Recurrence (I think)

I have recurrent Gliobastoma Multiforme (I think).  My GBM has been sort of a shapeshifter, growing and shrinking, but mostly growing a few millimeters at a time.  This time, it grew more than within the comfort zone of the Northwestern Tumor Board, so I am signed up for my 3rd (gulp) craniectomy (or craniotomy, I can never tell for sure).  I could easily google the difference, but I choose ignorance.  I am not sure how much Craig Alguire will be left after this surgery.  After consulting with my PCP, I am only going on short term disability, but that may morph into long term disability.

I think I am having this at the University of Michigan.  Duke has always been attractive, especially with their poliovirus  therapy.  That helped 20% of the population really well against ‘historical controls.’  That’s not the headline.  The headline is that it is a “breakthrough treatment for GBM.”  I consulted with my first surgeon and the love of my life (JK, but not really), Shawn Hervey-Jumper.  I trust him with my brain.  He had a “slight” lean toward the Tocagen Trial, another form of immunotherapy.  This trial is much further along in research, and now into phase 3 trials.  The poliovirus needs to go through phase 2 and then phase 3 trials to prove effectiveness.  The Tocagen Trial is randomized, so I have a 50% chance of receiving placebo.  If placebo is the case, we have a back-up plan of taking an EGFR inhibitor instead (again, not proven to work in GBM, but what else is?).  The poliovirus trial was published as a phase 1 trial in the June 26, 2018 New England Journal of Medicine.  That is the most prestigious medical journal, but a long stretch for a phase 1 trial.  Oh, and thanks for all the links.  Yes, I did see it ;).  

If you google Tocagen, the title of the first page states, “No One Should Die of Cancer.”  Keep talking, you have my attention.  Totally agree with that statement.  If I actually get in the treatment arm, I will let you know more about the mechanism.  Otherwise, I will take an anti-EGFR inhibitor which targets a protein on the surface of my tumor cells.  If I fall into the placebo arm, I will also let you know more about the mechanism.

That’s my story.  That’s where I am at.   Now, as requested by Meg Weller, here are some pictures of my kids.

 

Figure:  Upper left, Connor off the blocks.  Upper right, Allison and Staci posing.  Middle right, Allison swimming.  Lower left, Gen and Coach Jim having a moment.  Lower right, Queen Elizabeth and Connor showing their Stars and Stripes gear.  The Queen won the most patriotic participant.

 

 

Figure: Left, the partial gang of cousins.  Middle left, the ‘littles.’  Middle right, our 17th anniversary (neither of us really like cake).  Far right, Mia and Tai brought their progeny.

 

Figure: Upper left, Uncle Jim and Mia steering the boat.  Upper right, the Queen and me.  Middle right, all of the cousins.  Lower photo, my work buddies.

Cherry Capital Cup

Connor had exactly zero wins after three straight years to the Cherry Capital Cup, + or – zero.  He just wanted to win one game.  On his first game, they won in a convincing style with a 4 – 3 victory vs. North Storm.  We accomplished our mission.  Time to go home.  Alas, we had 2 more tournament games to play, and his team kept winning, 7-1 and then 3-2.  We were on the way to the championship game.   This game was pretty anticlimactic since we also won that game 6-1 vs. Fury FC.  That means our total record went from 0-8-1 to 4-8-1.  We do that again next year at the Cherry Capital Cup, we will pull our record to even.

After the championship game, I had another seizure.   

“Dad, I am going to have a seizure,” I said.  

He did not hear me.  He was joking around with some other parents.

“Dad, I am going to have a seizure,” I said louder this time.

He turned and saw the anxiety on my face.  
“Lay down,” he said as he helped me to the ground.  I hear that advice a lot after I tell someone I am going to have a seizure.  That said, if I tell you I am going to have a seizure, tell me to lay down.  In Starbucks on 12/21/17, I actually stood up and then hit my head on the way down.  Those simple instructions are very effective. 

I was awake the whole time, just did not have any control of my right side as it contracted and relaxed again and again.  That’s a partial seizure.  A generalized seizure is when you wake up in an ambulance outside of Starbucks.

I was on the ground, and I felt something wet hit my face.  I hope that was a tear from my mother.  Anything else dropping from her face (specifically, her nose) would have been pretty gross.  I was also surrounded by several doctors including Heather Slay, Brett Brinker, Tom Auer, and my PCP.  We even had a nurse practitioner Tara Webb.  None of them had every seen me seize.  Actually, only Dr. Amy Bishop saw me immediately after my last seizure.  After I started to get control of my right side, I remained on the ground.  ER doctors: do not read the following couple of sentences.  You have a very difficult job.  Just start at the next paragraph.  An ER doctor came by helpfully and suggested I put my legs up in the air.  I did, but then I realized he thought I was having a vasovagal spell, not a seizure.  That’s what ER docs are good for:  What is the most common diagnosis and the diagnosis I cannot miss?  Rule in one and out the other, and then send them home.  If I went to the ER, I would have probably gotten a PE protocol CT, troponin level, and a cardiology consult if the troponin was ambiguous (or, at least that’s what it feels like on call).  

Welcome back ER staff. 

We kept my mom busy by sending her to the car to get my backpack with my Ativan.  After she returned and then walked the backpack back to the car, we sent her back again for a second dose.  It was a good distractor for her while I recovered. 

I finally got up off the ground and took some pictures with my son like nothing happened.  The rest of the parents must have been like “wtf?”  Excuse my foul language, but I can’t imagine anything else going through their minds.    A few of them that Connor has played with for a few years knew my diagnosis.  Newer parents had no clue until that moment.  Well, there was my announcement to the soccer world!  As I walked of the field, I waved to a group of them.  See y’all later!

Figure:  Left, Connor, my PCP, and me right after my seizure.  Nothing to see here!  Upper right, Connor showing his moves.  Middle right, some of his teammates after the game.  Bottom right, giving Connor extra motivation (okay, that picture was meant to be a joke).

 

I had a funny look at work, and Nurse Cindy could sense something was wrong.  Some people just pull that out of you.  Nurse Jane did the same after I showed her an e-mail from Dr .Brahmajee Nallamothu.  His father-in-law also died of brain cancer after a good, asymptomatic run after resection.  And I thought I was special.  I needed to gather myself.  Nurse Jane helped by seeing my first patient for several minutes while I gathered myself.

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What else is going on?  Allison played lacrosse and went a perfect 24-0 over the season.  That’s 24 wins, zero losses if  you are not sure what 24-0 means.  She likes it, but I don’t think that will be her high school sport.  They only play 6 girls on the field over 4 grades.  

Queen Elizabeth ran a 400 meter dash at the LBW race (Lakeside – Breton – Wealthy).  From now on, she will also be called the Silver Bullet.  Margaret McIntosh coined her that through her mother on a text: “Ella is the Silver Bullet, and I never want to run that again.”  Connor has to try a little harder to make the podium (top 3 make the podium), but he did for the second year in a row.  Phew.  He is all willpower, but not as much intrinsic talent as his sister.  The Silver Bullet just has another gear.   Connor tells her to “Go” and she just takes off.  At that point, she went from 3rd to 1st pretty easily.

 

Figure:  Left, Ella has always liked to run from behind.  Seen here, she is letting Connor and Gen take the lead.  Upper right, picking it up for the last quarter of the race.  Bottom right, the top 3 finishers from 4th grade.

 

I try to make it to more of my kids’ events nowadays.  4th grade science fair?  Check.  Aforementioned LBW race?  Check.  Second grade restaurant?  Check again.  Last day of school or anything for Allison?  Okay, she would have killed me.  She left early and came home at about 8:30 PM.  I had Staci text me the photo she took prior to driving her to school.  Check? 

When I went to the second grade restaurant at Breton Downs, I surprised Ella.  I was supposed to be working that day, but I snuck out for about an hour.  It was kind of like those videos when military personnel come home without telling their kids, but not quite as dramatic and no music.  

