Cancer Taught Me Important Lessons and a Positive Outlook

Introduction

My first encounter with Cancer was early in 2004.  I didn’t know then that it was a huge understated preview to the real show.  Let me first introduce a dry synopsis of these encounters (click here to read the more detailed story of my cancer experience).  The insights and lessons learned follow, with the anecdotes and incidents that created them. 

First Cancer Appearance

It started in early June 2019, as a result of a dull pain in my upper abdomen. I immediately went to see my primary care physician.  A CT Scan showed a rather large, about 5” in size, tumor in my liver.   Connie my wife and I engaged into high gear in our pursuit of a solution.  The first step was to recruit an oncologist that we felt comfortable with to consult and direct us.  we chose Dr. Dawn Lemanne, who has been crucial in integrating several approaches and disciplines that complement each other.  It took several additional tests and seeing three specialists in one month to come up with a plan.  During this month we built our team of experts.

We decided to follow the plan that the surgeon Dr. Clary and his team at UCSD laid out for us.  It involved removing the whole, larger, right lobe of the liver.  However, if he did it right away, the remnant left lobe would be inadequate to sustain me.  His solution was to block the blood supply to the right lobe, and hence force the left lobe to grow.  During the following six weeks the left lobe enlarged and became adequate to support life on its own.  This procedure would also temporarily slow the growth of the tumor itself.

In Mid-July I had a portal vein embolization procedure done.  A CT scan I had five weeks later showed that the future left lobe remnant was large enough to support life.  The surgery at the end of August was successful.  Dr. Clary succeeded in taking it all out with negative margins; albeit a rather minimal margin in one area. It was Intrahepatic Cholangiocarcinoma (ICC), stage 2 without involvement of lymph nodes and no metastases.  Dr. Clary’s prognosis was that I had a 30% chance of living more than five years.

Dr. Dawn insisted on chemotherapy, due to the small margin and the possibility that cancer cells may still be present.  Soon after I started taking twelve chemotherapy infusions over a period of five months.  Along with it started the surveillance protocol I would follow.  Every three months I had a scan, be it an MRI or a CT, and blood tests, looking for recurrences.  It was already March 2020 when I finished the chemotherapy, right at the beginning of the Covid-19 pandemic.

First Recurrence of the Cancer

Eleven months after the conclusion of the chemotherapy a new tumor appeared in my liver.  Its size this time was only ½” when it was found.  Dr. Clary summoned his Tumor Board at UCSD again and they recommended to resect it out of the liver.  The surgery was in mid-April 2021, and in early May we came back home; returning to normal life.  Our team did not recommend adjuvant treatment, thanks to the large negative margins that Dr. Clary took out with the tumor.

Third Occurrence

Twelve months later in May 2022, I was serving as Rabbi of a congregation near Tampa FL. I maintained the surveillance protocol at MOFFITT Cancer Center.  They discovered yet again another recurrence during a routine MRI scan.  The oncologist there offered a palliative radioembolization treatment called Y90.  Their approach towards me was completely different from the way UCSD dealt with me.  I didn’t like their approach, nor their treatment suggestions, “Only palliative?” I asked.  I was not yet prepared for a palliative treatment, and looked for a curative option. 

Our team in San Diego concluded that surgery was not an option, and instead recommended systemic treatment.  We looked for alternative solutions in other medical centers, and found basically none, except for a novel combination of immuno‑chemotherapy.  Dr. Clary hoped that the therapy would shrink the tumor and then he could excise it.

Immediately after the 4^th of July I started the infusions back at home.  After the first four, the scans showed that the tumor shrunk considerably.  Dr. Clary asked me to continue with four more infusions and then let the body recover for six weeks.  He would then operate and remove the remainder of the tumor.  Indeed, the continued treatment was working well and the tumor shrunk even further.

The surgery took place on the last day of October.  To Dr. Clary’s amazement, he did not find any tumor at all.  Though, he did excise the presumed location of the tumor, based on the previous scans.  Pathology analysis verified that there were no cancerous cells in the resected tissue.  Rather they identified dead cells which probably were the cancer.  The conclusion was that the systemic treatment trained my own immune system to fight the cancer.  Hence no adjuvant treatment was needed.

