk for serious infection, so I'll need to be extra careful. This will also extend the time in which I'll be in treatment, obviously. It doesn't necessarily mean that the next cycle will be 28 days as well, but this is certainly a possibility. In any case, my white blood cell counts should start to rebound by next Monday, since the usual nadir for these counts is around the middle  of the 21-day cycle (with today being day 15). If my counts haven't bounced back up by next week, they can also give me some (very expensive, but covered by insurance) shots to boost them, but the oncologist didn't seem to think that this was called for in my case.

He also didn't give me special advice about diet or exercise (I asked), but said to try and avoid sick people. This sort of advice seems to be the way things are moving--apparently the special "neutropenic diets" that used to be an absolute rule (no fast food, no raw vegetables, no yogurt, etc.) have recently come under attack as being ill supported by the evidence. Everything I've read suggests that it is important to make sure I'm extra careful to follow all food safety guidelines, though (clean cooking surfaces, properly cook food, throw out old leftovers, and don't eat any place sketchy).

 In other news, I still have most of my hair, though my beard has begun shedding, and I will probably have to shave it off within the next day or two. The only other reminder to me that I have cancer (beyond the port sticking out of my chest, and the scar on my lower abdomen) are my nipples, which continue to be a bit tender on the account of the betaHCG my tumors are producing. 

Recap of Week 2

The week started off a bit rough, and I was really wiped out (and bit nauseous) for the first few days after my bleomycin dose on Monday, but I've felt progressively better all week. By Thursday and Friday, I could almost pass for normal, except for the occasional odd ringing in my ears and the fact that every half hour or so I'll have a moment when I feel a bit off-kilter, and am reminded that I'm still pretty beat up physically. The steroids from last week are finally out of my system, and on Thursday I slept a full eight hours for the first time since chemo started.

On the Monday after week 1 (day 8), my blood counts were basically fine in all the important ways--both white and red cell counts were normal, hemoglobin and blood sugar were OK, and there weren't any signs of worrisome infections (though I've started coughing stuff up again after my immunosuppressing steroids wore off). The only exception were my potassium levels, which were a bit lower than what they should have been. The oncologist told me that this was probably from the cisplatin, though my bet would be the huge amounts of fluid that I'd been drinking for the previous week had probably exacerbated this as well (though I've been instructed to keep it up, which is what I plan on doing).

I've also learned to manage my nausea medicine a bit better, and have been relying almost exclusively on the ondansetron, which I take every morning and occasional evenings. Both subjective experience and internet research have told me that this drug is more effective, and less likely to cause unpleasant side effects, than the prochlorperazine. The nausea got progressively better throughout the week, and Sunday morning was the first day I could get through without any pills whatsoever.

I felt pretty well the last few days, especially when compared to the week and a half that preceded them. Restaurants no longer sound disgusting, my run on Sunday felt almost normal, and I managed to write a 4,000-word article (though I'm not sure how confident I am that what I wrote makes sense). I thought I would devote this week's post to my cancer diet, since this week has been pretty good for eating, and I'm not sure how long I can expect this to continue, especially given the white blood cell counts. So, without further ado, here are some of the food-related highlights from week so far:

Beans, Beans, Beans!

The staple of my diet think week has been beans, as it is in almost every week. For those who don't know (though I'm guessing most of you do), I'm a vegan-except-for-hunted-and-fished-things-who-sometimes-cheats-by-eating-cookies-and-pancakes. My reasons are moral ones, but I'm very nonevangelical (so, it's perfectly OK if you eat a large steak with a side of bacon in front of me; I used to love both steak and bacon.). In any case, since I think most animals raised on factory farms probably live unhappy lives and I don't think there any health benefits to eating animal products, I usually don't. I've got no problem with using animal products I do need (my running shoes have leather uppers) or with using medicine tested on animals (I sincerely hope they did some sort of testing on all of these drugs they are feeding me...). The doctors seemed fine with me continuing to eat more or less as I always have.

In any case, I've had lots of good bean dishes this week, and especially on Sunday and Monday. For lunch Sunday, I had some leftover black-bean-and-pumpkin soup my mom and Anne had made on Saturday. On Sunday evening, Kate and Graham had I Anne and I over for dinner. We had some excellent pinto beans and vegan cornbread, and then some Hershey's dark chocolate for desert. Then, on Monday, we had some excellent bean-and-vegetable soup that Tara had brought over for us, together with some leftover bread (from Mom) and cornbread (from Kate). And, of course, some cookies, since I have now taken to having deserts after every meal, including breakfast.