Figure: Left, 4th grade science fair.  Upper right, at the second grade restaurant.  Lower right, trying to make the most out of Craig’s Cruisers.

 

The kids all successfully completed a school year.  Mia graduated from preschool, Ella finished 2nd, Connor 4th, and Allison 7th.  Next year will be big with graduations from elementary school and middle school.  I told Allison we would both go to our favorite kids’ graduation, but she will just have to wait and see where we end up.  Connor and Allison are both strong candidates, but the best bet is the Silver Bullet.  I’m sorry, but she is just so fast!

Figure:  Left, Allison on her way to school on her last day.  Middle left, Mia finishing preschool.  Middle right, Connor and his teacher, Mrs. Ries.  Far right, Ella and her long term substitute teacher, Mr. Wondergem (sadly, one of our favorite teachers, Mrs. Vikki Boersma, is going through a family tragedy).

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I have another MRI in the next few weeks.  This one will be a little more nerve-racking since I have had some symptoms (seizures).  Well, not necessarily more nerve-racking because they all are nerve-racking.  (How many times can I write nerve-wracking in this last paragraph? I’ll tell you, it’s 4).  The most difficult part is not knowing.  Some patients refer to that as scanxiety.  Once we know, we can at least form a plan.  As Lucia Steinlage said before my last surgery, ‘This is just one more mountain to climb, so grab a pickaxe.’  Or maybe not.  I’m not sure.

Mother’s Day 2018

I had an eventful 5 weeks since my last ambiguous MRI.  First, I got a second opinion at Henry Ford, mainly because they have a research trial I am interested in.  The consensus there was that I had recurrence of GBM.  Also, I had another generalized seizure.   With Henry Ford’s opinion and that seizure, I moved up my follow-up MRI at Northwestern from 6 weeks to 4 weeks.  This MRI, however, showed no change compared to 4/11/18.  This is not consistent with recurrence since once this cancer recurs, it recurs with a vengeance.  

The day I had that seizure, I worked out for about 2 hours in the morning.  I ran 9 miles on the treadmill, lifted weights, then biked to MVP for a 1000 meter swim.  That was an extreme day by my standards.  That was peak training for the Riverbank run.  

At MVP, I told lifeguard Karyl that I had seizures, but none since 12/21/17.  The sign by the pool said, “Swim at your own risk.”  That scared me a bit.  Lifeguard Karyl also worked as an ER nurse.  The stars were aligned for me that morning.

“Are you on Keppra?” the lifeguard / ER nurse asked. 

“Not anymore,” I said, impressed with her seizure med knowledge.  “I transitioned to Lamictal.”

“You should get a medical ID badge.  That way, if you have a seizure, everyone can read your identification and contact number.”  

“Good idea,” I said, thinking that was a good idea.  Later that very day, I had that seizure at my house around 9 o’clock.  Well, damn, I am not going to be driving again until 10/24/18 (or maybe never).   So much for my the summer solstice celebration.   

I don’t really know what my aura is, I am simply aware that I am going to have a seizure in about 10 seconds or so.  

“Staci, I am going to have a seizure,” I said.

“Lay down on the ground,” she said.  Good idea, I thought for the second time that day.  

She took my glasses off and I started to seize.  The seizure began with my right arm contracting violently without my permission, then my right leg, then on and off for a while.  My head starting hitting the carpet, and I lost consciousness.  I woke in my postictal haze to see ER doctor Amy Bishop in our house. 

I am not sure what triggered the seizure, be it too much exercise or taking my lamictal a little erratically (that day 5 AM and 9 PM).  I never missed a dose, but took it whenever I remembered.  Now, I am now setting my alarm for 5:55 AM and 5:55 PM to take almost exactly 12 hours apart (within 5 minutes or so). 

My kids witnessed this seizure.  Staci didn’t tell them to go out of the room, but they all congregated in Allison’s room.  Connor was first to come back and sit by me afterward.  

“Does it hurt?” he asked. “I was scared and worried.”

“Hum, not really,” I lied.  If you have a partial seizure and you have extreme right sided contractions while bouncing your head against off the carpet, it certainly does not feel good.

He offered to read to me, and then started quizzing me about NBA facts.  

“Who is the best player of all time?” he asked.  

“Lebron James,” I said, knowing he is not a big fan.

“Who are some of the best players in the NBA?”

“Magic Johnson, Larry Bird, Isiah Thomas…”

“What teams are in the playoffs?”

“Detroit Pistons.”

He smiled and knew I was just teasing him by answering great teams from the 1980s.  He sat with me for a while until his sisters came out of Allison’s room.

I am taking pembrolizumab locally nowadays at the Lemmon Holton buidling.  This is a quick 30 minute infusion that takes more time to prepare than actually infuse.  Why stop what is possibly working for me and has no side effects?  The studies on this drug are mostly null (no benefit), but there is subset that may benefit.  I do not really want to know if I am part of that subset.  I believe it works, so it does.  

Figure: Upper left, my support group during my infusion: the always cold Jeff Decker.  Upper right, my personal ER doctor and race companion, Todd Chassee.  Bottom, Todd and I after the race.

Riverbank Update

I ran the Riverbank race 5/12/18.  The whole 25K.  Much slower than my peak times, but near my lifetime average at 1:55 and some change.  I was trying to keep a low profile since I was not sure if I could do it but received multiple texts before, during and after.  Several of the nurses at the hospital were wearing Team Craig shirts.  Well, got to do it now!  From first step to my last, I ran with my portable ER doctor Todd Chassee.  Every year that I have run this, no matter the pace, the last several miles just hurt my legs.  Staci was driving Allison to a lacrosse games in Okemos.  It rained and was cold there.  I’ll take the 25K run, thank you very much.

Alguire Update

Within the next week of my seizure, Connor asked if he could go to his friend’s house Zach.  “Oh, can I go?” I said jokingly.

“I wish,” said Connor without a trace of irony.  That may have been the nicest thing I heard from one of my kids in 2018.  These moments always make me want to be nicer to my parents (at least a little bit).

I even started crying while at Connor’s swim practice as my dad was showing me pictures of a vacation last spring. It was a fishing trip for the boys.  No, I don’t really like fishing, but I do like my only dad and my only son.  We were scrolling through pictures of the beach at night, dolphins riding the waves of the boat, and hanging out with Joe Aufrey (whom my son still thinks of as the most knowledgeable on cars…maybe true).  Joe can be full of stuff, but he knows a lot about cars.  In hindsight, that was a fun trip.

Figure: A soccer game in Grand Haven always brings out Connor’s relatives. Upper left, Connor and Mia before a game at the MSA Fieldhouse.

While I am clearly Connor’s favorite, Staci is clearly Mia’s.  Every once in a while, Mia asks for me, maybe one out of 10 times.  Usually it is to wipe her rear end after defecating, but I treasure those moments of bonding.  And she always asks to ride on my shoulders.  She just stands in front of me and says, “shoulders.”  It is my cue to lift her up.  She is also playing soccer on Thursday evenings and Saturday at 12 PM.  Finally I have a girl interested in soccer.  Truth be told, I am not sure if we have the bandwidth to handle more than that.  In addition to biking Connor to swim practice, it is also my parenting job to go to her soccer practice.  We usually get picked up by one of her friend’s parents.  I can’t say it isn’t fun watching her play, but I also get to hang out with the other soccer dads.  Now that I know them a  little better, it is a lot of fun.

Figure:  Mia right where she likes to be.  On the right, Mia buttering her own toast just like Grandma.

I realized I do not mention Queen Elizabeth that much anymore, or have her in individual photos.  That is life as the middle child.  Well, here you go.  I do love jumping on the trampoline with her because she just flies up in the air when I bounce her.  Seriously.  She has the biggest delta from her individual bounces to when I bounce her.  She has learned to time this perfectly, watching me go up and down, and landing a split second after I do.  Up she goes.