Fourth Appearance

The fourth recurrence appeared sooner than we expected, only six months from the previous surgery.  It was small and located centrally inside the liver, without metastases.  It seemed to me that Dr. Clary could take it out with ablation, and not necessarily with a major surgery.  I was wrong.  The tumor was close to main veins and bile ducts, rendering a surgery or ablation too dangerous.  The Tumor Board recommended to start with systemic therapy that may be followed by radiation.  We soon learned that doing both treatments would be better, and Proton Beam Therapy was superior to X-ray radiation.  We convinced Dr. Clary to refer us to California Protons to begin that therapy.

The treatment started with an infusion of immunotherapy, and then a series of 15 daily high dose proton radiation treatments.  Immunotherapy would then continue once a month thereafter, for a year or so, similar to a vaccination.  Two months after the radiation a CT scan will show the outcome of the Proton Beam Treatment, and surveillance will commence from thereon.

Insights, Lessons Learned, and Viewpoints

Writing and reading have a linear nature: one reads a sentence, a paragraph, one at a time.  It might create a perception of an order of priority and a timeline.  The earlier part that is read seems to be first in priority or order of happening.  That is not the case here.  All the different viewpoints and lessons learned are intertwined and there is none more important than the other.  The order I write the following paragraphs is completely arbitrary, and all are equally important.  Please keep that in mind while reading and hold back that natural bias.

Be Your Own Advocate and a Key Member of your Care Team

It is all about you, your health and wellbeing. You and your loved ones are living with the health challenges around the clock.  Your caring team, no matter how much they care, do not have you in their minds all the time.  At the end of each day, you are the one that bears the consequences of those decisions and actions.  So, you might as well be the one that makes those decisions.  You are an important member of the team that cares about your health and the hub that holds it together.  Act as such!  A professional that does not see you as a team member, whose view is important, does not deserve to be on your team.

Educating yourself is a prerequisite for you to be able to make those decisions and manage your health.  Learn about your condition, possible treatments, read articles about cutting edge research relevant to your situation.  The purpose of this familiarization is not to replace the professional teams.  It serves instead two objectives:  First , so you can better understand the outcomes and consequences of the options the medical team offers.  Second, so you can ask questions.  Questions that challenge the thinking of your medical team and help you better understand what they explain end up with a better solution.  If you don’t ask, you’ll never know; and if you do, there is a chance that something different will happen.

Our team is a multidisciplinary one from various institutes.  Our first team member was Dr. Dawn Lemanne, a distinguished professor that specializes in Integrative Oncology.  She helps us managing the team, recommends the overall approach and helps us understand the scientific aspects of the issues.  We have consulted with oncologists, radiologists and surgeons and other professions around the entire world.  Johns Hopkins, MD Anderson, Sheba in Israel, OHSU in Oregon, and Providence in Santa Monica are just a few examples.  Eventually I received the treatments at UCSD CA and in Medford OR. Having many eyes looking at the problem only benefited the solution that was implemented.  There is no shame in asking for a second and third opinion.

Here are a couple of examples of how it worked.  Dr. Lemanne recommended performing two different tests on the tumor of the second occurrence.  One was a DNA mutations test and the other was sensitivity of the live cells to different chemotherapy drugs.  Yet, some of the tumor also had to go to UCSD’s pathology labs.  Dr. Clary did all the maneuvers to satisfy the needs of all laboratories in response to our request.    The oncologist at Johns Hopkins recommended the immuno-chemotherapy that eventually killed the cancer of the third occurrence.  My oncologist in Medford accepted that recommendation without hesitation.  That treatment had just been released from clinical trial and destroyed the tumor in half of the planned sessions.

Our own research and learning benefited us immensely.  We learned the risks in doing a needle biopsy on the first tumor and declined the procedure.  During the third occurrence Dr. Lemanne guided us in researching for relevant clinical trials.  Our research led us to visit a leading Gastrointestinal oncologist at MD Anderson TX.  Based on our independent research with the fourth occurrence we convinced Dr. Clary to refer me to Proton Beam Therapy.  So, don’t be shy.  Your research will lead you to ask questions.  The answers the team will provide you will enhance your understanding.  It might even bring the team to an “Aha” moment and make them consider something they didn’t think of before.