On Monday night, Anne made vegetable stuffed tofu with mushrooms, cabbage, tofu, and onion, which we had over brown rice.The food was great, but I was so zonked out from the benadryl they'd administered with bleomycin that I think I barely noticed the fact I was eating supper (the leftovers were tasty, though!). We also had some good baked beans and chili later in the week, though I won't bore you with the details.

Favorite bean dish: The misir wot (spicy lentils) at the Red Sea restaurant in Minneapolis, MN (it's on Cedar, across the street from Midwest Mountaineering). They are served (together with a bunch of other dishes) on a huge, spongy pancake called injera. On occasion, I've driven over an hour just to eat there.

Potassium-Loading at 6:00 AM

The big thing the oncologist told during my meeting with him on day 8 was to try and get some potassium. He mentioned bananas, vegetables, and Gatorade as possible sources. I bought some bananas and vegetables, but not the Gatorade, on the grounds that sports drinks are actually pretty poor sources of potassium (you'd have to drink about 50 servings to get a normal daily dose, and I needed to get *more* than an average daily dose). When I was working with developmentally disabled adults, I noticed that prescribing these sorts of drinks remains the standard practice for low potassium diagnoses,which I think is a pretty disappointing failure for evidence-based practice (but a success for Gatorade marketing, I guess). In any case, I chose tomato juice as my liquid potassium source (it has 10 times as much as Gatorade!), and made a concerned effort to drink more soy milk. This worked well enough to get my potassium levels backed to normal, apparently, so I'll keep it up.

In any case, my breakfast this week was (almost without exception) a bowl of Grapenuts with soy milk, a banana, some tomato juice and, if I was still hungry, some bread and peanut butter. Soy milk aside, this reminds me a bit of breakfasts I had growing up, when Grapenuts and bananas were always a popular combo with me dad.  Today (Monday), I had second breakfast at the Carle Cafeteria, which consisted a bagel with peanut butter and some fried potatoes. I remember that this was the same breakfast I'd had every day during the spring semester of 2001, which was when Anne and I had just started dating. This time, though, I didn't have to share my potatoes :).

Favorite breakfast: I love breakfast restaurants, so it's tough to choose just one. Some highlights from my childhood include Mickey's Dairy Bar in Madison, where I've had some great (and very large) pancakes over the years, and the now-defunct Heckel's in Eau Claire, where my Mom would often go before school on Thursdays.

Brendan Cooking Italian

I tried cooking Italian-ish foods twice this week, with mixed success. On Tuesday, with potassium on my mind, I made baked flounder over tomato sauce with olives, which I served with smashed garlic potatoes. I thought the basic idea was OK, but the fish took longer than I expected to cook (we had to microwave it even after it had been in the oven for 20 minutes) and was still a touch fishy tasting even through the sauce (though neither Anne nor I thought it tasted at all spoiled).

Whenever I make a mistake cooking, I think of my sophomore year of college, which was the first year I'd really had to cook for myself. From the start, I was a pretty excited, passionate cook, but I distinctly recall some moments of questionable kitchen decision making, such as Lolo telling me "No, Brendan, the recipe said to add two cloves of garlic, not two bulbs" or my lighting the garlic bread on fire on Anne's and my second date (if I remember right, we ate it anyways).

On Saturday, we had Eric and Todd over for pizza and a game of Risk. I made a vegan pizza with seasoned vegetable protein (using sausage spices like onions, garlic, fennel, pepper, and vinegar), mushrooms, tomato sauce, and hummus. I then put cheese on half of it for Anne and Todd. I usually use a french bread recipe for the dough, and I thought everything turned out fairly well. In any case, it felt oddly reassuring to be able to accomplish the sort of ordinary task that has eluded me the last few weeks.

My greatest cooking success this week was probably a loaf of oatmeal raisin bread that I pieced together out of what was laying around the house:

3 cups flour
1 cup quick oats (I actually used instant, but I normally use quick)
1/2 cup maple syrup
1/3 cup raisins
1 1/2 cup warm water
2 tablespoons oil
3 teaspoons cinnamon
1 teaspoon salt
Bread yeast

Best pizza: Since I'm not a cheese eater, I rarely go out for pizza any more, though I have had some pretty decent cheese-less pizzas in the last few months. When I was young, I think every group I belonged to (soccer and boy scouts, in particular) met at Pizza del Re about once a month, and I've always had an affection for their (perhaps objectively somewhat mediocre) version of midwestern flat crusted pizza.