I think Allison is okay.  At least that is what I am hearing from her friend’s parents :).  Maybe that is a self selecting group.  Who would tell you that your kid is annoying and a pain to be around?  They all love her company.  She is actually quite funny, some crude, others more reportable on this blog.  Without any examples, you can just trust me on this.

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Figure: I decided to take a picture of Ella without anybody else.

To my mother, MK, who always seems to get what she wants without even trying.  Pulling the levers behind the curtain without any of us really noticing.  Happy Mother’s Day, Mom.

Staci and I are good.  Every once in a while, we go on date nights (about once a month).  Our favorite place to go is the Grove, and since we have limited nights out, we almost always find ourselves there.  I am not going to say she is the best mom ever, but she is in the Top 10.  She keeps our house afloat.  I love you, Staci.  Happy Mother’s Day.

 

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Figure:  At the Grove.  Some guy literally in between us, but never figuratively.

Ambiguity Part 17

I had another MRI on April 11, 2018 at Northwestern.  I got the usual news:  probably ‘treatment effect,’ but cannot rule out some growth of the brain tumor.  

“Let’s repeat an MRI in 6 weeks,” said Dr. Kumthekar.   

I should just schedule these every 4 – 6 weeks and cancel if not needed.

I will not have tumor progression for lack of trying, but I am not sure what ‘lack of trying’ means in the setting GBM.  Same goes for ‘putting up a good fight.’  I can only take my medications as scheduled with Lamictal (anti-seizure and happy drug) and Vitamin P infusion every three weeks.  A recent trial in lung cancer patients showed treatment with pembro was clearly superior to treatment without it.  That sounds good to me.  Unfortunately, it only works works for some people in some cancers.  As far as I know, I drove to Chicago every 3 weeks for 108+ weeks for something that is equivalent to the other Vitamin P (placebo).  Placebos are generally nothing more effective than sugar pills.  However, I am not going to diminish the effects of Placebo on disease and outcomes.  About 35% of patients report a ‘response’ and / or ‘side effects’ to placebo.  If I just believe in Pembro, maybe it will help? 

GBM is so bad, researchers are just throwing stuff at it and seeing what sticks.  As I always like to think to myself, ‘there are a lot of new and exciting treatment options that haven’t been proven ineffective yet!’

So, I exercise to burn off my worries.  My longest run is still in the single digits due to a left quad injury.  I am in pretty good shape, but probably won’t run 15.5 consecutive miles until race day.   Sitting still is the most bothersome since I occasionally get some myoclonic jerks (random arm or leg movements) since my last surgery.  If I’m active, this just does not happen.  I ran 8 miles prior to my AM clinic on April 20th without a problem.  I had so many myoclonic jerks starting at 11 o’clock or so, I thought I was going to have a another generalized seizure.  This lead to a panic attack, and I was sort of shivering all over.  One of our NPs, Tania Pratt, sat by me until Staci arrived.  She suggested Staci should bring my Ativan.  Hum…good idea.  After some Ativan (since I haven’t carried it around for a while), we got something to eat, and I took a nap.  Sounds like a pretty good remedy for most ailments in life.

Since my seizure 12/21/17, I have been biking most places around town.  Once it gets warmer, I may even try to bike to work (to the hospital through town, not to the office down the Beltline).   Biking gives me a little more independence.  I will also bike to D+W to get my craft beer, and bike home.  I may get a few funny looks as a pack just beer into my backpack, but whatever.  I won’t judge you if you don’t judge me.

Figure:  Left, my lovely chef and chief in the kitchen.  Good thing I was assigned something easy on our Whole Food Plant Based culinary class.  Middle, my pembro partner locally.  Right, bumped into Elaine Milnes at the infusion center.

Here’s what happened at 1429 Ridgewood since my last blog.  We spent two weekends in a row at swim meets: the 12 and under state meet at Zeeland and the 13-14 and open state meet at Eastern Michigan.  Zeeland was a little small of a venue for a 12 and under state meet, and the Fire Marshal stopped by to stop the meet for over an hour as he checked things out.  And Eastern Michigan, the  pool, well, is just a complete dive (no pun intended).  Of course, at EMU, we needed to stay in a hotel.  The exercise room Rules of Use I liked the last line: Do Not Over Exercise.  Discontinue Use at the First Signs of Stress.  Well, don’t tell the swimmers at the state meet!

Figure: Upper left, one of several EGRA “B” relays that made the podium.  Upper right, Connor’s Medley relay that finished Top 16 (and didn’t DQ!).  Below, good advice except for the swimmers at state.

Allison and Connor had great swim meets, although Allison developed some respiratory ailment by the end of the meet.  All of Allison’s “B” relays placed somewhere between 7th and 9th where the top 8 ‘podium.’  I think she was proud of that.  Connor has the perfect birthday for swimming, and will probably take multiple podiums in his individual events next year (not to put any pressure on the kid…don’t tell him I said this).

Queen Elizabeth pretended to be Eleanor Roosevelt for a school project on great historical figures.  The good thing about having parents that are highly functional hoarders includes they have a costume for everything, including Eleanor Roosevelt.  I also took the Queen to the Sweetheart dance again this year with her little sister, Mia.  Once we got to the dance, I barely saw either of them.  I sort of teased Elizabeth about not dancing with me near the end of the dance, and she apologized to me later after reading to her ind bed.  Oh girl, that is okay.  I just hung out with a bunch of other dumped dads.  

Mia is playing soccer for the Little Rascals and could not be more excited.  Everyday she asks when her next practice or game will be (practice is always Thursday night, games always Saturday if she asks you).

Figure: Far left, Mia before her first practice.  Middle left, warming up with Papa before her first game.  Middle right, introducing Eleanor Roosevelt.  Far right, my two dates for Sweetheart Dance.

Oh, and we went to Bradenton Beach (island off Tampa) for Spring Break with my two sisters, two brother in laws, parents, and everybody’s kids.  We all stayed in the same house.  Despite 18 people staying under one roof, we are all still talking.  That is probably the biggest accomplishment of the week.  The Cousins, as they refer to themselves, had a great time, but I think they would have a great time wherever they were together.  They are divided up into the Bigs (Anna, Kathryn, and MV), Middles (Allison, Grace, and Rosie), Littles (Gen, Ella, and Mia).  Connor is just the boy.

Figure:  Upper Left, Anna holding Mia while jumping off the pier.  Lower left, the safest place in the ocean.  Upper right, watching Manatees in the rehab center.  Lower right, the safest place on land.

Another Figure from Bradenton:  Far left, My parents and me.  Middle left, Grandpa showing the Connor the proper technique for sharpening knives (much to the horror of MK).  Middle right, we were very good customers at the local putt putt.    Far right, Alli shows her allegiance before flying out of Chicago.

 

I am grateful for every day I am still alive, but greedy because I want more.  I am still exercising, working, and just hanging out with my family and friends with minimal symptoms.   I’m trying to end the family’s obsession with The Greatest Showman, but not very successful as I listen to the soundtrack while typing this.  Lead by example, Craig.  Can’t get much better than that 2.5 years after my diagnosis.

As Promised, the Viso Blog

I finished my 2 year clinical trial with pembrolizumab after a few scrapes, emotional bruises, and two new scars on my head (one from surgery, another from a seizure). That is 40 plus trips to Chicago which included labs, an appointment, and then a 30 minute infusion of pembrolizumab. All that took about 3 hours with 7 hours on the road. That’s not including pre and post-op testing or MRIs every 9 weeks (plus a few extra MRIs for questionable findings).

So, what are you doing now, Dr. Alguire? Well, I am so glad you asked. After consulting with my PCP (dad) and primary oncologist (sister), I will be continuing pembrolizumab off label.

