November 4, 2014

Dear Friends,

Each of you has asked that I keep you up to date on my journey through the woods of bladder cancer, so here is the scoop.  Most of you know I've been scheduled for surgery this coming Thursday.  The cancer I have is an unusual one and in an unusual site: a single tumor in a diverticulum (a little balloon) that extends an inch or two or three outside of the bladder proper.  That tumor was actually removed in late September, but all the urologists I've seen agree that that removal is highly unlikely to have been complete, meaning that the tumor will recur--and spread--without further surgery.

Thus, after a certain amount of medical controversy, and of first, second and third opinions, I am scheduled to have surgery at the UW Medical Center performed by Dr Jonathon Wright--agreed by all who know about these things to be a first-rate urologist and surgeon. The planned surgery is a partial cystectomy, meaning the removal of part of my bladder--the part with the diverticulum.  This surgery is unusual, mainly because the standard treatment for bladder cancer is complete cystectomy, or a full removal of the bladder.  Some 4000 cystectomies are done each year in the USA; something like 300 partials are done each year.  So the number of surgeons with much experience doing them is not high, and that is the main reason my surgery is being done not by a Group Health doctor (I've been with GHC since arriving in Seattle 40+ years ago) but by someone outside.

Like the course of true love, this run up to the surgery has not run smooth.  The stakes are high, obviously, and everyone would like to make sure all due care is taken.  And all would have run true except that a preliminary CT scan done two weeks ago showed a "suspicious" spot on a rib, meaning that there had possibly been a metastasis of the original cancer (which is what actually kills you when you get bladder cancer--its jumping to other parts of your body).  That was a shock, and triggered a new scan, this time a nuclear bone scan, which was negative--and was therefore good news.  The suspicious spot was no longer suspicious.  The week of waiting for that wasn't a lot of fun, but you do get sort of gloomily accustomed to the uncertainty.  That the new scan found nothing wrong made me as happy as one can be when still facing serious surgery.

Unfortunately, this Friday morning, at more-or-less the last minute, I learned that one of my docs had decided that the nuclear bone scan was not thorough enough, and that I should therefore have yet another scan, this a PET scan which can give even more detail than can the bone scan.  This is less often done, and requires an internal referral process within GHC.  It was requested Friday, and cannot even be scheduled until the referral is approved.  So that may prevent the surgery from taking place on Thursday.  This has been upsetting.  It is an unusual step, and I don't actually understand fully why it has arisen.  It is worrying both because delay does not in general seem a great idea, and because surgery dates are not that easy to come by.  Rescheduling may put me into December--all with that very-likely-still-present cancer ticking away.

In any case, that's where I am.  I'm reading books with strong plots.  I'm playing too much Freecell, and I've cut back my already low intake of caffeine and red wine.  But I'm still up and about--the cold that showed up last Wednesday aside, I actually feel just fine.  A weird experience all around.


November 17, 2014

It's been almost two weeks since my last update, and several things have happened. First, I met with Dr. Wright to review the films of my innards. These made clear that the "lesion" (vs. tumor--same meaning) has been in my body longer than had seemed true when we first began this journey. It has likely been there many months, perhaps a year. Its appearance in the diverticulum was deceptive, and my urologist was unable to see clearly enough in there to assess it as accurately as he thought he could.

That means that it has grown more than was first supposed, invading the fatty tissues outside the bladder wall. Some of this was to be expected--these cancers are burrowing malignancies. There is, however, enough growth to create a challenge for the surgeon in a number of ways. Wright was at no time cast down by the challenge--you like confidence in a surgeon--but he was clear that this was not an easy pull. There are some bits and pieces of me that may have to be removed, though nothing described yet will cause significant future impairments.

But because the lesion has grown as far as it has, Wright has contacted a radiation oncologist who can do inter-surgical radiation therapy. It may not be necessary, but my guess is that it will be used. I meet with him on Wednesday afternoon.  Obviously, having the site exposed during surgery makes it relatively easy to zap what needs zapping. There may be follow up radiation as well.