Fish and Chips

With my white blood cell counts being what they are, I'll probably minimize my takeout eating for at least a few weeks, regardless of whether or not it is technically "permissible" for me to eat this sort of stuff. And really, this isn't really a terrible thing, as it's easier to cook healthy, high-protein, high-potassium foods at home than it is to order them.

I did get to have some of my favorite takeout this week, though, in the form of Seaboat fish and french fries, which Rachel and Scott came over to eat with Anne and me on Wednesday. The Seaboat, which is more-or-less a South Chicago style neighborhood fish and chicken restaurant that has become of a C-U institution. When Anne I first came to town, it was located in one of the poorer neighborhood in north Urbana, but this didn't stop all sorts of people (students and professionals, especially) from driving to get food there. A few years ago, it moved to a new location near Hessell park, which works well for Anne and I (we often pick up food and go eat it in the park).

I have a number of good memories of fish-and-potatoes from over the years: fried bluegill at the Feck trailer, fish boils when visiting Door County, and countless fish-and-chips diners ordered at bars where this was closest thing to a "vegetable" on the menu.

Favorite Fish and Chips: I'd never really been a fan of fish and chips until I moved to Dublin. So, let's say Burdock's Fish and Chips (the Rathmines location, not the original one in City Centre). I think Seaboat could probably give them a run for their money, except for the whole not-being-next-to-the-ocean thing.

The Future

The next week will basically be one of waiting--making sure I eat well, exercise enough to get the bone marrow going (but not intensely enough to set me back), and avoid anything that looks likely to give me an infection (sick children, expired food). I'm going to try and go back to work on Wednesday through Friday, which will at least give me something to do. I have a feeling this week will probably be a long one, subjectively speaking, and it also means that I'll have to wait an additional week before finding out about my tumor markers, which is when I'll finally find out if the cisplatin has made an impact.

Sunday Morning Coming Down: Chemo Side Effects

So, I've finished the first week of my first cycle, and more importantly, I've finished my first heavy (i.e., cisplatin) week and think I've dealt with it pretty OK (still eating, exercising, not in the hospital, etc.). If the reports are true, days 6-7 are usually the low point of the cycle (at least in terms of fatigue and nausea), because this is time when cisplatin levels peak. The next few weeks will probably see my blood cell counts drop a bit (as blood cell production slows), and then hopefully rebound in time for day 1 of the next cycle.

Overall, this week hasn't been too terrible in terms of side effects, but I thought I would document my initial response to the loads of drugs that I've been taking. I've arranged this in the temporal order of my average day so far (so, if you run into me at 3:00 AM, you know what to expect...:) )

Thanks so much to everyone who gave me rides, stopped by the cancer center, or just checked in -- it's been a good time seeing everyone, and has certainly made the time pass faster.

12:00 AM: Steroid-Induced Insomnia

 The steroids that I've been getting every day before cisplatin help quite a bit with nausea, but they have the unfortunate side effect of making it a bit difficult to sleep. I've tried a variety of combos of sleeping drugs throughout the week (melatonin, Ambien, Ambien + Benadryl), with mixed success. I think I've done fairly OK so far, though, at least compared to some of the horror stories I've read on the internet. I had difficulty falling asleep the night I took only melatonin (but ended up sleeping a little later in the day), and have had difficulty staying asleep I've taken just the Ambien (I usually am up for the day by around 5:00 AM).  I've averaged between 4-6 hours of sleep a night so far, which is enough to be (barely) functional on, so I can't really complain.

As far I understand the treatment schedule, I should be off the steroids entirely from days 9-21, unless I encounter unexpected problems with nausea. So (hopefully) this sort of insomnia might really be a short term thing.

2:00 AM: Cisplatin, Kindeys, and Peeing!

Because of the large amounts of fluids I've been taking in, I don't think I've made it through a single night this week without having to get up and pee at least once or twice (which I never do normally). This plays a bit in to the insomnia, obviously, but I'm usually able to get back to sleep after my initial pee break.

I get a liter of saline every day with my cisplatin, and have also been told to drink an additional 2-3 quarts of clear liquids over the course of the day. This serves to protect my kidneys and bladder from the harsh effects of the cisplatin. Ideally (though I don't know how plausible this really is), this might also help reduce the chance I suffer some of the other negative cisplatin side effects, like hearing loss (the chance and degree of hearing loss is dose-dependent, and it's at least plausible that flushing a given dose of the drug in a timely manner will help alleviate these sorts of side effects).