I always said I would wait until the end of the trial to decide on my future treatments. Now, I don’t think I could do anything but continue. If I had recurrence off pembro, I would be kicking myself. When my primary oncologist prescribed it, Priority Health promptly denied it as an experimental therapy. Next, we applied to get it as compassionate usage directly from Merck. It was promptly approved, and so I can continue on the medication without paying for it (at $12,000 a dose every 3 weeks, it adds up pretty quickly). Unbeknownst to me, my Mom was thinking about selling my childhood house on Lake Avenue to pay for these treatments if not covered by Merck.

“I hate cleaning this big old house anyway.” Well MK, you gotta keep on cleaning.

Honestly, I do not know if it is actually helping me. In theory, with a high burden of mutations in my GBM, my immune system would only need a nudge to recognize these cells as abnormal and wipe them away. Yay for extra malignant mutations! In practice, it is really uncertain if it works in GBM or for me. There were only 4 patients in my phase 1 clinical trial. That is 4 as in four. Two of us are still without recurrence at the end of the trial. That’s 50% survival without recurrence at 2 years.*

*Not significant.

These drugs usually work really well in a small percentage of patients in other cancers (ie, specifically melanoma and non-small cell lung cancer). So, I will travel to Lemmen-Holton Cancer Pavilion, right across the street from my work at Meijer Heart Center, and get my 30 minute infusion. I can actually bike there, but I do not think Staci will let me for my first infusion. I may even be able to work on those days. Nah. I will still travel to Northwestern for my MRIs, but that will be every 2 – 3 months or so.

Figure:  Upper left, an old picture of Connor and me while I get my infusion.  Bottom left, best nurse ever, Lily Santana. Right, Chicago from the 21st floor of Northwestern University (the oncology floor).

Viso

In other news, I had several visitors from Ann Arbor: Sara Saberi, Scott Visovatti, Brahmajee Nallamothu, and their Uber driver, Peter Hagan. After a 2 hour drive from Ann Arbor, we went out to dinner at the Grove, and then back home for them. I’ve been replaced in Viso’s life with Brahmajee, but I am okay with that (you may remember Viso from earlier photos at my first surgery). I am actually happy for them. Brahmajee is a great guy. Hagan reminisced about days in the echo lab that made me laugh so hard, I started crying. It was about an article in the Ann Arbor News about a naked man at a local library and our discussion in the echo lab afterward. As he said, if you are explaining, you are losing, so I’ll just stop there. Trust me, it was really funny. Sara reminds me of my neurooncologist in Chicago: that’s the highest compliment I can pay to either of them.

So, there you go, Viso. You got your shout out. Thanks for visiting.

Figure: Left, the visitors from Ann Arbor.  Right, the last time I saw Viso was after my first surgery (with Shelley Schmidt on my left).

A Brief Note About my Blog

wordpress.com, the website that hosts my blog, gives me stats about who visits the site and where they are located. I’ve had about a 100 a day or so over the last few weeks. But I have had one visitor from Finland daily for about a month. Whoever you are, here is your shoutout, too.

River Bank 2018

Spectrum has replaced Metro Hospital as one of the title sponsors for River Bank Run 2018. 5th/3rd is still a title sponsor as well, but they no longer ‘own’ the race. In addition, Amway is a new title sponsor with Spectrum. What does this mean? Not a whole lot except as a sponsor, we provide medical support for the race. David Wohns was asked to represent SHMG Cardiology, and as any good leader, he delegated me as a adequate cardiology representative. I feel so honored at those meetings. My only condition was that I could still run the 25K. I’ll be available for cardiology care during the race if you are going about my pace, but Todd Chassee is an ER doctor, so probably doesn’t need me. Maybe we’ll wear our volunteer T-shirts while we’re running in case anybody around us needs help. After I finish, I plan to help at the end of the race for all those behind me. If you beat me? Well, don’t expect any cardiology care.

The key to running a really fast River Bank is three fold. Run it a couple of times to get used to the distance. Start out kind of slow, and try to negative split (go faster the second half of race then the first). Over a few years, start your fast tempo a little earlier in the race until you can run the same, fast pace (for you) the whole time.

The second piece of advice is interval training. Start and stop. Run as fast as you can for a short bit, and then rest mixed in with longer runs and tempo runs. We almost always do this in the pool, and I incorporated into my running. This training will maximize your endurance (or minimize your time).

The third piece of advice is to throw out the training plan as recommended on the website over the last few years. It is just too much running. Better yet is to cross train with biking, swimming, and weight lifting. Or, that’s just what I do.

Family Update

Let me take you back to October, 2015 when I was first diagnosed. Allison was 10, Connor was 7, Ella was not even Queen Elizabeth, yet. Mia was still a baby sucking on a pacifier(s). I really did not think I would feel this normal in 29 months. In fact, I kind of thought I would not feeling anything at all. Now, I am training for the River Bank Run (again). Recovering from a running injury (or just older). All is well.

Allison is doing well in school. I do not know what she does in her room at night, but seems to be working out okay. Connor, our most emotional kid, is swimming and playing soccer like a champ. He had the game winning shot in his last rec basketball game. This came after a wide open lay-up that he missed with about 45 seconds left and down by one. They got the ball back, ran the same play, and he nailed it on his second chance. He went from crying to jubilation over a short period of time. He also has the perfect swimming birthday in late March, right after the state meet. Not so much for my December bday Allison, and let’s be honest, girls swimming has traditionally been a lot more competitive in the younger age groups. Ella, or Queen Elizabeth, won the 25 free at the WMSL A meet and quickly shut it down for the year. She likes to be read to while she does her crafts at night. I cannot tell if she is really paying attention, but when I quiz her, she usually answers correctly. And Mia is just a craftaholic. She must get that from her Grandma Alguire.

Figure: Left, the 9-10 boys and 11-12 girls 100 IM champions (and cousins) at the JO meet.  Ella with her co-champion at the WMSL meet Kate Blake (Ella won the 25 free, Kate the 50 free).  Middle right, my sissies and me volunteering at a swim meet.  Right, Connor stops by after his 100 IM to get positive feedback from Staci.  He loves positive feedback.

Figure: Upper left, at Grandma Constant’s 90th birthday part, the youngest great grandchild stole the show.  Middle top, I went with Connor on his 4th grade field trip to Lansing to see the capital.  Middle right, my fat tire bike.  Lower pics: left, all the Alguire cousins.  Right, Connor has special time with Anna Ackerman.

 

In conclusion, all is well at our house.  There are no Stormy Daniels out there in my past that I have paid hush money too (that Staci knows about), but if I keep doing well, I may need to spice up this blog a bit.

MSU Basketball

Okay, where were we?  I had to glance back at my last blog to figure out a good starting point.  That was published 12/24/17 and titled “Seizure at Starbucks.”  I have a scar on my head like Harry Potter (imagine Harry Potter except 2 parallel lightning bolts).  These are from my personal Voldemort, glioblastoma multiforme.  I also noticed my right eyeglass lens couldn’t be completely cleaned. I guess you cannot completely wipe away a scratch.  I brought them into Family and Pediatric Eyecare Center down on Monroe, and they told me my lenses were still under warranty.  Yes!  I needed some good news after this seizure.

I started on Keppra (an anti-seizure med) in the Spectrum Butterworth Emergency Department on the winter solstice.  No driving, assuming nothing else happens (a big assumption with GBM) until the summer solstice.  Despite many kind offers, I have settled into a routine for looking for drivers. I look at the schedule, figure who is going to the same place, and text them at least 24 hours prior. Everybody has said yes so far with no complaints even though my house is not exactly en route for many drivers.

