Chronos Kairos and the Cottage.

Chronos Kairos and the Cottage.

 

Growing up in Northern Ontario, and working in Sudbury for many years, and now Kingston, I know a great number of people who have their own private heaven.  They call this heaven by different names – cottage, camp, cabin, etc. Of course there is work (heaven isn’t a place for lazy people) – fixing docks, clearing brush, cutting lawns, chopping wood, repairing screens – and there are some nuisances – mosquitoes, black flies, noisy boat neighbours, occasional bears, raccoons, mice, cold mornings etc. – but there is no denying that it is their private heaven :).  Just writing this post makes me smile because I can go there in my head 🙂 – calm lake…a sunset…a drink on the dock..a Sauna and jump in the lake….a rainy day with rain on the tin roof…

Yep, Heaven.  Ahhhhhh.

In my job, I always ask patients “What is most important to you, and what do you enjoy doing?”  Answers vary (I don’t keep a formal database) but often for importance: family, spouse, quality of life, religion, quantity of life, not being a burden.  Interestingly, I never (rarely) hear :my job, politics, the Blue Jays, the Maple Leafs, making money.  For ‘what do you enjoy doing?’, again “spending time with family, spending time with friends, travel, hunting, fishing, driving etc.

When I tease out the question a bit more – What does Quality of Life mean to you?  What quantity is important?  What do you mean ‘being a burden’?  – answers vary.  For some, quality means freedom from suffering – for others quality means ability to do everything fully independently, for others – quality means travel, cottaging, and “bucket listing”.  For Quantity, what is important and meaningful varies from person to person – it might be a few months, or some other preconceived time frame, or it might be ‘until a special day’ – a wedding, an anniversary, a granddaughters birth, Christmas, Summer Vacation etc.

The Greeks called these different concepts of time Chronos and Kairos – i.e. time measured by a unit such as days, weeks, months, years etc. is Chronos (and easy to measure).  Time as an experience is Kairos.  Going to the cottage, spending time on the lake, sitting under the stars on a summer night – these are Kairos.

 

Groundhog Day and Allergies – misadventures in bad news delivery.

Treating patients with cancer is not a funny business, but sometimes funny (odd) things happen.  Early on in my career I had a patient I was about to see with a very curable cancer.  I was suffering from seasonal allergies at the time, and entered the room with my eyes watering, blowing my nose, and looking like sh@t.  The patient also had her eyes watering, was blowing her nose, and looked like she was having a hard time.  In my self-absorbedness I asked her “Oh, do you have allergies too?”.  She looked at me like I was from Mars and said “No, Cancer”.  There was an awkward pause as I apologized, and then we both had a good laugh at my faux pas.  Not the icebreaker I generally use, but it did ease the tension and relaxed everybody…

One of my other memorable patients had a very bad cancer – pancreatic cancer, which he was going to die from at some point.  He was simple – picture Forrest Gump simple – and tolerated chemotherapy really well which held his disease at bay for several months with good quality of life.  However, everytime I saw him, we’d have the same conversation.  “Doc, I’m doing well, but be honest, pancreatic cancer isn’t good is it?  I’m probably going to die from this?”.  For the first few times, I answered him honestly – “I’m sorry, but yes this cancer will get worse at some point and you are very likely to die from this”.  He would then break down and cry unconsolably for the next five to ten minutes, and then suddenly stop, feel better, and be chipper and positive once again.  The amazing thing was that every four weeks when I saw him it was the same – it felt like Groundhog Day.

After the first several times, when I realized that this wasn’t a matter of repeating things so that he would eventually come to terms with it, I stopped answering him directly – in general I’m a doctor who when asked a direct question will give a direct answer.  However, with him, I didn’t think I was offering any therapeutic benefit by answering his question, and instead would redirect and give a political answer..  It probably didn’t affect him one way or another, but it saved me from the devastating feeling you get as a physician when your patient is devastated with bad news.

