Wednesday, April 16, 2014

shit just got serious

Will I owe my life to President Obama and John Roberts?

Since roughly my 40th birthday, I've been feeling an increasing pressure to get a colonoscopy.  My family has a history with colon cancer on both sides.  My father had a polyp removed about 12 years ago, and on my mother's side, her mother and an aunt or two all ended up with colon cancer.  It actually took out my Nana, the first family death I dealt with at the age of 11.

So when Obamacare was implemented, I made it a priority to finally get a colonoscopy.  I thought it would be a wise precaution, given the family history.  But even though the family has a history, we don't have a history of early onset cancer.  So I was pretty much assuming I'd get a clean bill of health.  And when I met the GI specialist, he said that there was a 20% chance of finding something.

Well, we hit that 20%.  And three times, to boot.  Two polyps: one 9 mm and the other 5 mm in size.  Both were removed. Also, and most worrisome, there was a 25 mm "mass".  And, worse, the doctor didn't think that he got all of it when he removed it "piecemeal".  

So that's going on.

There's a lot to talk about here.  For starters, I've done a good amount of work in modelling cancer,  and in particular I know some of the genetics of colon cancer.  As cancers go, colon cancer is a softie, esp. if detected early.  It is predictable, but it's also dangerous.  It's not clear, from what I've been able to read so far, what percentage of polyps are pre-cancerous. What I learned when I first studied this issue in the late '90s, was that there's a well-known path along which genetic mutations cause a polyp, and then a second mutation or a chemical change triggers the transformation from polyp to cancerous mass.  I figure as a writing exercise I can talk about this a bit, going back to the model of Fearon and Vogelstein (1990).  Basically there are two types of genes involved: oncogenes and tumor suppressor genes.  Oncogenes are genes over-expressed in neoplasms.  (Neoplasm is a general term for a tissue undergoing uncontrolled growth.  Tumor is a word for a neoplasm in hard tissue [as opposed to, say, in the blood stream like leukemia].  There's a reason to use this language as opposed to the word 'cancer', which has a specific meaning in oncology. More vocabulary later.)  Anyway, oncogenes tend to be genes that do things like promote cell growth and division.  The other major category of genes related to neoplasms are "tumor suppressors".  They typically serve regulatory roles in the cell cycle, and their inactivation is often part of oncogenesis.

Anyway, colon cancer is one of the most common cancers, and one (along with breast cancer) most associated with a genetic basis.  First, let's recall that every* human (*let's concern ourselves with 46-chromosome humans for the moment) has two copies of each gene (except on the X- and Y- chromosomes).  What happens with cancers like colon cancer and breast cancer is that a person an be quite healthy with one mutated copy of said gene.  But where most people have some redundancy in the genome because of the second copy, a person with only one non-mutated allele is vulnerable to the process of mutation on the healthy gene. Every time a cell undergoes cell division, there's a chance of a miscopy of the gene.  And in tissues, like the large intestine, that undergo a lot of cell division throughout the life of a human, there's a good chance that a second mutation will knock out the second copy, thus leaving the cell without a functioning gene.  If this is an important tumor suppressor gene (like BRCA1 or BRCA2) this can lead to a neoplasm.

Anyway, there's a lot to talk about here, and there's also a psychological aspect to consider.  For the first 24 hours or so, I was in a state of emotional denial about this.  I've still got a large defense of denial, since the survival rates for early stage colon cancer is 95%, and that includes people of all ages and states of health.  As a younger person in otherwise good health, I'm reasonably confident that this can be dealt with.

The other "stages of grief" of Elisabeth Kübler-Ross are anger, bargaining, depression, and acceptance.  I tend to be prone to depression, so that's the one I'm keeping an eye on.  I've yet to feel anger, but that's largely because I still feel like this will be a minor issue with high likelihood.  There is some kind of bargaining going on in my mind.  Part of the result is a decision that blogging about this experience would be a good idea.  Clearly "acceptance" hasn't even entered my mind yet.  Nah, I'll probably stick with denial and bargaining for the time being.  

My siblings have suggested that I might feel fear.  Oddly, I don't - not really.  Again, part of that is that this is unlikely to be life threatening.  I am concerned, but that's far from fear.  Another is that, when it comes to fearing for my life, I have a history of being a complete idiot.  On 7/7/2007, when terrorists blew up four public transport vehicles in London, one of which was a bus that blew up 2-3 blocks from my office (and took out Poon's! Damn you, terrorists!) I wandered around Bloomsbury with my camera, hoping to find photographic subjects.  Some things naturally inspire fear: heights, drowning, and fire are all hard-wired fears (in my lay opinion).  Slowly developing genetic diseases are too abstract to fear in the same way.  

Anyhow, I should get the results of the pathology report by the end of the week, at which time we'll find out if either of the polyps or the "mass" (read "tumor") is benign, pre-cancerous, or cancerous.  I've spent some time on Pub Med looking for papers that might give me some odds here, but I haven't found any, and, in any case, knowing odds would only lead to a premature bias in my expectations which will be resolved conclusively soon enough.  The doctor's report says that my likely outcome is either a resection or a second colonoscopy in 3 months.  Right now I'm assuming I'll need a resection.  25 mm is bigger than it sounds (25 mm = 2.5 cm, which is roughly an inch).  When I told Papa Whispers about that, he immediately did the conversion  ("That's an inch") and noted that it's about the length of my thumb.  So, apparently, I've spent the last few years growing an extra thumb up my butt.

By way of comparison, the tumor that took out Pandora was the size of a baseball before it was discovered.  Also, I've been without any noticeable symptoms - no pain in the sides, no bloody stools, nada.  Mama Whispers M.D.'s main concern was that the mass was far enough from the anus that a normal resection could be done.  What one really doesn't want is a tumor at the anus, that requires a colostomy, and I think we know how revolting that possibility is.  That's not an issue here - the mass is 50 cm from the "anal verge".  That's plenty of distance.  

So, in any case, that's what's going on.  I think the worst case scenario would be if the mass had already spread to the lymph nodes, in which case I would need chemo.  But I'm hopeful that won't be the case.  But even if it were, my aunt Bonnie has survived multiple, multiple rounds of chemo.  Chemo isn't as scary as it used to be.  The field of oncology is light years beyond where it was back when I was 11 and it hit Nana.  

I'll provide an update on the weekend after I get the pathology report.

One final thing: big shout out to Landru, who provided me with transport for this appointment.  He's also promised a possible person for a 2nd opinion.  I also contacted my boss from my NCBI days, and he's suggested looking at Hopkins.  Obviously, Hopkins has one of the best medical programs on the planet, and the guys I mentioned above (Fearon and Vogelstein) work there.  If anything remotely tricky comes up, I'll probably be running to Hopkins.

Oh, and one final, final thing.  I don't want anybody saying "I'm sorry to hear the bad news."  That's just depressing.  Instead, just say "You're so good looking!" (a la Seinfeld) [Ilse is granted a waiver from that choice - exploding her brain would be fun and all, but then somebody would have to mop up the mess, and Landru might be cross with me after the giggling subsided.]

Seriously, the sister of a high school friend is dealing with an aggressive tumor in her brain.  This little butt plug ain' no thang.

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