The approach at MOFFITT FL was the opposite.  The oncologist knew what was best for me without even asking me.  He decided for me what will be the treatment that I will take.  The radiologist there was following the oncologist’s referral and did not inquire what was my preference.  We disqualified MOFFITT as a team member, and returned home, after the discovery of the third occurrence.

Gam Zu L’Tova – This Also Will be Good

What’s in the title of this section? You may wonder. It comes from the name people attached to Rabbi Naḥum, the man of Gamzu.  Gamzu is two words, Gam and Zu, combined, meaning ‘this also’.  The reason for his nickname was that he used to say on everything that happened to him that it was also for the good.  The Talmud lists many incidents in which Rabbi Naḥum used this phrase that became part of his name.

Throughout my life, as probably has happened to many of you, I went through crises.  Many of them were serious, devastating, the kind that took me down to rock bottom.  Being down there, desperate and having no clue how I will get out of that situation, nothing looked good.  The feeling of loss, confusion and devastation were overwhelming.  And yet, I succeeded in climbing out of those situations.  Long after those events, in retrospect, I realized that the good state I was at happened thanks to that calamity.  When it happened the first time, I attributed it to coincidence.  And so was the second, and the third time.  But then, I realized that it was a pattern. 

Since then, I truly believe that whatever it is that happens with me, has something good in it.  Its not an insignificant, residual, portion, but rather bears major good consequences.  Most of the time, at a first glance, I will not able to tell what is good in what happens to me.  And sometimes I wouldn’t be able to recognize the good at all.  And the truth is that not being able to see the good is inconsequential.  The knowledge that the suffering leads to a future goodness, turns around the focus of my energies.  Rather than spending energy on feeling bad and lamenting about my fate, I take a positive attitude and adopt an optimistic demeanor.

This knowledge brought me to come to terms with whatever the outcomes of the first surgery would be.  I was OK with any possible outcome, including the one that I will not make it out of the surgery.  It enabled me to see Dr. Clary’s news regarding my chances to live 5 years after it. 

Don’t ask what is good in the situation that you are in now.  Believe that it will turn to be good.  This belief/knowledge will put you in a different state of mind, a positive one.  That by itself is good; the first good that goes with the situation.

You may ask me: what is good in the cancer you have?

I have asked myself that question when I learned that I had it.  My answer to myself, and to you, has two facets.  First, I don’t really know what, at the end of the day, will really be the good.  Second, having cancer sharpened my vision about what are the important things in my life.  What I need to focus on, and what to let go.  Here I am, writing about my experience and insights I gleaned from my cancer and am sharing it with you.  I believe that it will help – even if it’s only a single person – in one’s struggle with a serious disease.  Isn’t that awesome? Here is one good thing that came out of my cancer.

Integrate Means and Methods

This way of thinking goes with me back to my days in the Israeli Navy.  The practice we exercised when our boat was under a missile attack was as follows:  Head towards the incoming threat at flank speed.  Make sure that the ship’s Electronic Warfare (EW) suite is at full power, transmitting all possible suspicious frequencies.  Deploy the chaff rockets. Fire all weapons that the ship has in the direction of the incoming threat.  Pray.  It worked during the Yom Kippur War.  And no one knows, to date, which was the measure that saved the ship.

I told this story to Dr. Lemanne during our first visit, and it chimed perfectly with her integrative oncology expertise.  In addition to working and directing us through the mainstream approaches of treatment, she added many more means.  She explained and backed up every suggestion she made with scientific research, and provided us with the relevant references.  If I dared to share some examples, I must urge you not to implement them on your own prior to consulting with your physicians. I’m far from being a Medical Doctor.

So, a benign example was adding ctDNA liquid biopsy.  Now it seems more prevalent, but four years ago when I got the first diagnosis of cancer, it was not.  Today it is the gold standard for any cancer.

Applying a low carb – not keto – diet, limiting my daily carb intake to less than 100 grams, was another example.  The cancer that I have, she said, feeds only on glucose that the body creates from carbs.  Lowering the carbs intake will make the cancer growth more difficult, and may slow it down.  It also helps me to lose weight and arrive to a better Body Mass Index (BMI) that the cancer dislikes.  That wasn’t the only culinary suggestion she made.

