This morning, my wife and I were talking about cancer. If you’ve read earlier posts from me, such as there are here and here, you’ll know that twenty-eight months ago, I was first diagnosed with high grade bladder cancer, and after two years of chemotherapy, it seems like the cancer may have returned. I had another small tumor surgically removed yesterday. The surgeons sent specimens of the tumor to the lab, of course, but more importantly, they also sent specimens of the muscle tissue immediately proximate to the tumor to see if there were cancer cells in the healthy muscle tissue. If not and the cancer in the tumor is confirmed, then I’ll be facing more chemotherapy or perhaps immunotherapy if BCG is finally available. If there are cancer cells (even a few) mixed in the muscle tissue, it will mean my bladder and prostate will have to be removed and my life will proceed on a different trajectory. It will be what Hegel would call a synthesis in terms of his dialect. So, let the hunt begin!
We talked at length about the more metaphysical and philosophical aspects of cancer. Deena mentioned how my doctor called cancer “sneaky” and I mentioned “smoldering” multiple myeloma. From there, our discussion became increasingly freewheeling and speculative.
My wife and I have travel plans for the summer. It doesn’t matter what the tumor will turn out to be. The tumor is gone now and regardless of whether it was malignant or benign, our summer will unfold as planned. But …
If the muscle biopsy shows cancer cells, then all bets are off and I may observe Independence Day independent of England and independent of my bladder as well.
People deal with cancer in different ways. Some people practice visual or guided imagery. Ruth Carter Stapleton, the late sister of President Jimmy Carter (also of late) practiced guided imagery when she had pancreatic cancer. In a meditative state each morning she would visualize in her mind her cancer as a serpent in her body and would “see” an imaginary eagle fly down to reach in and grasp the serpent, pulling it out of her, much as the eagle pulled at Prometheus’s liver. Unfortunately, in the end, Ruth Carter Stapleton died of pancreatic cancer. as most patients do. In my mind, I see a cancer cell as a hungry wolf, silently staring while slowly stalking the innocent sheep representing (to me) the healthy cells in my body. The wolf is always in the distance, among the trees and rocks, watching, waiting for a chance to creep in among the healthy cells of my bladder and my body unobserved, only to savagely attack at a time of its choosing and when least expected. In good times and bad, rain or shine, day or night the hungry wolf lurks nearby. As the British group Duran Duran sang:
“Burning the ground, I break from the crowd I’m on the hunt, I’m after you Scent and a sound, I’m lost and I’m found And I’m hungry like the wolf Strut on a line, it’s discord and rhyme I’m on the hunt, I’m after you.”
Cancer cells, like wolves, do not always immediately attack. They can remain dormant for years. Take Wilm’s tumor (nephroblastoma.) When I taught at the Air Force’s School of Health Care Sciences in the 1980’s, it was in our course content and we were required to discuss it. It appears in girls a slight bit more than in boys, and does not appear usually until the child is between the ages of 3-5 years. Why then? Why 36 months after birth or sixty months post-natal? The working hypothesis back then was that a child is born with the “seeds” of cancer (oncogenes?) But the cancer is “set” to activate almost always only during that narrow time frame. Even today, scientists don’t know the answer to this question with certainty. And then there is bladder cancer.
People as young as perhaps seventeen can develop bladder cancer, but the typical age is 73. My bladder cancer emerged when I was 73. Why then? If it was triggered from hormones, infections or smoking, then why not when I was much younger? If it comes from exposure to pesticides, then why does it take decades to “out” itself? I’m on the Agent Orange list and I’m told my bladder cancer was presumably from exposure to dioxin when I was in Vietnam (in 1971.) Where has it been all this time? What has it been doing?
Sometimes cancer cannot be picked up by scans and tests. Based on someone’s blood values or immunoprotein levels (e.g.., immunoglobulins, etc.) you can infer the existence of cancer, but cannot catch it red handed. Suppose, for example, your house fills with smoke, most of us would think there is a fire somewhere even if we cannot find it (else, where is the smoke coming from?) So it is with cancer. Sometimes cancer just hides, like a wolf in a flock of sheep.
There is also a phenomena called “micrometastises.” This is when individual cancer cells or small groups of cells find their way into other organs. Rather than a brute force frontal attack on the patient’s lungs, bones or brains, these little critters hide among the normal cells, like a wolf hiding in plain sight, minding its own business until months or years later when they state proliferating. We think there are “switches” that cause it to grow or spread. We have just not either discovered them or learned much about them.
The location that cancers develop in can in some cases conceal the emerging threat. Cancer in the brain and in other parts of the body where there is deep tissue often have the opportunity to grow fairly large before they are noticeable. Ovarian and pancreatic cancer frequently does not announce themselves until they have been present for a while, and even then symptoms can be quite vague making a differential diagnosis challenging.