I have to admit that I'm already a bit sick of drinking gobs of water, which doesn't taste quite the same as it is used to (and I'm sure that this will get worse). On a positive note, though, the cisplatin should be mostly out of my system by the end of next week, so this might also be a pretty short-lived side effect.

5:00 AM: Awake and a Little Nauseous

My nausea has gotten a little worse each day this week, which is what I had been led to expect. However, it hasn't really been enough to keep me from eating, and I usually can handle it by making sure to have some bread and liquid every two hours or so (if I start feeling nauseous, I usually try to eat something small fairly quickly). The nausea apparently has (at least) two causes: the cisplatin itself makes most people nauseous (this is actually the reason it's given over 5 days instead of in a single day), and the chemo regimen will eventually degrade the lining of my GI tract, which can also lead to nausea. So, the good news is that the nausea will most likely get better over the course of the next two (light, cisplatin-free) weeks; the bad news is that there will probably be some cumulative effect as well, with cycles 2 and 3 being a bit worse than this cycle has been.

The advice for nausea is to eat small portions of fairly bland, easily digestible foods (rice, pasta, toast, etc.), and to avoid eating things you really like when you aren't feeling well (so chemo doesn't ruin them for you for the rest of your life). Protein is all well and good, but fatty or super- spicy food can be bad. So far, I've found I prefer eating at home to eating out, both because I can decide what exactly I want to eat, and because I don't have to smell and see all the weird shit strangers in the restaurant are ordering or eating (which is strange for me, because I usually think everyone's food looks good, even it is something I never could or would eat).

In any case, I'm usually up by 5:00 AM and have a snack, but generally don't do much besides read newspapers and/or lay on the couch until Anne gets up 7:00.

9:00 AM: Fatigue, Exercise, Cancer, and Chemo

Fatigue can be caused by both chemotherapy and the underlying cancer, and is (along with nausea), the most common side effect for those undergoing chemotherapy. The main remedy for fatigue is (not surprisingly) physical activity, which can help boost energy levels, and maintain immune function. Weirdly enough, I've worked on several books on cancer and physical activity over the last few years, so this one of the few areas of the whole experience in which I really felt like I knew something.

The Department of Health and Human Services and the American College of Sports Medicine recommend that patients undergoing chemotherapy aim for the same exercise targets as normal adults (at least 150 minutes moderate-intensity aerobic exercise + 10 minutes resistance training twice weekly), with the big caveat that that you don't do anything to endanger your recovery, such as going to dirty, sweaty gyms; lifting heavy weights; or doing intense, long-duration workouts. My exercise has mostly been walking 30 minutes a day, with a few short jogging intervals thrown in every few days. I've also tried lifting 3 or 5 pound weights to maintain functional strength in my upper body, but I don't plan on doing on any sort of progressive resistance training beyond this.

The basic goals of exercise for chemo patients seem to be (1) avoiding massive loss of muscle mass and bone density, which can complicate treatment in all sorts of ways and (2) to maintain functional ability, which can help you feel better. Exercise is also linked to outcomes like less insomnia, less nausea, and prevention of diabetes-related complications (which the steroids and chemo can sometimes cause), all of which would certainly be nice. The first point is an especially important one -- I remember seeing studies that the muscle loss due to a single bout of cancer and chemotherapy can (in many cases) be the physiological equivalent of 10 years of normal aging. The chance of a late cancer relapse is also inversely related to physical fitness, with fit people being quite a bit less likely (up to 50% less likely) to have late relapse.

OK, so that's it for my evangelizing in favor of exercise. If you see me out waddling around West Side Park, though, now you know the back story.

11:00 AM Chemo and the Brain: Trying to Write

I've been trying all week (mostly unsuccessfully) to work on an article on Jeopardy and Philosophy for Open Court Press. I did get an outline mostly done, and my hope is that next week will be quite a bit easier, as I'll be on less drugs and, hopefully, able to sleep better. In any case, lots of people complain about "chemo brain" making it more difficult for them to work, and I can certainly see where they are coming from.

Cancer and chemo can make mental function difficult in all sorts of ways, and the effects seem to vary by individual. In my case, I think it's mostly been an attention-span thing: I simply find it a bit more difficult (though not impossible) to maintain focus on doing things like taking detailed notes, or making sure that I've included all my articles in the appropriate places (I have a long-standing habit of leaving words like "of" and "in" out of my sentences, and I can see this trend getting worse). I also find myself staring blankly at the screen for extended periods of time, though I've always had a habit of doing this.

