Sing All Seven Verses

"Speaking to yourselves in psalms and hymns and spiritual songs, singing and making melody in your heart to the Lord" -Eph 5:19

Round 3 in Progress

Third infusion was yesterday, the pump is with me and comes off tomorrow afternoon. This time Pepcid and Benadryl were administered in the premeds, which somewhat mitigated the side effects (we assume) of oxaliplatin: Twitching eye muscles, difficulty thinking clearly, and difficulty speaking due to numb or paralyzed tongue (very funny to observers, I assume). There was much more drowsiness throughout infusion and especially into the evening this time. But as of 1:30 am today, I'm happy to report zero drowsiness! Christina credits this to a steroid in the premeds, and cautions not to make any important decisions, speak out of turn, or think anything is as important as I think it is (I may have added a couple of those myself, but that last one is definitely hers).

A good suggestion coming out of yesterday's visit was to use a different anti-nausea med Compazine rather than Zofran to avoid excessive constipation. The main side effects are slightly blurred vision (not too bad) and drowsiness, which I obviously am not susceptible to. 

More Details on Current and Future Treatment

The visit with the nurse practitioner prior to infusion yesterday was interesting. It included our care coordinator and the dietician, both of whom were not in the office during my last appointment with Dr. Yang two weeks ago, but were present in both the prior appointments. The most interesting thing to me was the NP's interpretation of why we would adapt chemo treatments as needed in the coming months. She explained that usually they drop oxaliplatin from the FOLFIRINOX regimen I am on because the neuropathy becomes more severe and prolonged (or even continuous) between infusions. I kind of need my hands to have a minimum of pain and cramping/paralysis, so this was useful information.

But it was also interesting that the NP and my care coordinator ignored and/or denied Dr. Yang's clear implication from prior appointments that he expects the tumors to become resistant to the current regimen, which will require a different regimen in the midterm future, and ultimately be unsuccessful anyway. Don't misunderstand me, the Great Physician is the one Who makes that call, not this physician. But no disrespect to Dr. Yang - he told me in the first appointment that he has seen miracles, but does not know how to cause them. So his predictions are completely fine with me - You all and I can worry about the miracle part with the Great Physician.

Another interesting point from yesterday was that the NP and care coordinator were surprised that Dr. Yang started with the FOLFIRINOX regimen in my case. Usually, they said, this is done only for advanced pancreatic cancer patients because the survivability is so low/short in their cases. With colon cancer it is more common to start with the FOLFIRI regimen, which is basically the same minus oxaliplatin. Their interpretation was that due to my age Dr. Yang was hitting me with the big guns first in case it would improve overall survivability.

This piqued my interest to read a little more about these regimens. Some interesting points I noticed:

-The key metrics most articles and studies tend to focus on are: Response Rate (RR), which is the percentage of patients whose tumors responded favorably to the treatment; Progression Free Survival (PFS), which is how long the patient lives from diagnosis until a subsequent treatment is needed after a "successful" first treatment; and Overall Survival (OS), which is how long the patient lives from diagnosis to death.

-Many studies seem to come from France, which is oddly fitting given my exposure to the French when I worked at Michelin. One trait I noticed in my time there is that the French have a tendency to study the individual effects of things almost to death (no pun intended). You normally think of fashion and artists, but in my experience they really wish they could have a perfect DOE (statistical design of experiments) on EVERYTHING where the fundamental mechanism is not fully understood. One study in particular I noticed is headed up by a cancer research institute in Clermont-Ferrand, which is also where Michelin headquarters are also located (and a soccer stadium, and a gothic cathedral built from lava so unusual that I put a picture below, and not much else).

-FOLFIRINOX definition from cancer.gov:

FOL	= Leucovorin Calcium (Folinic Acid)
F	= Fluorouracil
IRIN	= Irinotecan Hydrochloride
OX	= Oxaliplatin

-FOLFIRNIOX was found in one study to extend overall survivability in metastatic pancreatic cancer patients from about 7 months to 11 months.

-Colorectal cancer is the second leading cause of cancer deaths worldwide, including roughly 200,000 per year in Europe. This is by no means an America-specific problem.