The point of this – rather extreme example – is that there is a widespread belief that oncologists don’t discuss prognosis with their patients, or that patients are somehow misinformed.  If this patient would have went to see another doctor – like an emergency room physician, there is no question that they would have said “No, I have no idea what’s going to happen”, and the ER doc would say “Damn oncologists, they never talk to their patients about prognosis”.

Lessons learned from hitting a tree with an ATV.

When I was starting my practice, a cousin of mine was diagnosed with brain cancer (glioblastoma).  Unfortunately, he passed away, but before he did he taught me (inadvertently) a valuable lesson when dealing with patients.

In cancer practice, it is fairly routine to tell patients with brain tumours (or other cancers that have spread to the brain) that they cannot and should not drive anymore.  Letters are sent to the MTO (in Ontario) to inform them of this restriction, and we hope the roads are a safer place because of it.  In many cases, it is the taking away of the license that upsets the patient more than the other thing we talk about… It’s one thing to be dying, and patients often accept this – it’s another to lose independence.. Breaking the bad news of “you can no longer drive” is something patients are often unprepared for, and often makes people angry.  I’m not overly religious – but it’s almost like people can accept ‘God’s Will’ when it comes to life and death, but accepting what seems like one more government intrusion limiting independence is another story…

Anyway, he had his license taken away, and then, on Thanksgiving weekend, he had an ATV accident at camp – although he had a few scrapes, there were no significant injuries –  Except, possibly, to the tree.

This made me realize is that there are a number of issues for patients in real life that we don’t always think of when related to life with cancer, and seeing patients in clinic.  While it is beyond the scope of this blog (or my expertise) to discuss sex, money, relationships, or religion, I will discuss fishing, hunting, camping and cottaging.  If I figure out how to set up a discussion board, I’d like readers input too.  How have you (or your loved one) managed a lung cancer diagnosis with your hobbies or passions?  Have you been able to do the things you’ve wanted to do?  Have you felt that you missed out on some of these?  How have you managed?  etc.

 

 

Immunotherapy and Jesus Christ Superstar

Life has many of those incidents that change your life.  In University I stumbled upon auditions for Jesus Christ Superstar and Chicago.  I got parts (chorus type), due to the fact that not many guys auditioned.  Afterwards, I tried writing and directing.  I wrote a play (musical) thereafter, which was really, really, bad.  (At least, so I was told by one person I showed it to, the other person I showed it to liked it, but I think she was just being nice.)

The play was a musical, where the main character had HIV.  It was part comedy, part drama, and  part informative science.  There were two separate stories intertwined- one was the main story ‘real life’, and the other was a story of cops, army, intelligence, foreign armies, and home-grown terrorists (which were supposed to represent CD8+ T cells, B cells, CD4+ T cells, bacteria and malignant cells respectively.)  HIV (which kills or inactivates CD4+ cells, essentially inactivating the bodies ability to respond appropriately) was like massive budget cuts…..  Anyway, it’s clear I made a good choice NOT trying to make it in theatre :).

Immunotherapy or vaccines or other modalities to turn the immune system on has been one of the most promising avenues for cancer treatment over the past couple of years, and with drugs being approved in lung cancer treatment – such as Opdivo (nivolumab), and Keytruda (pembrolizumab), there is hope that we are just beginning to unlock the potential of these drugs and this avenue of treatment.

Basically, some cancers appear to be able to grow – i.e. the ‘home grown terrorists’ that are cancer cells are allowed to expand – because they have found a way to turn off the immune response in the tumour -i.e. they’ve paid off the local cops.  If we give a drug that turns off this ability (i.e., we confiscate the cash/freeze the assets), then we might be able to make those lazy cops active again, and fight the cancer.  (if you a police office reading this, please don’t be offended).