I was also given Ativan pills to take as needed from the ER. Intravenous Ativan is usually an acute treatment of status epilepticus (a persistent seizure), but I am not really sure what I was supposed to do with pills. They did come in handy after I went to see my neurooncologist January 10th.  GBM is just like ‘rocket surgery’ sometimes — very difficult to sort out subtle changes. We were told that I had recurrence, and then after Tumor Board, more likely just treatment effect.  Who knows?  I feel fine, just hyperaware of any twitch.  It was a good practice run for my sister, Katie, looking into alternative treatments and trials.  I have a 4 week follow-up MRI to help sort it all out next week.

I am actually in the process of switching to lamictal which is an anti-seizure with mood stabilizing ‘side effects’ (or maybe it is a mood stabilizer with anti-seizure ‘side effects.’) Dr. Kumthekar said she would just chart it was for seizures.

“Ah, you can say it is an anti-psychotic in the chart…I feel a little crazy.”

Okay, I did not say that, but this is my blog. Not even the president gets to call this Fake News.

Since I left Chicago without my infusion 1/10/18, I needed to return a few days later to get my pembrolizumab. Fortunately, we were trying to figure out when we could take our kids to Chicago, so the timing was perfect. The girls went to the American Girl Store, and my parents and Connor stayed at the hospital ‘getting their steps in’ as my Mom likes to say. Connor even snuck into the infusion area (nobody under 12 allowed at Northwestern).  Don’t tell anybody.

I had to review my pictures to figure out what else happened this last month.  Maybe I am just still postictal (confusion after a seizure usually only lasting about 5 – 30 minutes). It must have been closer to 30 minutes because I woke up in the ambulance with my Patagonia fleece cut off.  Staci said I had a pretty blank stare in Starbucks.  I don’t remember her even arriving or talking to me.  However, that should have worn off by now.

Let’s see, Constant cousins from Texas visited, I bought a fat tire bike (my excuse was transportation until I could restart driving), went to an MSU basketball practice, redoing our basement and continued part time work and following kids to various sporting events.

On January 20th, Connor and I went to an MSU basketball practice with Roger Jansen, Darryl Elmouchi and their sons.  Darryl read my blog about going to Midnight Madness and struggling to get autographs, so he hooked us up with Roger and front row seats for a practice.  It is just mind blowing how big and athletic these guys are up close. Even the walk ons were all conference or all state.

I am back in the pool on Mondays and Wednesdays with EGRA Masters, and still on the stationary bike and treadmill on the other days.  Swimming was a bit unnerving at first after a seizure, but 3 of the swimmers in my lane swam in college and are currently physicians, so I think I am safe as possible.  Allison was part of an EGR Middle School record breaking 400 free relay at the middle school state meet (3:51 for those with any swimming knowledge).   Connor is staying busy with swimming, futsal, and rec basketball (I am an ‘assistant coach’ to Coach Glen only so Connor can be on Grady’s team).  Queen Elizabeth is gearing up for the “A” meet in a few weeks, and we are just hoping she will do her best events, not strategically figure out which events she will place better.  Mia is still going to Goldfish swim school, now in the last group prior to moving to the swim team there.  Since she goes at 11:30 AM on Tuesdays, and most kids are in school if they reach this level, she essentially has a private lesson each week.  Staci is busy managing our basement remodel.  The workers quickly realize she makes all the decisions around here about interior design.

So that’s where we are at the end of January, 2018, 27 months into this unrequested ‘journey’ with glioblastoma multiforme.  There is no definitive evidence of recurrence, but I have had a second brain surgery and a grand mal seizure.  I still feel fine on a day to day basis.  A little anxious, yes, but we have plenty of meds for that (not that there is anything wrong with that?).

 

 

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First warm weekend in January, and we were outside on the trampoline.

 

Seizure at Starbucks

I had a really good run.  No major events in the first 24 months of my struggle with Glioblastoma Multiforme (GBM).  I had a few ambiguous scans, but nothing that required intervention until recently. Working part time as a cardiologist and full time as a father and husband, I had a nice little routine.  I would go to work Monday, Wednesday, and a half day Friday, and stay at home on Tuesdays and Thursdays with Staci and Mia. Sometimes I even felt a little guilty about not working more.  Sometimes.

My November 1st MRI showed likely recurrence, but that just ended up to be inflammation / treatment effect on pathology slides according to two neuropathologists.  I recovered well from that surgery, almost back to 100% (but never quite). Each treatment takes you back a little bit. Nonetheless, I returned to work (3 weeks after my second brain surgery, thank you very much) on 12/4/17.
On 12/21/17, the winter solstice and darkest day of the year, I had a grand mal seizure at Starbucks downtown in East Grand Rapids. My first 3 seizures were on 10/29/15, and were all partial seizures. I was conscious for each of them, but could not talk. This one was the real thing.

I met Allison and Ella G (we also call her big Ella in contrast to our much younger and smaller Ella) at Starbucks after school. It took me a while to get there. Allison called when I was pulling out of our driveway, and I made the mistake of driving in front of the EGR High School when it was getting out. She called me again en route. “Yes Allison, I will be there soon.”
Starbucks was packed. We waited for someone to get up to snag their table.  I sat across from Allison with Ella G to my left.  Allison was just finishing off the second part of her bagel with a frappuccino on the side.  I told her that was her “dessert” for the day, no doubt.  I just starting working on a grande iced soy latte.
“How come you get a Grande?” Allison asked.

“Because I am sharing this with your mom…” I replied.

I had worked 11 hours on Monday (7:30 AM to 6:30 PM), 13 on Tuesday (which included a SHMG Cardiovascular meeting, 7:30 AM to 8:30 PM) and then drove to Chicago on Wednesday for a routine infusion with Todd Chassee.  On Thursday, I was tired, but had to do some make up exercise in the morning.   Needless to say, I was tired Thursday afternoon.
At Starbucks, my legs started twitching, but nothing too unusual for me. I stood up to stretch them out, but then felt the twitching rise up. Oh no, these were not just some muscle fasciculations.
“I am going to have a seizure,” I told the girls. My arm tensed up, and I saw the ground get closer, but never felt the impact. Apparently I hit my forehead on the corner of the table and landed on the ground right at the front of the Starbucks line. There I lay in a pool of my own blood.

This Starbucks is a central place in East Grand Rapids. For maximal attention, I was there right after Middle and High School were let out. I know I caused quite a scene because they had to shut down Starbucks for several minutes to clean up my blood.
The first responding officer was asking Allison all sorts of questions about me, many she did not know.
“How old is he?”

“I think 41.” She got that one right.

“Who is his doctor?”

“I don’t know.”

“What medications is he on?”

“Don’t know that, either.”

Finally, Emma Israels intervened. “Her dad has brain cancer, and she does not know his meds or his doctor.”

I just remember waking up in the ambulance and hearing Staci’s voice talking to the driver.  When did she arrive?
“Do you know the date?” the EMT asked me in the back.

“December 21, 2017,” I replied.

“Really good.” The bar was set pretty low at that point.

Apparently, Staci already asked me some questions in Starbucks, but I only answered with a post-ictal blank stare. I couldn’t remember that.

And damn, where is my iced soy latte? I only had a few sips. And Allison only had a few sips of her ridiculously sugary Vanilla Bean Frappuccino with caramel on top. $7 down the drain. And where are my glasses?  And EMS cut off my fleece in Starbucks!

At the hospital, they did a CT scan of my head with contrast. No subdural hemorrhage, and not really comparable to my old MRI which always had subtle findings.

“We can do an MRI, but that may take several hours, and you may need to be admitted for that,” said my ER doctor.

“Nope. I am going home.” Also, I just did not want arrange for my MRI from one institution to be sent to another. And I did not want to be admitted to any hospital.

I learned Ella G’s mom, Danche, had my glasses. I also realized I wouldn’t be driving for 6 months ): Michigan Law. We are already figuring that out, but I may be buying myself a fat tire bike for the winter.

The next morning, I got up early as always, and had my exercise gear on.

“You are not getting on that treadmill,” Staci said.