All of this has been discussed by the UW tumor board, and they wanted as well complete certainty that there had been no metastasis to my ribs--a possibility suggested by the earlier CT scan (and ostensibly, but not, it turns out, completely, ruled out by the bone scan described in an earlier note). That required a PET (Particle Emission Tomography) scan, done last Thursday, the results of which were that the suspicious spot was NOT cancerous. That is good news, of course, and I think clears the way for setting a new surgery date. I'll let you all know when I have news on that front.


PS--if any of this is Too Much Information, let me know and I'll take you off the list.  I understand completely.  I'm pretty tired of it, too.


November 17, Addendum

Just got the update from Dr Wright: surgery is now scheduled for 24 November--next Monday.



November 21, 2014

It's the Friday before Monday morning surgery and it feels as though there is a great deal to get done in just three days. Probably not true, but because I will be gone for much or all of the next week, it's like planning a trip away.  The wonderful Kristi Plett (of Pets Dig Me [and they actually do!]) will be looking after Mercy; Robin will be looking in on her as well.

I met yesterday with the radiation oncologists who will be available for the intra-surgical radiation therapy.  They may not be called in, but I would be surprised if they were not, given what Dr Wright showed me on the CT films ten days ago.  This is not a technique available everywhere, though neither is it totally rare.  Still, it's one more reason to have troubles of this sort in Seattle.  Both docs were impressively informed and had clearly not just talked with Wright and studied the films but thought out a set of possible scenarios as well.  Should they in fact take part, the surgery will be lengthened by about an hour--a small increase in risk, since all anesthesia carries risk.  There may as well be some post-surgery followup radiation treatment.  Risks from these procedures themselves should be low, again, and not as sickness-inducing as some other kinds of radiation.

So the surgical team is ready at the U; now it's my job to sort myself out over the weekend.  Concentration hasn't been my forte for the past month, but I did manage to rehang the symbolic shower curtain--a curtain I put up about ten years ago and which suddenly fell down about three weeks back.  I tried to reinstall it twice; each time it stayed up for a few hours and then crashed down again.  At that point a medical emergency arose (with which I won't trouble you all), and I just showered without a curtain for a while, trying not to soak everything everywhere.  But tonight I went to work on it, and it will not crash down again. Well-anchored indeed.

I still don't know how long the hospital stay will be; it could be two days, and it could be a week.  It all depends on decisions Dr. Wright makes once he actually has uncovered the area and seen what the tumor has done.  At one end of the spectrum is a relatively minimally invasive partial cystectomy and tumor clean up; at the other end would be a full cystectomy with damage to a good part of the lower abdominal area.  That still seems unlikely, but stranger things have happened--I have seemed a kind of medical sport of nature for the past few years, at least in the urological realm. The thing is, this actually is serious surgery, and the stakes are not yet finally clear, and they won't be before sometime Monday mid-morning.

That said, I'll be watching the Seahawks on Sunday, and I plan on sleeping through the whole thing on Monday. 



November 23

I report to the UW Surgery Pavilion in just 12 hours; food stops at midnight.  My son Gabe and my long time friend Robin will both be there for the duration, and Gabe will send you all an update/updates as it/they seem/s appropriate.  Thanks to all for the conversations, notes and encouragements; they are a big part of building an aura of comfort as I make my way towards this big deal.



December 5

My computer has been acting up, and refusing to send mail.  But Rob helped me at long distance, and I think this will now go. So—

It is day 11 post surgery.  Recovery is slow, and it has been complicated in ways both real and imagined.  But I'm getting there, and hope it just keeps moving on one step at a time.

The good news is that the pathology reports are back and they are with one exception as good as they could be.  Negative margins all around (a positive thing!); no cancer cells in the lymph system. And (the exception--though not all that much) the one spot where the negative margin was least, and possibly even non existent, was targeted with the intra-surgical radiation treatment and dealt with it in ways the radiation docs think will be effective.