The problem with these drugs – different drugs having different problems, is that sometimes we WANT the immune system to be turned off, and if we give a drug that makes the immune system more active (i.e. really stimulates the cops), and there is the possibility that they will not only fight the cancer, but also harass some of the local ‘good guys’ – such as the gut, skin, lungs etc.  So the drugs have potential side effects.

We are working on our patient information/education, as well as education for all of the people who might contact a lung cancer patient in terms of immunotherapy toxicities.  I promise I won’t try to make the education materials be in ‘musical theatre’ format.

 

Breaking Bad. News.

I recently listened to a podcast on ‘Breaking Bad’, where it was considered one of the best shows of the 21st century.  I have never watched an episode – mainly because I don’t like a show that reminds me of work.

No, I don’t deal/make crystal meth (the drugs I deal with are much more dangerous if you don’t use them right).  I do however deal with patients with lung cancer.  The main character in ‘Breaking Bad’ had incurable lung cancer, diagnosed in season 1, episode 1.  This was enough for me not to watch.  Breaking Bad lasted for 5 seasons.  The odds of a TV show making it 5 seasons is about 10%.

When I’m dealing with lung cancer patients, the vast majority are in Walter White’s situation – advanced and incurable.  With lung cancer, approximately 10% of patients are alive at 5 years.   With advanced and incurable, that number drops to about 5%.

At least several times per week, I meet with new patients who have lung cancer that has spread.

I approach each patient I see with similar questions – “What have you been told, and what information do you want to know?”.  The majority of patients say they want to know ‘it all’, others say “I don’t want to know any bad news, I just want to fight”.  When patients say “I want to know everything”, they are usually asking what the timelines are, and what’s going to happen (am I going to suffer?).

People ask me “Don’t you find oncology depressing, how do you handle it?” – to which I reply – gee, when I chose a career in oncology, I thought we cured everybody with lung cancer, way to ‘bait and switch’ me Mr. Career Path”…

Of course the news I give is depressing, and of course it’s emotional giving that type of news, but that’s the topic for another post.

If you want to know though, here is how that conversation often goes:

Patient:  “Yes doctor, I want to know timelines”.

Me:  “Ok, why do you want to know?  What will you do differently?”

Patient:”Well, I guess I want to know for my family, so I can make arrangements.  What’s going to happen to me?”

Me: “Ok.  Well, as Dan Quayle/Yogi Berra said “it’s difficult to make predictions – especially about the future”, so I don’t know exactly what is going to happen to you.  I can tell you a worst case scenario, a best case scenario, and a ‘most likely scenario’.  I can tell you if I had 100 identical people to you in a room, how long it would be before half of those people died, how long it would be expected before 10 of those people died, and how long it would be before 90 people had died.  What I can’t tell you is whether you are in the 10 who die early, the 50 who die by 8 months, or if you are around in the room after all others have left.  Plan your stuff, get your affairs in order (paperwork, relationships, letters etc.) in case things happen quickly, but hope for the best.”

 

Of course (and as expected), the conversation often goes this way, but I think sometimes patients just hear blah, blah, blah 8 months, blah blah blah and tune out.  I don’t take this as an offense – I think it’s common for people in doctors offices to only remember one or two things when they are given bad news.

Breaking bad.  I would have expected it to have lasted less than a year, but there it was, still pumping out quality in year 5.  (so I’m told, as I mentioned I never saw it…)

 

 

Flux Capacitors, Non-Initiation, and passing time in boats with invincible people.

  1. Non-Initiation

If I could get ahold of a ‘flux capacitor’, and go back in time with Michael J. Fox to the 1950’s, I would probably run around like and try to get the teenagers of the time not to start smoking. I’d enlist Doc Brown, Marty McFly, and Biff to help me get the message out (take those kids that are starting to smoke, get them in a headlock, and tap them on the head until they promise not to start).  Those kids who were teenagers in the 50’s to 70’s’s are the fifty to seventy year olds of today with lung cancer… I’d say “Don’t start!”