“Okay, well, but I am going to work.” Why not? I had a seizure, couldn’t drive, but felt fine otherwise that morning. Fortunately, I was working with Jeff Decker that morning at the Meijer Heart Center. I texted him at 6 AM to pick me up, figured the 10 minute detour would be a net benefit for him on overall workflow.

So that’s where I am on this Christmas Eve, 2017. Status post two left frontal lobe resections, radiation, chemotherapy, pembrolizumab, and now a grand mal seizure in the most public space possible in EGR.  I always had a flair for the dramatic.

 

 

Figure: 12/21/17.  Left, Allison moments before I had my seizure.  Middle left, looking pretty bloody.  Middle Right, looking much better (with my glasses!).  Right, Connor read to me Wonder as I fell asleep.

 

 

Figure:  Mia having a water at Starbucks, and impatiently waiting at the mall (and foreshadowing her dad’s fall).  Queen Elizabeth enjoying a cup of hot cocoa.  Bottom left, boys day at Star Wars.  Bottom right, a rare sisters’ moment.

 

 

 

 

Figure: Allison’s birthday.  Left, Mom and Mia skate.  Left middle, Ella uses a few too many trainers.  Middle right, Staci and Mia again .  Right, Allison and her 4 grandparents.

 

 

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Figure: My girls making cookies on Christmas Eve.

 

“Stop Messing with my Dad’s Brain”

Team Craig Update

I had repeat surgery 11/13/17 for what appeared to be recurrent glioblastoma multiforme.  As described before, I had a new, growing lesion anterior and inferior to my prior resection cavity, but within the original radiation treatment field.  Fortunately, the pathologist has the final say on most things, including whether there is cancer present or not.  In his or her opinion, there were no cancer cells.  Like most pathologists, you never get to meet them as a patient.  They are doctors for doctors.  That means, I can go back on Plan A with Vitamin P (pembrolizumab) every 3 weeks at Northwestern.  When Dr. Kumthekar said I could be back in the clinical trial, I almost cried, but not quite.

The last few weeks were a whiplash of emotions.  First, I heard there was likely progression on the MRI 11/1/17, and I would be removed from the pembrolizumab clinical trial.  I needed to let the pembro ‘wash out’ prior to considering other treatments.  We met Dr. Tate, and a repeat resection was scheduled for 11/13/17.  In the next week, we did pre-op testing, including a functional MRI (which is about 1.5 hours) and Neurocognitive testing (also 1.5 hours).

After the surgery, Dr. Tate told my family that it looked like a recurrent GBM, but not quite as expected. Post-op day 1, my neurooncologist stopped by to say she still thought it could be treatment effect, about “50 / 50.” What? Then Dr. Tate came back around that evening (remind your kids not to do neurosurgery since I saw him around 7:45 PM).  He still felt it was most likely recurrence. The reason this it matters is prognosis and treatment options.  Once you have recurrence, new and different therapies are needed, but it also starts a different clock.

A week after surgery, my phone rang at 10:30 AM on 11/20/17: Priya Kumthekar.

“Hello Priya.”

“I think I have some good news for you.”

“Uhm.”

“They did not see any cancer cells in your resection, but I am making sure Dr. Tate sent them all.  We are going to see if we can get you back in our clinical trial.”

So we sat on pins and needles for a few days, waiting for another round of contradictory opinions.  And then Dr. Kumthekar just emailed us confirmation on the Friday after Thanksgiving that we could be back in the trial officially.

When I told the kids, Connor said Northwestern should “stop messing with my dad’s brain.”  That is true in more ways than one.

Well, Happy Thanksgiving everyone!

Figure: Upper left, having my last pre-surgery meal at the Green Zebra on Sunday night, 11/12/17.  Upper right, walking with Staci a few hours before surgery in Chicago.  Middle right, my kids showing their support for Team Craig.  Bottom left, Mrs. Boersma’s class shows Team Craig support at school for Ella (in the middle).  Bottom right, I need to be careful what I ask for on this blog (autographed hat and picture of Ritzenhein via Mike Vredenburg).

 

Pre-op Testing

On 11/9/17, I did a long day of pre-operative testing. Functional MRI followed by neurocognitive testing. This was followed by an appointment with an anesthesiologist to see if I was healthy enough to have my only problem removed. Spoiler alert: I was.

I showed up for my MRI with a sense of dread. I knew it was going to be a long morning in the magnet followed by a long neurocognitive evaluation. I sat (well, laid down in tight quarters) while a MRI tech gave me instructions on what to think about. That’s difficult. Then, we did a series of object recognition testing where I would press a button each time I saw the same object. On the first go around, I couldn’t remember the first object I saw, so I just tried to remain consistent. I convinced myself it was the one with the backwards C and dash. The next day, I swam with Jeff Flermoen who tried to convince me that this was a real science. Got it, but I need to discuss with a non-radiologoist sometime soon.

After a short break, I saw Dr. Mackie, the neuropsychologist that works with Dr. Tate started with simple questions: name, date of birth, etc. And then the questions got a little harder.

“I am going to say some words, please repeat them:

“Carpet, hollywood, camouflage, green…” (okay, I am just making these up, now, but they went on for like 10 words). I couldn’t believe how many she listed, so I gave my best shot and got about 3 – 5. Not bad. And then she repeated them. And I got a few more. And then she repeated them, and I just smiled. That’s all I got for you.

And then she just kept adding numbers to a point where I would just try to remember the last couple. And then I thought, who are you to be testing me? Let’s flip this game around. Repeat after me, Dr. Mackie!  But that’s not how it works…

Figure:  Upper Left, serial compression devices keeping me in bed.  Middle top, art line and IV = more restraints.  Top right, finally walking post op day 1 in the ICU.  Bottom left, family support crew.  I was ready for the neurosurgical rounding team on POD #2 after shaving, eating breakfast, and waiting for them while sipping my Starbucks by the window.  Bottom right, my recovery at home with Stranger Things season 2 on the treadmill.

 

11/13/17 Surgery Day

The surgery itself was not that dramatic. No first person narratives this time. I was pushed back to the afternoon case. I met a large number of staff that were all great. There were 3 anesthesiologists including the attending, a fellow in neuroanesthesia (Arun), and a senior resident (Millie). All I could think of was that it must have been crowded back there between anesthesiology and neurosurgery. I also met a neurosurgical resident, Bill, but but I told him I may call him Billy after the surgery due to confusion with the senior resident anesthesiologist Millie. Not a lot of highly respected neurosurgeons named Billy in the midwest, I presume. They wheeled me back to the OR. We went down the hall, made a few turns, and into the operating theater. I took a lay of the land, they started giving me some propofol (I presume) and I left the conscious world for a few hours.

I remember waving to my parents on the way to the ICU and being strapped to the bed with bilateral serial compression devices, blood pressure cuff, art line, two peripheral IVs and a foley. I couldn’t even roll over. I was a bad ICU patient at about 3 AM, deciding it was time to swing my legs over the bed. With all those attachments, this was no small feat. The nurses came in, gave Staci a bad look, and set a bed alarm. I was to be a good patient for the rest of the night.

The next night on the floor, I was awakened at 3AM by the floor nurse. I had some pain meds, sleep deprived, but less contained to my bed. The nurse asked my name.

“Heather Slay” I said after some deliberation. The nurse looked confused. “Heather Slay” I repeated. The nurse walked out, checked the room number, and then came back in. Staci told me she just asked for my name. “Oh, Craig Alguire.” That was my 5 seconds of delirium. Fortunately, with all the sexual harassment scandals across the politics and entertainment, Heather Slay is a fellow soccer parent and GI Surgeon in Grand Rapids. I officially deny anything beyond that.

Figure:  Left, Staci and I at thanksgiving hosted by the Springers.  Middle left, Queen Elizabeth and her living furs.  Right, Connor and Staci showing off their basketball skills at a 24 Hour Buccaneer fundraiser.