Fasting during Chemotherapy and Immunotherapy was another one.  I started fasting (drinking water and tea) 24 hours before the infusion and continued for a total of 48 hours.  She told us that the therapy would be more effective that way, and provided the scientific references to prove it.  As much as it was hard to comply with, it had a positive side effect:  I had none!  I had to fast for 48 hours once a month even when I was off systemic treatments.  That helped to kill more cancer cells that may still be floating around in my body.

Looking into the composition of bacteria in my gut’s microbiome world was yet another novel approach.  Dr. Lemanne said that certain bacteria can counteract the effect of chemotherapy, and she wanted them out of my system.  After analyzing the list of several hundred bacteria in my microbiome, she recommended what food I should eat or avoid.  Along with that came a list of a few probiotic supplements, and other natural extracts to consume.

Dental health, saunas with immediate cold showers and physical exercise were also part of the list.  Recommendations for specific precautions during minor surgeries, I went through and prior to radiation came at the appropriate time.  None of them are part of the mainstream practice, and yet, all are scientifically proven to one extent or another.  “It may help,” she said, “in any case, it won’t harm you in any way.”

The message is that you may benefit from alternative methods IN ADDITION to conventional medicine.  It is important that you understand what are the benefits and side effects of that treatment.  And you need to full heartedly believe that it will help you.

Set Goals to Look Forward To, Think Positive

Victor Frankl (1905 – 1997) was an Austrian psychiatrist and Holocaust survivor, known for his book, “Man’s Search for Meaning”.  He described his experience in living through having survived the Holocaust and introduced his Logotherapy psychological theory.  There is a single key point in his book that I took to heart.  Prisoners who had rich inner lives, future-oriented goals, and found a meaning in their suffering were more likely to survive.  In the horror of fighting cancer, though vastly different  from the Holocaust, these ideas did, and continue to, serve me.  And it takes a large doze of positive attitude and thinking to set these goals.

Before I knew about my cancer, I was committed to join and lead a congregation in Hawaii through the High Holidays.  For that I had to be in Hawaii by the 26^th of September 2019.  I was very excited to lead the High Holidays services, the first time as a Rabbi.  When Dr. Clary scheduled the surgery for the 26^th of August, I shared with him the commitment I had.  “I wouldn’t take that commitment to the bank.” was his response.  He envisioned me staying a few days in ICU after the operation, and at least 8 days before being discharged.  And then I would still need to stay nearby for a few more weeks, before he would release me.    

Breaking my commitment to that congregation was not an option.  They would not be able to find a rabbi to replace me in such a short notice.  It was something that only I could do, and I had to do it, no ifs, ands or buts.  Driven by this urge, I started walking the morning following the surgery.  The next day, I climbed up and down stairs, alongside the physical therapist who carried the pole with the instruments.  It was Friday, four days after the surgery, when I left the hospital.  This mission that I, and no one else, had to complete, was a major contributor in making this miracle happen.  I did lead the High Holidays in Hawaii.

Setting these types of objectives became a habit.  During the struggle with the third occurrence, I felt the need to visit Israel and celebrate Yom Kippur there.  I had to be with my family in Har Halutz, our community before we moved to the US.  It was decades since I last celebrated a holiday with my brother and daughter.  I wasn’t sure that I would have another opportunity to experience a “once in a lifetime” inspiring moment.  What a blessing!  We, my daughter and grandkids, my brother and his daughter, spent Yom Kippur of 2022 together with our Har Halutz community. 

And at that very visit, we set the next objective.  I will officiate my brother and sister-in-law’s renewal of marriage vows, after recovering from the cancer I had then.  In April 2023, we all were fortunate to celebrate this re-marriage, along with having the Passover Seder together. 

My current objective is to celebrate together with my nephews and nieces and their extended family, my sister’s 90^th birthday.  After all, it is a once-in-a-lifetime event, that I must attend! And for that, I need to heal and recover from the cancer that I currently have.

Share, Build a Spiritual Support Group

In the Bible, Numbers 11, we witness a conversation between Moses and the Eternal One, a conversation worth learning from.  Moses complains: “Why have You dealt ill with Your servant?  What have I done wrong that You have laid the burden of all these people upon me?”  Moses complains about the emotional and spiritual burden.  It is so bad, that Moses asks: “If You would deal thus with me, kill me rather, I beg You!”  The Eternal One’s solution was: “Gather seventy of Israel’s elders of whom you have experience with.  I will put upon them some of your own spirit.  Then they will share the burden of the people with you, and you shall not bear it alone.”