In the absence of a time-machine, the next best is just not to have teenagers start smoking. I’m pretty sure that between building a time machine, and having teenagers listen to sage advice from adults, that one is impossible –  I’m not sure which one.

On your fishing trip, if you have teenagers around, or even young adults who are old enough to make their own decision, but still young enough to feel invincible (be stupid), just don’t let them try cigarettes if they are available. If you are smoking around them (say in the boat), don’t let them have a drag, and maybe when you look at them you can put your cigarettes away for a bit.

Laws are put in place to stop teenagers from starting smoking, such as restricting sales of cigarettes, getting rid of flavoured “starter” cigarettes and cigarillos, and banning smoking at high schools (when I was young, there was an attempted ‘walk-out’/protest at the school as the teachers were allowed to smoke in the smoking staffroom, while students had to freeze outside – times have changed), which help, but laws are broken all the time.  Laws are also not in place for 18 yr olds or 22 yr olds, but they have all the features of an ideal target market for tobacco – they still think they are invincible, they don’t have alot of friends with lung problems, they need to fit in, and they want to look older.

Just don’t be a part of it.  Either don’t smoke in the boat (ideal), or if they ask for a smoke (because they had a couple of cigarettes when they were away at University and now want to show you that they are a real adult), tell them to Go Fish.

Good times, Bad times, Going half mad times – why people restart smoking.

The flip-side of quitting (cessation) is not re-starting (re-initiation). Re-starting smoking after quitting is common, especially in the first months, but even in the first few years.

The chemical ‘craving’ aspect is gone by this time, but the ‘memories’ of the enjoyment of cigarettes plus nostalgia may lead some people back to cigarettes.

There is no (or very little) information that I know of that is scientifically published on why people start smoking again after several month or years off, but in my experience – both with people I know who smoke and with patients – is that there are two main reasons –

  1. Stressful life events – death, divorce, illness, financial etc. etc., that leave people looking for any way to ‘calm their nerves’. What usually happens here is that they remember how smoking used to calm them down/ease their anxiety when they were smoking regularly, and try to apply the same thought process here.

 

Unfortunately, what they are remembering mostly is probably how smoking helped calm them down when they were having nicotine withdrawal etc. They will feel some stress relief with smoking (at a stressful time), and then if lucky they’ll quit again, if unlucky they are again hooked.

  1. Happy life events/Nostalgia

I personally remember when rock was young, and Susie and I had so much fun. Then I went downstairs and had a smoke, somebody spoke and then a man in a pickup truck nearly passed us by. We jumped right in, and the driver grinned, and he dropped us up the road. We looked at the swim, and we jumped right in (can you believe it!) not to mention fishin’ poles.

Ok, so maybe that wasn’t exactly what happened. I have a hard time sometimes separating real nostalgia from classic rock…, but nostalgia often occurs when fishing. There is quiet time, you are in nature (which hasn’t changed since you were a kid).  Things change in big ways and small- Berlin wall falls, waist gets bigger, smartphones invented, hair gets thinner, political parties change, ear hair grows etc. etc., but the river/lake/ocean is (relatively) timeless.  Going fishing is a way of connecting with the past, and is one of those “pause” moments in life.  What can happen however is that nostalgia can sometimes make people remember other things – smoking etc.  If not careful, people remember the ‘enjoyment’ of smoking, and may forget bad things – how hard it was to quit, the morning cough, the bad taste etc. etc.

 

Why is this important?  Well, if you start smoking on your fishing trip, then odds are you’ll keep smoking (hiding it from you spouse/partner for a few weeks, having a big fight, moving out, smoking more…..)   — ok, maybe that’s an embellishment.

It’s important because if you know that when you are in trouble, stressed, or in happy areas/nostalgic areas that lead to smoking, you can prepare for it.  Let your fishing friends/family know not to give you a cigarette if you ask.