The price of this is a lot of recovery.  They did a good deal of pushing stuff about, removing lymph nodes, removing whatever needs removing.  That means trauma, and I certainly have lots of that, along with a certain amount of nerve inflammation.  The main thing is that I feel really knocked down energy-wise.  I just can't do much at all--getting out of a chair is a chore.  And getting upstairs requires a pause at the top for deep breathing.

But I can do much more today than I could on Monday or Tuesday--we'll just see how long it takes to be back to some form of normal energy level.  Because this is more than expected, I will be staying with my brother Paul a little longer than I had at first thought--probably into Monday or even Tuesday.

That's the way it is--

Thank you all for your support--it has meant a great deal to me,



December 9, 2014

I've now moved home from my brother and sister-in-law's house.  They were terrific, and really made it possible to survive the first ten days out of the hospital.  This really was and in many ways continues to be an ordeal.

But my gut is getting better slowly; my energy level is much better able to match the challenge of sitting in a chair and of climbing a few stairs; my other functions are getting closer to functional. But it's still a big pull.  My docs said it would be at least a month before I was feeling anything like normal, and that now seems realistic--though potentially a little too positive, especially since radiation therapy will come next.

I won't go on about it all; I know that many of you know just as well as I what this sort of thing demands.  And now that the worst is through, it probably makes sense to discontinue the updates.  I'm happy to answer email; indeed, I won't (as the expression goes) be getting out much.

Thank you for your notes, your support, your good will.  They really did make a difference.


December 18

I shall not swear off updates again, though I will still hope that this can be my last.  In fact, a few hours after I sent the last update out, a new problem arose to put me back in the hospital for another week with a new collection of fluid in my abdomen.  They drained this, and while they awaited cultures of the fluid they put me on serious intravenous antibiotics.  The cultures came out clear, but the fluid also returned, necessitating on Monday the installation of a new drain--in effect replacing one that had already been there, though draining a different location.  The new drain should be coming out, too, either tomorrow or Monday.

Once that's done, the only thing left beyond recovery is radiation.  They have already done 20% of the possible radiation during the surgery proper; the rest will begin and run for as much as four weeks next month.  No chemo--not effective in cases like mine.

The experience, obviously, has been draining--on Tuesday shortly before my brother came to pick me up I had an unexpected moment of pleasure when a group of three Seahawks showed up to tour the ward.   The one I could recognize was Paul Richardson, the first year receiver who had his first TD reception last week, but all three (along with a Sea gal) were lovely people willing to spend some time with strangers.  I was surprised at how much my mood improved through the visit.  I include a picture below--


December 31
Well, it's been a slow week.  They removed my drainage tube a week ago; that was a traumatic experience.  Unexpectedly something went somehow wrong and what should have been a virtually pain free procedure went stellar--as in seeing stars.  But once it was done I figured there would be smooth sailing ahead.

Well, yes and no.  Sailing is ok, and I don't have a lot of pain, but neither does it abate much.  And sometimes it really starts to get going.  When I asked about it they asked me to come in for a scan and exam on Friday.  I was declared ok, and told that I was just going to be slow in recovering.  I have gotten a little more strength, but my concentration (or "mentation" as the docs like to say) is weak.  I started to write this note yesterday, but have become distracted ten times between then and now.

And that's the thing at this point.  I'm not in a fog, or a confusion—just not real good at focusing or concentrating.  And then there's just the more general abdominal distress.  Recovering from so much anesthesia is another thing that seems to take a whole lot longer than I could imagine.  I am getting there, but it really is one day at a time—with this nostrum one day, and that another--trying to balance what my digestive tract is going to do.

We are moving ahead, however.  Monday was a consult with Dr. Edward Kim, the radiation oncologist who took part in my surgery and did the intra-surgical radiation treatment.  The hope is that he will be able to continue to coordinate my radiation care—I find him a remarkable person, empathetic as well as the other things you'd expect, like smart, and well-informed.  They say they like to begin radiation within 8 weeks of surgery—we are now in week 6.  They have explained several of the side effects radiation therapy can have, none of which sound like fun.  Most likely is fatigue, setting in seriously in weeks 4 and 5, as well as more digestion trouble. Dr Kim even suggested I think about getting someone to help with transport to and from the Med Center when we get to that point.  But that story has yet to play out.