If this advice from the Eternal One was good for Moses, it certainly is perfect for us.

Throughout all my encounters with cancer, including the first, testicular cancer, I never hid it.  I talked about it very openly with family, friends and colleagues.  My demeanor helped all those around us, who we cared for, to offer thoughts, help, and express compassion.  There was no embarrassment at all for either of us.  It made me feel better, as if a heavy stone has been removed from my heart.  And my family and friends also felt better.  At least, they didn’t have to tiptoe around me.  

During my first two occurrences of the liver cancer, I used CaringBridge to communicate with our family and friends.  We updated everyone about the progress I was making, shared photos and received words of encouragement in response.  Reading all the comments and greetings was a delight to my soul, and elated my spirit.  It notched up my resolve to recover and fueled my energy resources to succeed in it.  All those who signed into our CaringBridge account could see and share comments and responses, thus creating a virtual community.  This community amplified the effect of mutual support, perhaps at a cost of less privacy to individuals.  Yet, a tool worth trying out in time of need.

Lately I started using newsletters that I send to my friends that have agreed to be on my mailing list.  People may sign up to receive these newsletters through my website and also may remove themselves from that list.  Many are responding to me with their words of encouragement, and sometimes we are having an ongoing dialog.  I chose this method over CaringBridge out of respect to peoples’ privacy.  I hope that without the concern of “what others will say” the responses are more genuine and personal.

As time goes by, I’ve learned from many of my friends that these communications inspire them.  Some have said that this “spiritual” community they are part of, changed their approach in dealing with their own burdens.  What a blessing!  Knowing that amplifies the effect on me and further lightens the burden.

Gratitude and Prayers

There are so many things to be grateful for, be it small or majestic.  Being grateful changes one’s demeanor and turns it to being positive and uplifting.  It diverts our energy from wasting it on feeling pity and being angry at whatever brought that calamity upon us.  Instead, our energy, already lessened by our situation, turns towards positivity, healing and rebuilding our own strength.

You may ask:  What is there in being grateful for having cancer?  There are so many things to be grateful for and we only need to look for them.  They are right there, in front of our eyes and under our noses.

I am grateful for all the miracles that have happened to me.  Being cured three times (and counting) against all odds from the tumors in my liver is certainly a miracle.  The lightning speed in which I flew through the medical system from tumor discovery to a curative treatment is another.  And there are countless more small miracles to be grateful for.

I am grateful to no measure for the kindness of people.  Dr. Clary is the most compassionate, understanding and accommodating physician I have ever encountered.  Dr. Sander for her kind support and humility, putting my wellbeing in the front and center of her decisions.  I can’t thank enough all the nurses, technicians and paramedical team members that I have met along the way.  They all expeditiously did everything I needed and asked for with a smile and warm concern.  The staff and members of Congregation Beth El who graciously filled my spiritual needs during my treatments in San Diego.  And last but not least, are you, friends and family, Aliza and Connie, that walk by me along this journey.

Above all, I am grateful to Eternal One, for all the good that He bestowed on me.  Both for  the good that I experience and recognize, and the unknown good that will manifest itself in the future.  I truly believe that the Acts of the Eternal One are materialized through the actions of people and the Creation.  The Eternal One inspires and instills the motivation to act, knowingly or not, in the hearts of people.   Being grateful to the kindness of people is also an expression of gratitude to the Lord.

Gratitude and prayer go hand-in-hand and are in fact, two sides of  one coin.  Most of our prayers and hymns are expressions of gratitude.  Even our pleas include gratitude.  Many times they start with gratitude, expressed by the words ‘Barukh Ata..’ – Blessed are You.  For certain, all ends with gratitude: Barukh Ata HaShem, Shome’ah T’fila – Blessed are You, Lord, who harkens to prayers. 

Elsewhere in my website I have elaborated on prayers for healing.  The Maimonides, a great 13^th century Jewish philosopher and physician, recited a prayer before he started his daily practice.  There are also the prayers for healing of the sick.  I do believe that they help, and there may be some scientific evidence to that effect.  The articles, Thoughts About Healing Prayers, and Healing Prayers – An Inspiring Conversation with My Friend may be of interest. 

Every morning, upon waking up, I recite the traditional prayer: