Flunking my Finals

 Last week was our toughest since last October. Our long series of clean MRI’s was broken, and that sent us into a difficult place emotionally. We feel better now, and ready to face whatever may lie ahead.

 

Anticipating the finish line has a strange effect on people. Examples are abundant, especially in the world of sports. Three great teams are virtually tied entering the final phase of the English premier league soccer seasons. Last weekend, inexplicably, two of them lost home games to lesser opponents. Alan Shearer wrote on the BBC website that you could almost hear panic setting in to the dressing rooms. That is the finish line effect.

 

More graphically, last year video emerged of a runner leading a marathon race into the final straight. Imagine running for 40km and then seeing the crowds and tape and banners ahead. But something affected this poor runner, and he took a weird right turn into a side street, to the consternation of the watching crowd. It is no surprise that several competitors passed him while he was on the wrong track.

 

I have experienced the effect many times myself, to the extent that I try to force my mind against distraction. Most commonly this used to occur during bridge tournaments, Competitors play for several hours, following a design enabling everyone to play the same hands but bot simultaneously. While the event is progressing, it is possible to roughly assess how you are performing, and I made quite an artform of this self-assessment. If I was playing in a prestigious tournament and felt that my partner and I were doing very well, a finish line might mysteriously appear in my head. Thoughts such as “Wow, we could win this thing” would enter my brain. Without fail this was a recipe for disaster. Results would immediately plummet. It happened time and time again. This was my own finish line effect.

 

Despite my best efforts, the finish line effect kicked in during the weeks leading up to our visit to my oncologist last week. He had been so (cautiously) optimistic for so many months. I had completed cycle twelve of chemo, offering the delicious prospect of being moved into a monitoring phase. The scans had been clean for over a year. I felt very well, perhaps better than I did before I had cancer. Exciting summer plans were ready to be finalised. Workers had already started upgrading work in our Portuguese villa, anticipating our permanent arrival later in the year.

 

The finish line beckoned. Just reading the last few entries in this blog would offer the warning clarion call. Due warnings were always posted about being ready for what could come at any time and about the tendency of this cancer to return quickly, but the general tone betrayed some expectation of longer good health. All this stuff about second chancers and Key Moments of Truth and alternative therapies gives me away. I could not help myself.   

 

So it is no surprise that reality hit us with a thud last week. The oncologist remains optimistic, but found something in the latest scan that he wanted to monitor. I was to undergo a PET scan in early May, and in the meantime, I would face a bonus round of chemo. It is like buying bagels, you pay for twelve and get thirteen (although nobody has yet offered us any discounts on cycle thirteen).

 

Even though the prognosis is highly uncertain, we were devastated to hear this news. We had come to the meeting with all sorts of questions regarding monitoring, and suddenly these were rendered moot. The finish line effect had done its worst. I am not superstitious enough to believe that we brought this negative outcome on ourselves, but we surely let undue positive thoughts lessen our preparedness for the bad news.

 

We bounced back. My wife had a fortunate day off on Wednesday, so we were able to spend quiet time together, at home and on a walk. By that evening we are fully prepared once more to face our futures and to continue our policy of openness to friends. The bonus chemo cycle is proving quite straightforward, and now our main task is to stay patient until May 14, when we will visit the oncologist again to learn what the PET scan will have revealed. We will be very anxious that day while we are sitting in his waiting room.

 

Apart from the emotional anxiety, which we have learned to live with most of the time, our challenge has always been choose an appropriate timescale for planning. During the worst months we were reduced to planning only a few weeks ahead, but our timescale gradually expanded over the last twelve months. We always reminded ourselves that things could go wrong at any time, but we have been actively planning for the possibility of prolonged good health.

 

Should this change now? We recognise that we may have to adjust our plans, but for now we are carrying on with our preparations. Perhaps as an act of defiance, we just booked all our flights for our June trip to Europe. The workers are busy in our villa, and the anticipated date for our permanent move is still late September or early October. It helps to be able to anticipate this exciting future, even if such thoughts are more tempered by nagging doubt than they were a week ago. We remind ourselves that nothing has fundamentally changed, at least for now, so our plans should be substantially unchanged too.

 

We have been bitten by the finish line. The same thing will probably happen again. I am not sure if there is a way of avoiding the effect. We could have forced ourselves to think negatively, but only at the cost of much joy over recent months. We kid ourselves that we could have been more ready for the setback last week, but I don’t think human nature works like that.  Finish lines screw us up, and we just have to put up with it, and bounce back as best we can.       

Key Moments of Truth

 In my later years at Shell, my division ran an internal campaign called Key Moments of Truth. It was a rather nebulous thing and I’m not sure it was very effective. The idea was that we would all keep our minds aware of the potential to change the course of events for the better, either by grabbing an opportunity or mitigating a risk. Such moments come along at unsuspected times, and, after a training course and some workshops, we are supposed to be a little better at identifying them and then responding appropriately. I suspect that most of us carried on with our lives much as before, blissfully unaware of what we were missing, but at least the campaign gave us a good corridor slogan for a while. 