Cancer cells can also “disguise” themselves from the cells in the person’s immune system in order to appear harmless or otherwise unremarkable. This suggests an intent or a choice, but it must be Darwinian genetics or just plain luck. In other cases, cancer cells can manipulate their environment to make it more cancer-friendly.
It is perhaps because of this “smoke and mirrors,” “now-you-see-me, now-you-don’t” behavior of cancer that explains why many oncologists prefer to not tell their patients that they are cured or cancer free. That and the limitations of current technology, the tendency of some cancers to return, the nuances between the terms “remission” and “cure,” and the fear of creating false hope in patients through error (see “The two types of errors” below) leave many patients dangling through no fault of their doctor.
Cancer, particularly bladder cancer, spreads through local invasion, lymphatic dissemination, and hematogenous metastasis. The cancer starts in a specific area of the body and then spreads to surrounding tissue, the way an invading army might envelop the surrounding territory as it secures a foothold. As it speads, it does so in three directions by entrenching itself deeper into healthy tissue in the process. Using different methods, it can slip by and pass through barriers designed to contain healthy cells.
A three-D representation of a single urothelial cancer cell. The wart like “bumps” appear to be papillary structures which assist the cell by increasing its surface area and interaction with the surrounding tissue. The “tentacles” are cytoplasmic projections (filopodia) that either anchor the cell or assist the cell in moving place to place. Credit: PRB Arts (Adobe.)
The lymphatic system of your body is a network similar in structure to your circulatory system (but only broadly so. You cannot put too fine of a point on it) In some ways, the lymphatic system can be compared to a storm drainage system which collects excess rainwater plus whatever debris such as dead leaves and trash that are found in ditches and along the roadways. Thus, dead cells, pathogens and toxins flow through the lymphatic system of your body. But your lymphatic system is much more than that as well. A sewer system is passive. Once it is cleaned out, it runs on its own. Your lymphatic system is active as it contains T-cells, B cells and macrophages to isolate and attack dangerous cells such as cancer cells, though occasionally a malignant cell can slip by. And it only takes one rogue or maverick cell to spread cancer throughout your body. Bladder cancer cells can spread to your lungs, bones, and other organs. It can do this through the lymphatic system or the circulatory system, because the two networks interact together. Yet, a bladder cancer cell that takes root in your bones does not become bone cancer. It remains as a bladder cancer cell which attacks your bones nevertheless with equal relish and mortal consequence.
A hypothetical urothelial cancer cell was programmed to be a normal bladder cell found in the inner layer of the bladder, but there was a “glitch in its matrix.” One misplaced digit in a string of coding. This glitch gave it a new identity and repurposed it. Eventually, it entered the lymphatic system under attack from other healthy cells in the bladder. It drifted lazily downstream, like a leaf in a slow-moving river. Here, it pretended to be a protein to avoid detection from the macrophages, the T-cells and other immuno-defenses that it passed along the way. It approached its first lymph node, but the node was jammed up with killer cells. No room for it to push its way in and too great a risk of detection. Instead, it drifted past other nodes to the point where it could enter the blood stream. Up ahead it sensed several virus cells mixed in with the blood cells. Another threat. Today, some selected viruses can be reprogrammed to attack cancer cells.
Other considerations
Cancer cells can stimulate the production of lactic acid in the body which makes it difficult for your body’s immune system to function in any particular area.
Some cancer cells can learn to repair their DNA which makes it difficult or impossible for a drug to disrupt the cell.
Cancer cells mutate routinely and some mutations favor the virus by making the malignant cell more resistant to the treatment. A chemotherapeutic drug may be designed to disrupt a certain protein in the cell, but a mutation affecting that protein renders the drug ineffective. Also, cancer tumors have stem cells that cause the next generation of malignant cells to be more resistant to the cytotoxic medication.
Psych Ops
Cancer creates fear which it uses to its own advantage. The hypervigilance involved in “watchful waiting” burns a lot of energy. Every ache, pain, cramp and so on makes one wonder whether the cancer has returned and if the concern is misplaced, it can lead to error as well. This continual focus can consume a person. They may become fairly paranoid. Trauma, memories, even future possibilities of additional sequelae create continuing trauma to deal with, even if one for the moment appears to be cancer free. Understanding and confronting your fears is helpful, as are support systems of friends and family members. Adaptive coping methods (such as recreational activities versus maladaptive coping mechanisms involving drugs and alcohol have worked for many in the past. Another area to deal with involves anxiety. There may be medicines that your doctor can prescribe and there are stress reduction techniques that also control anxiety. Perhaps meditation, for example. Faith is important as well to many (and particularly so in my case.)