A quick internet search on "chemo brain" gives me all sorts of theories based on the potentially neurotoxic effects of chemo, but I'm not sure how well established these really are (I don't see any great proposed mechanisms that would cause this, for one thing, since most chemo drugs don't pierce the blood-brain barrier in therapeutic doses). I'd also find it perfectly plausible (and preferable!) to think that chemo brain is due to the more obvious suspects (insomnia, malnutrition, stress, whacky antinausea drugs, etc.), which everyone already knows impact mental function, at least in the short term.

On the bright side, I have one of those "memory trainer" programs on my Android, though, and my scores don't seem to have gotten significantly worse than before I started treatment. So, I'm cautiously optimistic that I'll still be literate when this is all over.

12:00 PM: Lunch and Chemo

I usually feel a bit less nauseous after exercising, and eating lunch hasn't been too bad. My usual experience (at least so far) has been that food never sounds especially appetizing when I am thinking about it, but actually goes down OK. I've been eating lots of lightly seasoned rice, pasta, and bread, and have tried my best to throw in easily digestible proteins like tuna and tofu for every meal. My hope is that I can broaden my diet a bit on my two off weeks, but I'll just have to see how this goes.

On my heavy weeks, chemo starts at 9:00 AM on Monday and 1:00 PM on Tuesday through Friday. It usually lasts until about 5:00 PM, but this depends on what rate the nurse decides to set the saline to (I'm not sure quite sure how they decide this, and I'm not positive there is any hard and fast rule). The Carle Cancer Center is a brand new building on the south side of University Avenue, and I can usually be found in the main lounge, which consists of 20 or so recliners (in groups of 4), and a huge window looking north toward the hospital and north clinic. There are usually 5-6 patients at any time, most of whom are either visiting with guests, napping, or listening to music. I haven't really got a chance to talk to many of them yet, but I'm hoping that I eventually will (on Wednesday, there was an Amish/Mennonite party in the chair across from me, which for some reason had surprised me, but I suppose that it shouldn't have).

There is a team of around 8 RNs that staff the chemo center (1 male in training, plus 7 females who seem more experienced), and I've had positive experiences with all of them. When I first get there, a nurse will insert the line into my med port and hook me up to a bag of saline, which stays hooked up for the entirety of the afternoon. Then, I cycle through (1) a bag of antinausea drugs, (2) a bag of etoposide, and (3) a bag of cisplatin. Every time my drugs are changed, a team of two nurses will come by and confirm the name and birthdate on the bag, just to make sure all is on the up-and-up. My only worrisome experience this week concerned getting my antinausea drugs for the weekend, which took about eight requests on my part, and didn't actually get done until Friday at 6:00 PM (I could tell something had gone wrong, because the nurse had looked a bit befuddled as to why no one had ordered the drugs before this time). But, overall, I've had a really positive experience with the team at Carle.

6:00 PM: Nightcap

When I get home in the evening, I've found it a bit hard to stay focused -- the steroids keep me awake, and the chemo and other antinausea drugs make it difficult to be productive. Dinner is, by and large, very similar to lunch -- I'm never super excited to eat it, but neither have I had (so far) much problem keeping it down. So, mostly, I play around on the internet and read stories about college basketball (i.e., Illinois) and/or the Republican primaries (i.e., Rick Santorum), neither of which has really done me much good. Again, though, this seems more like an exacerbation of old, bad habits than anything created ex nihilo by cancer treatment.

Because of the steroids, I'm never really "ready" for bed, but I usually take some sort of sleeping aid at 10:30 or so, and will usually be asleep within an hour.

Next Week

Next week, I should (hopefully) only have to be at the Cancer Center tomorrow (Monday), then home the rest of the week. Tomorrow at 12:00, I'll get my blood drawn for a basic metabolic panel (iron, trigylcerides, blood cell counts, etc.), then meet with the oncologist, then get a round of bleomycin, then go home at 4:00 for the week. This is presuming my blood counts are all acceptable for me to go home, which I expect they will, based on how I am currently feeling.


As far as I know, they won't be checking for tumor markers tomorrow, though, so I still won't know how well the cisplatin is working. For this news, I'll have to wait until the beginning of cycle 2, which will be two weeks from Monday.