Red Devils, Unexpected Bites, and Quitting smoking

  1. Red Devils and Quitting

I hated using a red-devil lure as a kid.  I thought it was the least effective lure – no Williams Warbler or Mepps Fly or Rapala.  It was a cheap knock off lure, and I didn’t catch anything with one.  It was the lure I used when I wanted to go use one that I wouldn’t care if I snagged it and lost it.

That is, until the biggest fish I ever caught as a kid – a 17 pound Northern Pike – decided it wanted to bite on my red devil lure.

Smoking cessation – the act of stopping smoking, is one of the hardest things some people do – others find it easy. The only truth about quitting smoking is that everyone is different. I have never actually smoked, so I don’t have the ability to speak directly about the quitting experience.

The most successful way to quit smoking is, for most people, a combination of medications and behavior change. Basically, medications can take away some of the short term physical effects of quitting, and treat the chemical dependence. Behaviour therapy is a way of making sure that you are aware of all of the cues that trigger you to smoke, and preparing you for them. – for some people, it’s when they speak on the phone, for others, it may be when they drive, or when they have a drink, or when they go out with friends. For people who are going out fishing, it may be when they are in a boat, or when they are waiting for the fish to bite, staring at their bobber/float.

Each time quitting brings people one time closer to quitting for good. Some people decide to quit once, and then stay quit, while the majority quit 3,4,5 or 6 times before quitting for good.

Something I often hear from patients is “I tried drug x before, quess it didn’t work because I’m still smoking!” or “I tried the patch, but it didn’t work” etc. etc. Quitting is difficult even with medications, and takes a mix of attitude, medications, and planning. If quitting didn’t work with drux x (Champix/Chantix, nicotine patches, Zyban etc.), it can still be tried again at a different time – they increase the chance of quitting, they don’t guarantee it. This would be like saying “I tried to catch a fish with a red devil before, but I didn’t catch any, therefore I’m never using it again…. It may be a perfectly good lure, but there needs to be technique, a good cast, some patience, and (most importantly) – fish. Things need to line up usually to catch a fish, just like things need to line up to quit smoking for good.

 

Cajun Man and 7 Ways to Reduce Death and Suffering from Lung Cancer

Adam Sandler had a character named Cajun man when he was with Saturday Night Live. When I think of the top ways of lowering death and suffering from Lung Cancer, I somehow develop a Cajun Man accent in my brain, and everything ends in “shun”, or, in a Cajun man accent, with “shone”, i.e. non-initiashone.  When looking at chest x-rays, one of the doctors I learned from developed a cajun man accent to teach me how to assess whether it was a ‘good’ x-ray – i.e. look for rotation, inspiration, and penetration – for some reason it was easier to remember when I pictured Adam Sandler saying it.

For lung cancer, the seven are:

1.  non-initiation (not starting smoking)

2. cessation (quitting)

3.  non-reinitiation (staying quit)

4.  detection (screening in some cases, early detection in others)

5.  operation (surgery is still the best treatment when it can be done)

6.  radiation (radiation can help cure some cancers, and help relieve suffering from others)

7.  medication (chemotherapy, immune therapy, pill therapy)

8.  palliation (helping patients live without suffering for as long as possible, and have a good death).

I’ll be spending a blog post on each of these, but will add in some camping/fishing posts too.

Why Fishing and Lung Cancer?

Fishing is one of the most popular outdoor pursuits in Canada, amongst both women and men. Personally, I don’t get fishing as much as I would like, but have fond memories of fishing trips with my family – (often on the May long weekend, a time when the weather often seemed more suited for ice-fishing in Northern Ontario, freezing my fingers and butt off…  thank god for warm gloves and long johns). Oddly, although fishing wasn’t a constant part of life, some of my most vivid memories of my father and his family are from fishing trips in Northern Ontario.

Currently, I treat patients predominantly with lung cancer. While fishing and lung cancer may seem to be very disparate, I often find myself hearing from patients about fishing.