Contemplations
So, I’m sitting here wondering where the wolf is at this very moment. I don’t know for sure. I’ve heard his mournful howl in the night. The pathology lab is at this very moment trying to get a fix on it. Once I hear from them, I can get my bearings. But I know the wolf is hungry and does not give up the chase. I escaped from it two years ago, and had a much more harrowing encounter only several days ago. I may not be as lucky in the months ahead. With my new cT1 staging when the most recent tumor was removed on Tuesday, it seems that I have three options if my muscle tissue is clear: One is to continue chemotherapy, but that has not kept this particular wolf at bay. Another option is BCG, but that is in short supply in the U.S. and I don’t know if my clinic can get it. The third option is to sacrifice my bladder.
I’m not sure what my urologist will advise when I see her on June 19th. Even if the wolf did not cross the red line this time, my doctor may advise me to get my bladder removed now (at age 76) rather than wait until I am closer to 80 if she feels that removal is inevitable. I do know her recommendation will carry a lot of weight with me, as well my wife Deena’s advice. She has been caught up and battered in this journey with me as well. And if I must undergo this surgery, then I really don’t have a choice either. It will likely be an ileal conduit that I get because it is a shorter procedure and safer, particularly given my several comorbidities.
I see myself as an old mariner that has made many ocean crossings, and now I am in a storm, close to shore fortunately, but then the rocks, reefs and shoals that follow the shore make my position especially perilous. I have my faith to weigh against my fear, but this will be one heck of a ride either way.
The two types of errors
When it comes to diagnosing cancer, there are two possible errors that can be committed, both by the patient and/or the doctor. A type I error is a “false positive,” when it seems there is cancer but there really is not. As an example, a woman might discover a breast lump which she fears is cancer, but it is actually benign. Until that diagnosis is confirmed by biopsy, then the patient may go through a good deal of alarm and anxiety.
A Type II error is when the patient and doctor should be alarmed over a sign or symptom, but they unfortunately are not. For almost three months before my bladder cancer was diagnosed, I had intermittent episodes of hematuria (blood in my urine.) If someone had told me that they had this same bleeding, I would have told them to get to a doctor post haste. But I was in no hurry, largely because I was on a new medication and was told by an authority that the medicine sometimes changes the color of the patient’s urine (including to make it bloody in appearance) so there is no reason to be concerned in that case.
JUNE 19, 2025
My pathology report did not note any evidence of cancer, so my urologist was in a celebratory mood, which was infectious for my wife and I. My thorough examination on June 3rd did not reveal any wolf bite. In fact, there is no sign of the wolf at the moment. However, a person who has had cancer can never truly let their guard down. Once the wolf has chosen it’s prey and tasted its blood, the hunt goes on. This is because my cancer, like the wolf, is hungry and must be satiated, tomorrow if not today. Yet, because malignant tumors generally do not pop-up overnight like mushrooms, my wife and I will have a few months to enjoy life together, knowing that there is a good chance we’ll see the wolf again.
Afterword
This post continues here as it appears I have another tumor.
Journaling helps me though difficult times, and I hope that these words may likely minister to you as well. You are welcome to contact me through the comment section of this post or the Contact menu option on the page header.
Teaching your body to fight back!
A hybrid virus ghastly as a ghost looms large against several rogue cancer cells as it moves in for the kill. The cancer cells are not bladder cancer cells, however. These cells (called oncolytic viruses (OVs) can be naturally occuring or specially engineered to target different types of cancer. In oncology, there is a so-called “seed and soil” hypothesis which states that stray cancer cells that enter a new organ can be compared to plant seeds, and for plant seeds to grow, there must be good soil present or the seed will not thrive. This hypothesis is more than 130 years old. Not every cancer cell that enters the lympathetic system or the circulatory system and travels to the lungs or the brain will necessarily proliferate. Apparently, different types of cancer (seeds) are more compatible with the “soil” (environment) of a distant organ. For example:
“Colon carcinomas metastasise usually to liver and lung but rarely to bone, skin or brain and almost never to kidneys, intestine or muscle. In contrast, other tumour entities, such as breast carcinomas, frequently form metastases in most of these organs. This specific formation of secondary tumours at distant sites appears to require the successful completion of a number of steps by metastasising tumour cells “
See the following for more information: Ribatti D, Mangialardi G, Vacca A. Stephen Paget and the ‘seed and soil’ theory of metastatic dissemination. Clin Exp Med. 2006 Dec;6(4):145-9. doi: 10.1007/s10238-006-0117-4. PMID: 17191105.
Photo credit: CI photos (Shutterstock) upper right photo. A variation of the engineering process appears below courtesy of Adobe. Again, the cancer cells are under attack by an engineered blood cell. In the context of this post, it could be described as “Man bites wolf.”
