There is black and white in medicine, but mostly gray. Consider even the most basic question in cardiology: should a patient with no history of heart disease take a daily aspirin? Aspirin is an old therapy, possibly even dated back to ancient Egypt (do you need to cite Wikepedia?). We’ve had plenty of time to study it. The question sounds so simple. Currently, the United States Preventive Task Force (USPTF) recommends low dose aspirin for people 50 – 69 that have greater than a 10% risk of developing cardiovascular disease within 10 years (calculate your own risk). For people outside of that age bracket, they found insufficient evidence to make any recommendation. Simple, right? But the 2012 European Society of Cardiology guidelines do not recommend aspirin for primary prevention; the American College of Chest Physicians recommends it for everyone over 50. I tend to follow the USPTF, but you can see why patient input matters as well. Aspirin decreases risk of heart attack, but increases risk of bleeding. Now, who should we screen with mammograms? Women, primarily. After that, an even more heated debate…

Medical imaging of the brain is no different. There are some black and whites. My first MRI, for example, showed a large, white tumor with contrast enhancement. The immediate post surgical MRI was clearly different with a black hole. Black is good. However, right from the beginning there was still a rim of inflammation or scar tissue or residual cancer. Granted, 100% resection is not even possible with GBM unless you resect the entirety of the brain, maybe spinal cord, too. The residual cancer, in a weakened state, will hopefully respond to radiation and chemotherapy. But even from my first post-op MRI, I had some ambiguity that I had to get used to. I don’t look for normal MRIs, or cancer free MRIs, just ‘stable’ or ‘unchanged.’ My neurooncolgist Dr. Priya Kumthekar, felt my tumor measured the same size. The resection cavity (black space), however, has enlarged a bit, which she attributed to treatment effect. That’s the best possible explanation. The radiologist felt the residual scar / tumor ‘slightly progressed’ compared to prior exams, but still possibly post treatment change. Continued “close follow-up imaging is recommended.” Thank you, doctor. I am fine with ambiguity. I am also fine with completely obvious recommendation by a radiologist.

Basically, it is a 9 week vacation until my next scan. If it was unquestionably the same, or ambigious, it wouldn’t change my summer plans unless it changed my treatment. It won’t make the next scan any more or less of an event. I would not hold it against the radiologist for hedging, or my neurooncolgist for giving a false sense of reassurance. In fact, the next scan could show clear progression, and she could still be right about the most recent scan. So, with this ‘clean bill of health’ for 9 weeks, I will carry on with my summer plans of a few adventures with my family, swim meets, maybe another triathlon, and get back on the comfortable side of the examining table.

Figure: Left, for some reason, I was getting a lot more respect around the cath lab while supporting structural heart procedures.  I am wearing this lead again.  Right, watching “our” Warriors crumble against the Cavs.  No melatonin means Connor lasts longer than me.

Anniversary

On the evening of June 22, I asked Staci if anything was going on June 23rd. I had it off after a few busy days at work.

“Our anniversary.”

That would be 1-5. Fifteen. No ambiguity there. I did not mean to forget it, I just did not want to make a big deal, so I repressed it. I get a little uneasy nowadays about putting ‘special meaning’ on annual events. Here is the lamest excuse for not getting a present: I wanted to keep things the way they were, not act like this has some special importance considering my health. That would put too much pressure on a present. We have spent multiple anniversaries apart due to random scheduling, either because I was working as a resident / fellow or moonlighting at the Ann Arbor VA. I spent my last night as an intern on the inpatient cardiology service June 23, 2004. Actually, the last few years have been the exception and we would have dinner together. On June 23, we celebrated by going to a dual swim meet against Rockford Riptide. Fitting. Tonight, we just got back from a 3 hour vacation to downtown Grand Rapids (without kids). Anyway, including our 8 years of dating, this is actually somewhere between year 23 and 24. No big deal.

I have not been reading for the last week, engrossed in the ESPN documentary “O.J: Made in America” with Staci. See? It could be worse than forgetting anniversaries. Too soon?

Figure: Left, anniversary date at Rockford pool.  Upper right, it is sort of a break with only one kid in the stands with us.  Lower right: our downtown Grand Rapids vacation.  San Chez, Fro Yo, Biggby.

Anyway, I am not sure what the secret is for a successful marriage. She brings balance to my life. Unfortunately, she would recognize that as a quote from Todd Chassee (about his wife), but it is true. We have similar lifestyles and habits, quirks that offset and fit together. For example, she’s passionate about interior design and I don’t care. No compromising since she gets to decide. 4 kids? Sure, why not, I thought. She packs the lunches and the bags and makes the schedule. She is our chef (unless it’s omelets). She is our cleaning lady. She is our coach.  She is our family team captain. She is my beauty queen. She is my best friend and lover. Happy Anniversary and to many more.