It comes up in one of two ways – the first is when I ask patients what they enjoy doing, and the second is when I ask them what they are looking forward to. For many patients, they enjoy their cottage or camper, and getting outside to fish. Often, because they may be short of breath, or lack energy, or are afraid of falls, they lack the ability to do this activity. For some patients, going on their annual fishing trip with friends or family is a highlight of their year, and often something they are very disappointed if they can’t go for health reasons. Several times I’ve moved chemotherapy treatments for patients to accommodate safe travel or special life events, and moving or delaying treatments for the annual fishing trip is common.

Sadly, lung cancer is one of the most lethal cancers, and in fact causes more death from cancer than breast cancer, colon cancer, prostate and pancreas cancer combined. For patients who are diagnosed with localized disease, just over half are cured, while for those with disease that has spread, only 1 in 25 will live for five years. For patients diagnosed with lung cancer, over half will die within the year. For the patient going on their yearly fishing trip, there is a high chance that this will be his or her last trip.

One of the reasons that lung cancer continues to be such a lethal disease, is the lack of significant fund-raising, the lack of research money, and the lack of money to support and optimize screening programs. The reason for this lack of $$$ is complex (in some ways) and simple in others. The main reason is that lung cancer patients are often blamed – by themselves, and by others – for their disease. Everybody knows that smoking causes lung cancer, the majority of lung cancer patients smoke or have smoked, so therefore, why spend money on them?

People are, of course, entitled to their own opinion. However, there are a few facts that are relevant. The first, is that no-one ‘deserves’ lung cancer. People who currently smoke cigarettes, don’t do so because they are suicidal, they do so because they are addicted. I’m sure there are some ‘perfect’ people out there, who don’t smoke, don’t drink alcohol, are not overweight, drive at the speed limit, eat a perfectly healthy diet, get 8-10 hrs of sleep per night, have never had a sunburn, and are putting themselves at the very lowest risk of cancer possible, but the majority of us are living in glass houses if we feel this way. People who have an addiction to tobacco have one of the hardest addictions in the world to break – that does not mean they are deserving of the consequence of that addiction.

The second fact, is that the majority of lung cancer currently occurs not in current cigarette smokers, but in people who used to smoke and have now quit. Basically, while quitting smoking reduces the risk of lung cancer, there are many more ex-smokers than there are current smokers. So, the majority of lung cancers occur in people who may have quit smoking 5,10, or 15 yrs ago.

The third fact, that is surprising to some, is that lung cancer in never smokers is far more common than most realize. Whether it’s due to second-hand smoke, age, environmental or occupational risks, or other factors that we don’t know yet, lung cancer in never smokers currently accounts for 10-15% of lung cancers in North America. If non-smoking related lung cancer were considered a separate cancer, it would be one of the top 6 to 8 causes of cancer death.

 

Almost everyone I know knows someone who has been touched by lung cancer – either a family member, coworker, or friend…..or fishing buddy – given that 1 in 12 people will get lung cancer, this is not surprising.

 

This project – catchlungcancer.com, has three main purposes.

 

  1. Create a webpage where people can post their fish pictures   facebook.com/fishselfie
  2. Promote discussion, and allow people to remember those who had/have lung cancer (if you can post a picture of them fishing on the facebook page, then great!)
  3. Raise money for lung cancer screening and early detection – support and research.

 

Here is how it works:

 

  1. Catch Fish
  1. Take picture of fish and self and post the #fishselfie on the facebook page facebook.com/fishselfies
  1. Donate money.

Go to www.lungcancercanada.ca and hit the ‘donate now’ button. Donate what you feel comfortable with. You can do ‘a buck a pound’ (I don’t mind if you embellish a bit…), you can have a fishing contest with your friends, and the one who catches the largest fish everyone puts in a buck a pound, you can put in 5, you can put in $1000 per pound – it’s up to you. You can have people pledge your fish beforehand if you wish.

 

Hope you enjoy fishing this year, that you make some great memories, and that you take time to reflect on those who’ve fished before and have a smile.