 

This concept came back to my mind recently while pondering the course of my cancer journey, within the context of celebrating what seems to be an unusually positive outcome so far. How did this happen? Were there some Key Moments of Truth along the way? Did I spot them at the time or only in retrospect? Might I be missing Key Moments of Truth at this very time, doming me to a worse outcome than would have been possible with a stronger response?

 

It turned out to be quite a simple matter of identifying three distinct Key Moments of Truth, all of them occurring during the second half of 2022. Each case has its own hero, and in each situation that hero chose a path that ultimately led to a benign outcome. If any of these three situations had been handled differently, I suspect that I would be dead by now, instead of sitting here in a state of quite good health wasting my time writing nonsense.

 

I am the hero in the first Key Moment. Indeed, this time was the only one in my entire journey where I feel I had any real choice of action. My good fortune was to notice a marginal change in my vision, and my heroic action was to trot off to an ophthalmologist to try to confirm what was happening and to discover what was wrong. Now that I Look back, I wonder if my left sided peripheral vision might have been deteriorating for months or even years, but I became of various indicators during July and August 2022. I undertook a long night drive home in poor conditions from the Washington DC area, and I seemed to find the trip more difficult than before. Then I started noticing that I was making mistakes with my reading, seeming to miss or mis-guess the left-hand word of a column. Finally, I spotted that I needed replay to clarify what had just happened while watching sport on TV. How had that goal happened? Was that really a strikeout? Suddenly watching all sports became like watching ice hockey had always been.

 

Initially I thought I was imaging my problem, and then I guessed it was something temporary in my left eye that would probably disappear in time. That inaction would have been my normal response, but something led me to the doctor this time. Perhaps I was lucky that it was mid-summer and I was a bit bored and fed up with air conditioning noise at home.

 

How smart that simple action proved to be. The ophthalmologist found nothing wrong with my eyes but was confused and credulous enough to consult his boss who suggested a field vision test. That test was mishandled but generated enough concern to refer me to a neuro-ophthalmologist. After I finally made it there in mid-October, it was a short process to identify the growing tumour in my brain. Another month of growth and I might have suffered a catastrophic seizure before diagnosis, and a month more growth might have made it too late to operate. Curtains. Kudos to me; perhaps I had learned something on that training course after all.

 

The hero of the second Key Moment was my wife. As soon as we found out that something was seriously wrong, she started hospital shopping. My wife is an excellent researcher and very persistent when pursuing a campaign, and in this situation, there was no stopping her. I was not much help. I find that Americans are generally too quick to find fault with hospitals, one of the traits that leads to a society with an unhealthy level of litigation. I remain sceptical that the differences in the quality of clinical care between hospitals are great, though the secondary aspects such as communication and pace are certainly evident.

 

The research of my wife led her to the doors of Memorial Sloan Kettering and her persistence led them to accept me as a patient. It is still not certain how much of a clinical difference this made, but what is clear is that my original hospital initially declared a reluctance to operate on my tumour, while MSK followed a path that led to surgery, and that surgery has surely prolonged my healthy life. Both hospitals spotted unusual features and initiated a series of diagnostic tests, and both would have the same courses of radiation therapy and chemotherapy to hand. Would they have relented and operated too once they had a clearer picture? We will never know for sure, but the intervention to admission at MSK certainly feels like a Key Moment of Truth. Any story with my wife as hero is a good one as far as I am concerned.

 

My third Key Moment also strays into the area of medical speculation. It concerns the surgery ultimately performed by Dr Brennan of MSK on December 22, 2022. Any brain surgery is sensitive, but this tumour was clearly in a dangerous location since the other hospital had expressed reluctance to operate at all. Despite the risks, Dr Brennan took a course that would be able to remove the entire tumour. Then his patient, me, made his life still more complicated by having a seizure on the operating table, and then followed that up with a second seizure.

 

Dr Brennan later told us that I had snapped an unbroken seventeen-year streak by having these seizures. It is speculation, but I like to think that I only suffered the seizures because he was working in a very marginal area of my brain. Then, when the seizures happened, is a seventeen-year streak a good thing or a bad thing? Perhaps prior experience would have been helpful. I am surely fortunate that his intensive training kicked in, he handled the complication, and then had the courage to complete the operation as planned, when surely a safer course would have been available to him. That safer course would surely have left more cancerous material in my brain, and, in all likelihood, that material would have been resistant to subsequent treatment, and by now be growing again and in the process of killing me.

 

I am aware that I cannot produce any decisive evidence to support this explanation of events, but it certainly feels credible. This third Key Moment of Truth has Dr Brennan as a hero, one who gave me a far greater chance of prolonged healthy life.

 

Three Key Moments of Truth, three different heroes, and an outcome at the extreme positive end of probabilities. I am a lucky boy indeed, no matter how long this reprieve eventually lasts. Have there been subsequent Key Moments of truth already, ones that I don’t yet see the significance of? It is possible, and it is likely that other Key Moments of truth lie ahead. I only hope that when they come my supporting cast rises to the occasion once again.

 

The Shell campaign surely has nothing whatsoever to do with these outcomes. But it helped me pass another rainy afternoon of reflection filled with awe and gratitude.