-It is hard to get the raw data to filter out the parts of statistics I don't really care about, like patients who experienced serious side effects or died of cancer above, say, 70 years old. This is one of those times when your worldview affects your goals: If you think your job is to remove every cause of old-age death so you can extend the life expectancy of humanity, you will waste a lot of time and resources. Life expectancy is given as 70 years in Psalm 90:10, and this is the case for reasons discussed before. If you noticed, this is also what has inflated COVID death stats - they include individuals who were already well beyond typical life expectancy, and ones with co-morbidities who would have died of something else in the next month if they had not contracted COVID. I only care about stats on treatments that work well for younger patients. And even those stats are only for making wise choices while trusting the Great Physician. For example, I would like to know what is my risk as a 39-year-old to develop longterm or permanent neuropathy from oxaliplatin so I can ask to discontinue it sooner than later. If this longer term side effect mainly occurred in 80-year-old patients, I wouldn't worry about it. But I don't have this data yet.

-One article pointed out that the best goal of chemotherapy in metastatic cancer patients is to shrink tumors to the point they can be surgically removed (or whatever other criteria are used to make the choice of operability). This greatly improves overall survivability rates versus repeated chemotherapy only. The article focused on the importance of resectability (operation to remove tumors) of liver metastases and I don't think even mentioned the colon or lungs. This is consistent with Dr. Yang's point before - You can live without a colon but not without a liver... which implies, the foreseeable cause of Reason #2 death (from an earlier post, life ends because cancer interferes with a vital organ function) is that the liver masses will eventually interfere with liver function. This helps me understand that the most important midterm priority would be to get to a place where the liver could be resectioned. I could be misunderstanding this - maybe Dr. Yang would say this is pointless because we already have masses in the lung, which means we will have masses shortly elsewhere in the body, as the circulatory system continuously delivers new cancer cells everywhere...

-In short, chemotherapy works by attempting to kill DNA replication. This is one interesting article explaining why this is needed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797825/

-As noted for example at the bottom of the above article, it is apparent in much of this reading how capitalism has its advantages in the medical industry despite the bad connotation: The margins achieved on patented drugs allow for the massive R&D budgets required to make further advancements. It's true that Flurouracil (5-FU) is one of the oldest chemo drugs - 60 years to be exact. But several others, including the other two in the FOLFIRINOX regimen, are newer than that. Oxaliplatin was patented in 1976 but not approved for medical use until 1996 (first in France) and in the US in 2002. Irinotecan was first approved for medical use in the US in 1996. By the way, this one comes from the natural compound camptothecin, which only comes from the Chinese ornamental tree camptotheca. How's that for a 100% natural remedy??

-Pharmacy and genetics are extremely fascinating. I applaud anyone with the interest and boldness to pursue a career therein.

The Incalculable Value of Faithful Preaching

One significant set of events at this time in my life that I want to point out is how perfect the preaching content has been since just before my diagnosis. If you go to church with me you already know all of this, but it bears mentioning that my response is due to faithful teaching since my childhood on the Biblical truth of why these things happen and how we should respond. The recent teaching was not particularly new in concept, but new in the level of detail and understanding conveyed. 

First, a Wednesday night series on the Sovereignty of God was preached (3 sermons posted so far with slides: Part 1 Part 2 Part 3). God's sovereignty is probably the attribute that makes him God more than anything else. In fact, the reason earthly rulers are called "gods" in Ps 82:6 is because they have authority over others. And this is the primary respect in which man was created in the image of God - the dominion over the creation we were instructed to exercise from the beginning. The key point: Love and trust the God who rules over all, just because He is God and for no other reason! Appreciate the beauty of a King against whom there is no rising up (Prov 30:31)!

Second, our pastor says he was impressed like seldom before in his entire ministry to interrupt a prior series and instead preach an exposition of Job 34-37. This impression occurred prior to my diagnosis. These sermons have been highly significant in strengthening my response to this trial, because Elihu in those chapters is explaining in graphic detail what Job's response SHOULD have been.

