The Fight Against Terrorism

War and cancer have a lot in common. And there have been a lot more practical pieces written on war than on fighting cancer. So, as we try to decide the next step in our battle, let me refer to what is commonly known as the Powell Doctrine. Caspar Weinberger originally identified eight questions that need to be answered affirmatively before taking military action:

1. Is there a vital national security interest?
2. Are there clear attainable objectives?
3. Is there a complete cost/benefit analysis?
4. Have we tried everything else?
5. Do we have an exit strategy?
6. Have we considered the consequences?
7. Do our people support it?
8. Do our allies support it?

Powell's expansion to the questions was an assertion that once we choose military action, we must do so decisively, with overwhelming force and minimize our own casualties.

So, Bo has a form of cancer. We have two plausible diagnoses, similar, though they differ on the continuum of malignancy. Metastatic benign pleomorphic adenoma and myoepithelial carcinoma are both salivary gland neoplasms. Neoplasms are tumors, and the diagnosis has been complicated all along by the fact that they found a second tumor, relatively far from the first, that is histologically similar and in a node. Nodal involvement is generally considered worse than second tumors in some other sites because nodal involvement can signal lymphatic metastases which means the cancer has become more systemic. Like flus and colds. The conditions that can only spread through direct contact are a lot less scary than the ones that can travel through the air and live a long time. AIDS may be a scarier condition, but it is still a lot harder to get than tuberculosis or the flu which can become epidemic very quickly.

And in that way, cancers are like people. Some are very geographically specific. Jay has a very dear aunt who starts to get heart palpitations when she leaves Maine soil. Bless her heart, there was a time she was younger and more adventuresome and she could leave for short times, but she could never happily take up residence anywhere else. A lot of cancers are like that, they can try to move, but adjusting to a new environment, different food, weird neighbors, all takes too much work and they give up. Stronger cancers do take up residence in other places, they thrive and their children leave home, travel to distant places and successfully take over their world--and that world would be our bodies.

So that little node has always been our bugaboo. Is it just a freak accident like the first tumor? Pleomorphic adenoma is a relatively common benign neoplasm of the salivary glands--they are usually identified near the parotid gland, in front of the ear, but can also be found in other salivary gland tissues, including in the lung. In about 20% of people, they are removed and that's it. In about 60% of people, there is a recurrence, or a couple, they remove it again, and that's it. And in about 20% of people, this "benign" tumor metastasizes and becomes unruly. Myoepithelial carcinoma is our other diagnosis, higher in the malignancy spectrum and much rarer. Carcinomas are usually treated with chemo. But the problem is that the "epithelial" nature of the tumor makes it an adult cancer that is treated with adult drugs--as one of our oncologists said--"big guns" that are not normally used or tested on kids.

And so back to the Powell doctrine and the war on terrorism. It is very difficult to answer those questions affirmatively and commit to bringing in the "big guns," ever, it seems to me, and we won't get into politics, but I think Powell felt the same way. So, as we fight our little war on cancer, it is akin to fighting terrorists in our own country. What if we found out tomorrow that there is a terrorist cell in Columbia (or your town) planning a devastating attack? What if we know that we have one opportunity to drop just one bomb and end their plans forever, but it would cost the lives of about 1000 innocent Columbians and save tens of thousands, maybe hundreds of thousands more. What if we also know that the bomb would have to be dropped near the University reactor (or in your town a chemical plant, the dam or some other dangerous target), thus harming Columbia and Columbians, possibly forever. If you choose not to, they may fail this time and sulk away never to be seen again. More likely, they will continue working, with outcomes that could still be catastrophic. The Department of Homeland Security wants YOU to make the decision NOW.

It may seem like a somewhat twisted analogy, and it is extreme, but life and death decisions are made every day. Our newspapers the past couple days have been a forum for debating the recent police use of tasers that resulted in serious injury to a suicidal man. I can't imagine having to make those decisions every single day, I am having a hard time just this once. But that is where we stand, we have not been given a definitive treatment recommendation yet, but like the whole process, there is always a continuum. We know that we will have to choose either to watch and wait, or opt for some form of chemo. But by the Powell Doctrine, it is too hard to say that we are sure there is a national security interest and it is not possible to weigh the costs and benefits. Being in a position to decide to take definitive military action in a nine year old boy that may save him, but could also ruin him forever is an uncomfortable place to be.

In some ways we are very fortunate. We are pretty sure it is not pleuropulmonary blastoma or carcinosarcoma. But on the other hand those devastating diagnoses REQUIRE big guns--there is no alternative. Having to make decisions in a very gray world is very difficult and very scary. I kind if wish I could be more pessimistic or more optimistic and just "know" that we are lucky and everything is going to be great, or that we just have to do everything we can and go at it with everything we have because we can. I feel like Kermit the Frog when he sings "it's not easy being green," but he got the color wrong, if the muppets were in black and white, he would be just another shade of gray, and that's way harder!

Thanks for listening, giving feedback, and being there. Bo has had an amazing couple days. The support of the 11-12 DBLL National All-Stars has been awesome for him in a way I could never have imagined. And I like to think it's been good for the team--after losing their first game and adopting Bo, they are on their way to Regionals in Indianapolis! Could little DBLL send another team to Williamsport? They are fighting for Bo and he is fighting for them, good karma does make a difference, and spending time with them yesterday, getting to be a real boy again after six weeks of almost full-time hospital and recovery was great. He laid down on our bed last night after we got home and said in a very tired voice "Today was a great day." And so you all have a great day too, with love, Lisa