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I am recovering well, trying not to do anything “too crazy.” That was the take-home point after surgery, or at least that’s how understood my discharge paperwork.

I am headed back to Northwestern this week for post-op appointments and follow-up testing. I am hopeful to get back on pembrolizumab soon and back to work sometime next week.

Figure: Left, Queen Elizabeth putting the star on the tree (Mia put it up at first, then we had to repeat it again for Ella since she felt left out).  Middle left and right: decorating the tree.

 

 

Figure: Left, Staci and me, hanging out at the Greenwell when all of our kids were at the Ackerman’s house.  Right, drinks and a dessert at the Grove.  After a beer at the Greenwell and my first ‘wine pairing’ at the Grove, I was more than a little tipsy.  I did not even touch my last two glasses of wine, but we certainly were celebrating a small victory in glioblastoma multiforme!

It Is What It Is

Wednesday, 11/1/17, was a long day. My 2 year survival party came to a halt on the 21st floor of the Northwestern Medical Center. My MRI showed the prior resection cavity remained stable, but a new mass anterior to this in my left frontal lobe continued to grow. It was growing slowly enough that it fell within the parameters of scar / inflammation / necrosis on the last few MRIs. Not anymore.

Damn.

My nurse practitioner, Meg Schwartz, called me about this ‘ditzel’ on June 30, but we were not really sure what to make of it. It grew minimally through July and August. For the last 9 weeks, it progressed to an extent that it could not be written off as inflammation anymore.

Let me introduce a new character to the blog, and the star for Team Craig on 11/13/17: Matthew Tate, MD, PhD. He is a neurosurgeon at Northwestern. Shawn Hervey-Jumper, the neurosurgeon that performed my first resection, left the midwest for University of California at San Francisco. As much as I love Dr. Jumper, UCSF is just not practical for surgery. Dr. Jumper recommended Dr. Tate. Since I had been going to Northwestern every 3 weeks for 2 years, I developed a certain comfort at that institution. We knew where to park, the best food spots, and the Starbucks locations (everywhere, but on the first floor).

The growth is small, and according to Dr. Tate, not in a very ‘important area.’ He also mentioned my prior surgery was in a ‘very delicate area’ and more challenging. A biopsy was considered, but he felt like it just made more sense to do a maximal resection since a few biopsies would basically take half the mass. Fair enough. This surgery will not be an awake craniotomy since it is not close to motor cortex (not close to anything that could be really tested while awake).

We arrived home and mentally, physically, and emotionally exhausted. Staci told me I had to ‘get it together’ for the kids. I mean, football players usually have 24 hours to get over a loss or celebrate a win, but I only get six? The kids have seen us come home so many times with good news, it was becoming routine.

Connor: (without glancing up from YouTube videos) “Did you pass your test?”

Me: Silence. Watching the YouTube video.

That got his attention.

Connor: (looking at me) “What’s wrong? Did you pass?”

If only MRIs were something you could prepare for, and either pass or fail. I would take Honors MRI. I walked out of the room to ‘get it together,’ and then came back to tell him we may have a chance to go to an MSU basketball practice, but this did not distract him.

Me: “Well, it has grown. I need a repeat resection. But the surgeon said it was pretty easy technically to remove, and not in an important area.”

Connor: “It’s your brain!”

Thank you. Tell that to Dr. Tate!

After we told Queen Elizabeth, she nodded, and asked, “what do you answer if you are not sure between yes or no?”

I did not know, but it sounded helpful.

“Yo. It is yes plus no.”

And then I went out on the trampoline with the kids. I find it easier to talk to kids in a less formal setting with a distracting activity. You can talk about things in bits and pieces. So we all jumped, careful not to bounce Mia too high (she sticks to the corner and does these little ‘butt bounces’) while trying to send Ella and Connor flying.

Figure: Upper left, lazy girls being dragged around the house.  Upper middle, you can now follow Northwestern Neurosurgery on all social medial platforms.  So reassuring that they are on Instagram and Twitter, not just Facebook.   They must be the real deal. Upper right, Connor made a special “Day of the Dead” mask in Spanish.  I don’t know what to say.  Lower left, fans of the EGR High School girls swim team (Allison was walking the finalists out).  Lower right, Connor and I watching MSU surprisingly beat PSU.  I certainly have reservations about football, but it makes for great television.

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I went to my own clinic the next two days, avoiding thinking about it too much. I had my scheduler remove my new patients for that day. I didn’t think I could focus on a new problem. At lunch, I had a chance to sneak out to D+W on Knapp for a quick bite with my section chief and colleague Jeff Decker. We bumped into my running hero Dathan Ritzenhein in the line at Starbucks. Among other running accomplishments, he won the 2017 River Bank Run.

Me: “Dathan Ritzenhein?”

Dathan: “Yes?”

Me: “Hey. Wow. This is my partner, Jeff. Jeff, Dathan still holds the high school cross country state record, and is the best runner ever from the state of Michigan.”

Misunderstanding ‘partner’ in 2017, Dathan asked, “Where do you guys live?”

“Oh, no. Um. I live in East Grand Rapids and Jeff lives in Ada.”

Anyway, maybe it is time to sign up for River Bank 2018, but no online sign up available, yet. GIddyup, River Bank 2018!

After work, I finally headed up to Nurse Jane’s desk on the third floor just for a hug and a cry since I was keeping my cool all day. Big sister Jane.  She said I needed to remain positive, but that was tough on that day.  I was still in my mourning period.  I returned a week later to prove I was okay.

After a few days of feeling sorry for myself and shell shocked, I started to accept my new reality. I became that crazy runner at MVP Sportsplex going all out on a treadmill, up to 12.5 mph for a minute or so (which was exactly Dathan Ritzenhein’s pace for full 25K in 2017!). Those treadmill sprinters must have problems, but it feels great. I swam the next morning, cutting time off the suggested intervals at EGRA Masters. I did not have time to wait around for intervals suggested by Coach Josh.

My last day of work prior to surgery was 11/8/17 in the testing center at Spectrum Meijer Heart Center. Nurse Cindy organized a potluck (no occasion is too small for a potluck in the hospital). This time, it was all vegetarian in honor of my last day. I received well wishes and good byes from many people. Finally, it was just me and Mike McNamara in the reading room finishing up at 6:30 PM. I wanted to get a selfie with him in the reading room, but when we were getting together, I just lost it. I hugged him for a while, balling my eyes out for no particular reason except everything, and he kissed my cheek in the most masculine, heterosexual, guy to guy way possible. I got that selfie after getting control of my emotions and walked out of Spectrum Hospital with him, hopefully not the last time as a cardiologist.

Upper left, Two runners just hanging out, talking about the River Bank race. I actually told Dathan my best time in the 25k for some reason.  Upper right, the start of my last day with Nurse Cindy and ‘partner’ Jeff Decker.  Middle right, wrapping up my last day with Mike McNamara after I gathered myself.   Lower right, my personal stress test.  Bottom, waiting for the anesthesiologist decide whether I am healthy enough to have my only problem removed.

I knew this story had a few more chapters. The last several blogs were all character development like those middle episodes in a Netflix series. Just filler. This protagonist apparently needs to another mountain to climb.

It feels like a cycle. It is cold and cloudy here in Michigan in early November, just like 2 years ago. Trout Steak Revival just released a new album (don’t wait for Rick McNamara to give it to you cheapskate doctors, go buy it!). I am in better shape than 2 years ago when I had my first surgery, training regularly and eating as healthy as possible. Staci practically has me on a whole food plant based diet with the exception of pizza weekly and local beer nightly. I hope it helps. I would celebrate another two years of this.