For those who aren't too familiar with the story:

-Job 1-2: God and Satan have conversations regarding Job's excellent character and conduct above all others on Earth, which Satan attributes solely to God's unprecedented blessings on him. We learn here that God wants His children to display perfect obedience and worship, and it is important to Satan that we DON'T. Job responded perfectly through the end of chapter 2, including the famous words, "Naked came I out of my mother's womb, and naked shall I return thither: The LORD gave, and the LORD hath taken away; blessed be the name of the LORD."

-Job 3-31: Job's attitude deteriorates quickly to the view that God is treating him unfairly in light of his righteous life - more or less that God owes him an apology. Job's three friends, Eliphaz, Bildad, and Zophar incorrectly attribute his trials to some secret sin in Job's life, which Job vehemently and correctly denies.

-Job 32-37: The young man Elihu speaks up and corrects both Job's error and the three friends' error with one very simple argument: God is greater than man (Job 33:12)!

-Job 38-42: God appears in a tornado and confirms all of Elihu's arguments, Job repents, his three friends are only forgiven because Job prays for them, and Job has double of everything restored to him.

In effect, Job is a textbook complete with history lesson on exactly how Christians should respond to adversity, and why. Meaning, if we don't follow the teaching contained therein, it is either because of willful ignorance or rebellion worse than Job's (because we have the hindsight of his book, which he didn't have). As taught in the series so far, we have even greater revelation of God and Jesus Christ in the rest of the Old and New Testaments, which Job also didn't have. But this further revelation is unnecessary for the simple and instinctive responses we ought to exhibit based on Job.

I would say this is worth your time if you have ever or think you might ever encounter adversity: Sermon Playlist

Further back in 2015, another series on Understanding Affliction helped me a lot with the prior medical trials in my youngest children I think the first couple of sermons are definitely worth your time, and if you need more than that there are more (Sermon Playlist). The reason I say that is because the first point is: Affliction comes from God. And if you fully understand that, it's the only reason you really need. But there are more.

One last comment for today: I thank God that hymn singing has been a staple family and church activity for my entire life, with proclivities dating back to at least my grandparents on both sides, maybe a couple of great-grandparents. My parents have always emphasized the importance of singing and will still attend or create whatever opportunity they can. My favorite hymn since my diagnosis has become How Firm a Foundation. I found out either at the Carnell Thanksgiving this year or at the Carnell prayer meeting after my diagnosis that this is also the favorite of several daughters and nieces (I have almost all daughters and nieces as you may know, so it's not that the son/nephews don't like it, just a skewed gender in the population and also confounded by age). Every verse has perfect valuable content. I've listed them all below for your edification in case you don't have them memorized.

How Firm a Foundation

1. How firm a foundation, ye saints of the Lord, Is laid for your faith in His excellent word!

What more can He say than to you He hath said, You who unto Jesus for refuge have fled?

2. In every condition, in sickness, in health, In poverty's vale, or abounding in wealth,

At home or abroad, on the land, on the sea, "As thy days may demand, shall thy strength ever be."

3. "Fear not, I am with thee; O be not dismayed, For I am thy God, and will still give thee aid;

I'll strengthen thee, help thee, and cause thee to stand, Upheld by My righteous, omnipotent hand.

4. "When thru the deep waters I call thee to go, The rivers of woe shall not thee overflow;

For I will be with thee, thy troubles to bless, And sanctify to thee thy deepest distress.

5. "When thru fiery trials thy pathway shall lie, My grace, all-sufficient, shall be thy supply;

The flame shall not hurt thee; I only design Thy dross to consume, and thy gold to refine.

6. "Even down to old age, all my people shall prove My sovereign, eternal, unchangeable love;

And when hoary hairs shall their temples adorn, Like lambs they shall still in my bosom be borne.

7. "The soul that on Jesus still leans for repose I will not, I will not desert to his foes;

That soul, though all hell should endeavor to shake, I'll never, no, never, no, never forsake!"

Gothic Cathedral in Clermont-Ferrand, France

https://en.wikipedia.org/wiki/Clermont-Ferrand_Cathedral