Browsing and Carousing

My two year anniversary as a glioblastoma multiforme (GBM) survivor is coming up on 10/29/17.  I no longer count my survival in months.  Just like a toddler, once you hit two, you can go by years.  Well, I’m two. October 29, 2015 was just the date of my diagnosis.  I had the cancer in 2015 in September, August, July, maybe June.  Certainly the seeds of abnormalities way before that.  Somewhere along the line, I had an insult to the glial cells of my brain, and their growth became unregulated.

Those insults, or risk factors, are not well defined for GBM.  One is brain radiation.  Never had that.  Well, maybe a little in the cath lab as a cardiology fellow, but pretty trivial overall.  Of course, my brain was fried daily for 6 weeks after the diagnosis, but not before my cancer.  A risk reducer is seasonal allergies.  The thought is that your heightened immune system will prevent any brain cancer from developing.  Never had that, either, but Staci does.  If I could do it all over again, I would chose mild allergies.  Maybe allergic rhinitis patients are suffering more than I can imagine. I just don’t have enough empathy, I guess.

Shawn Hervey-Jumper, my neurosurgeon, tweeted a link to an informative discussion about GBM on the National Institute of Health website.  It is easy to read, realistic, but also hopeful.  Of course, it starts with the usual ‘poor prognosis.’  No article on GBM article starts without that statement.  In the 1990s, the median survival was 8 – 10 months.  It is about 15 – 18 months now, with 15% of the patients surviving 5 years. Not great, but at least it is improving.  15% sounds better than a Mega Millions lottery ticket.  More like winning an NCAA basketball tournament pool (not at Spectrum, of course, since gambling is illegal).  I have won those before, but that’s when I lived in Ann Arbor amongst a bunch of Michigan fans and MSU went to 3 straight Final Fours.  Easy money.

Other than that, I still rarely read about GBM.  When I first was diagnosed, I did a cursory review in UpToDate, a resource for physicians to quickly read about some obscure condition and sound informed 1 minute later.  That was enough.  I got the idea.  GBM is bad and locally aggressive.  I do glance at immunotherapy clinical trials for various cancers in the New England Journal of Medicine.  This is easier because it is other cancers, and other people’s problems. Immunotherapy, and specifically Keytruda, is certainly not a panacea, nor do I know if it is actually helping me. Fortunately, it is not slowing me down.

Googling Myself

I googled my name the other day to see what comes up. After I got through Craig Alg, the first Google suggestion was Craig Alguire obituary. What? I can understand Craig Alguire cancer, Craig Alguire brain tumor, or Craig Alguire doctor, but who is looking for my obituary? Here you go: “Loving husband and father of 4 kids. Cardiologist. Gave generously, but always keep it anonymous. Tried to live as healthy as his recommendations to his patients. He is survived by his wife, 4 kids, and himself. In lieu of donations to some charitable organization (he has already given so much), you can write checks directly to Craig Alguire.” Maybe I’ll go to every computer in the hospital and Google “Craig Alguire sexiest man alive” until that comes up as the first suggestion. Spectrum computers will probably block that search. Never mind.

Once in a while, I do ask my elderly patients the secret of growing old. A 90 year old told me the secret to living until 90 was “No browsing or carousing.” I just wish I made a follow-up question, like ‘what do you mean, exactly?’  And, ‘why isn’t your husband here?’  Probably healthy advice, but not that fun for 90 years.  Maybe 80 years with some carousing would be better. I’ll need to define ‘browsing’ a little better before I commit.

Alguires in Grand Rapids Update

Staci and I went back to Chicago in late August for another short term follow-up MRI. After the good news, the night was suddenly more fun.  We stayed near the hospital, and kept our car in the hospital lot with a validated ticket.  We saved about $40 on parking #cancerhasitsbenefts.  We walked to a restaurant based on social media and my doctor’s suggestion at Girl and the Goat. Nothing against the fabulous restaurants in Chicago, but restaurants in Grand Rapids compare well.

The weekend before school started, we had friends visit from Los Angeles and Holland (Michigan). We have updated pictures below.  When school finally began September 5th, Allison started 7th grade, Connor 4th, Queen Elizabeth 2nd, and Mia another year of preschool at Mayflower Church preschool. Allison left on the first day of school without much fanfare. She wouldn’t let me take a picture, so I just got her biking down the driveway. She has found her groove in middle school as much as anybody can in that terrible social stew.

The late summer and fall is full of family birthdays, starting with Mia on August 17 and capping off on October 22nd with mine. Everybody upped their age by one successfully. On my 40th birthday, we dissed the kids and sent them home with Staci’s parents and had an adult party at our house. This year, Queen Elizabeth planned the party. She suggested Craig’s Cruisers for my birthday party (because I’m Craig, I guess). For breakfast, she suggested Anna’s House. Sure. Why not. I woke up that morning with a little headache, so it was nice to have a slow start. I can’t really do 3 beers and stay up until 11:00 anymore. 1 beer and 10 o’clock bed time is the usual limit for this guy. That cuts down on browsing and carousing.

 

Figure: Upper left, Allison’s first day of school photo.  Upper right, friends from Los Angeles.   Middle right, waiting for our table on my birthday.  Bottom left, Mia is growing up so fast.  Bottom right, picking apples at the Walters.

Mia is progressing in the pool at Goldfish swim school. She is in a group wth kids that look Allison’s age. Being around her siblings and cousins, she is comfortable and overconfident in the water. She was the youngest in my family to swim the length of a 25 yard pool at 3, but a little older than my niece.  No, not that niece (Kathryn).  It was Rosie who looked like a fish at 3.

Let’s see.  I did the Reeds Lake Triathlon September 9th. No excuses, but (which is the usual introduction to an excuse) I was not able to do as well as I wanted due to a knee injury.  It felt great swimming around Reeds Lake, biking and running, albeit a little slower than usual. And then Connor played multiple soccer games and Alli started her swimming routine.

 

 

Figure: Left, finding my footing in the muck of Reeds Lake.  Middle left, my support crew at the Triathlon.  Allison photoshopped her way into the pic since she was still sleeping.  Middle right, Mia and her lane at Goldfish Swim School.  Right, Connor’s soccer team trying to stay cool in the ridiculous heat of late September.

 

The sports team we are most excited about is MSU men’s basketball. Connor and I went to the MSU Madness practice 10/20/2017.  When I promised him I would take him 6 months ago, it seemed more theoretical.  He has an obsession with autographs, but everyone knows MSU will be good this year, so it was very crowded.  We got there an hour before the doors opened, and were behind thousands of people.  By the time we made it through the metal detectors, the lines were too long to get any autographs before the cutoff time of 9:30 PM.  We didn’t exactly cut, but we were not passive, either.  Nick Ward got up from the table and walked down the line signing.  I pushed Connor forward and stood back.  Who can refuse a 9 year old with an MSU hat, shirt, shorts, and socks? Then, we stood by the ropes, near Miles Bridges’s table.  We must have looked desperate, since a random Breslin Center staff asked who we wanted.  All of them?  I did not push it. “Uh, Miles Bridges.”  She took Connor’s ball, handed it Miles, and brought it back with his signature.  Happy kid = happy dad.  He got MSU’s two best players.

On the way home, we discussed Halloween and carving pumpkins. I thought I was decent with the knife (for pumpkins). Connor said about our neighbors, “Their dad is super good at carving…not to be mean.” I didn’t think it was mean until he said, “not to be mean.” Oh well. Might as well learn early about your parents’ deficiencies.

 

 

Figure: Left, Connor finds Nick Ward.  Middle, the lady in the baseball gave Connor’s ball to Miles Bridges for an autography.  Right, Sparty.

In summary, I feel fine, GBM is slightly less terrible than it was in the 1990s, I could’ve done better in the Reeds Lake Tri, still working several days a week, kids are doing fine, and I cannot tolerate even a little bit of carousing. As always, I have an upcoming MRI. And I am grateful to start counting survival in years. Two.

 

Figure: Left, It isn’t browsing or carousing if it’s your wife.  Right, the family walking around ArtPrize in GR in late September.