Finally, again a thanks for the food help.  You have been amazingly supportive.  The first week or so I had trouble just opening the containers and finding a way to eat.  I couldn't even put salad dressing on lettuce.  It's hard to explain the challenges of that week.  Now I can assemble things, and I've gained back some of the weight I lost in the hospital (no longer quite the same John of Gaunt).  I'm looking ahead to a time when I can declare myself out of food danger, and it is coming.  I'll be talking with my food health advisers about this soon, but again, in the meantime, I do indeed most appreciate your kindnesses.



January 11

Today is January 11, and the ongoing melodrama of my post-surgery life has taken a series of turns, some quite dramatic.  This entry runs a little long; I hope it deserves the length I've given it.

Up until last week I had been operating (!) on the principle that care begun at UWMC would be continued at UWMC; that had been true through surgery, and as we moved on to radiation therapy my UW care team had been expecting the same.

But that ran up against Group Health's initial assessment of my needs.  As many of you know, GHC also is equipped to do post-surgery radiation therapy, and on the principle that what they can do themselves should not be referred out, they denied coverage for radiation through UWMC.  This decision could be appealed, but my somewhat broken condition meant that I wasn't much able to address appeal issues for the next two weeks—one in the hospital and a second with my brother and sister-in-law in West Seattle.

Upon arriving back at my own home on or about the 20th, I again began to sort out the radiation issue.  I won't detail this here—suffice to say that after several requests for coverage and several denials, when a final request was made by my UW docs in the last week of December, this supported by better documentation than had been sent before, the reply was still negative.

A Parenthetical: I actually understand GHC's position.  It makes good sense.  I would not have been at UWMC in the first place had GHC urologists been well experienced in the operation my referring urologist believed appropriate for my condition.  They had approved treatment at UW because it wasn't available at Group Health, and I was delighted that they were able to do that.  But the surgery that had happened at UW had made my case unusual—even, my radiation oncologist said, "unique."  And that meant that transferring me back to GHC was not in their view a straightforwardly obvious decision.  Still, that argument did not at this point prevail, and thus this latest denial of coverage.

However sensible or not, all of this back and forth left me confused.  I didn't actually know what to do at this point, since I'd had as yet no contact at all with GHC Radiation Oncology (RO), nor they with me, and the treatment was supposed to be beginning within the next week.  So I called GHC Customer Service, in something of an emotional state, I'll grant, and asked for help. The woman I spoke with was wonderful.  By the end of this phone call I had an appointment for the following afternoon (last Thursday) with a GHC radiation oncologist—Dr. Chris Canning.

Accordingly, I met with Dr. Canning the next afternoon, and we had a full and thoughtful discussion of all dimensions of the problem.  He proved both an excellent listener and a clear spokesperson for what he could do for me.  He explained that Dr. Kim from UWMC had phoned him and explained my case; he had already given it thought.  All of this, combined with the unlikelihood of prevailing with an appeal, reconciled me to my apparent fate: while treatment at GHC might not be the perfect match for the treatment I could get at UWMC, I was impressed by Dr. Canning and therefore willing to go along with the new plan.

When I returned the next morning to begin treatment, however, Dr. Canning wanted to talk with me again. He said that while he believed GHC could supply excellent care, still, after reflecting overnight on my situation, he also understood the difficulties I had faced, and in order that I be as comfortable with the outcome as possible he had gone ahead and contacted the appropriate office at GHC and requested that they approve my continuing treatment at UWMC.  This request was granted.  As you can imagine, I was deeply impressed by Dr. Canning's thoughtfulness and generosity, and I truly appreciate his help.

So now I'm back at UWMC, and I must thank GHC, and Dr. Canning in particular, for making this possible.  After all of this emotionally challenging back and forth, with luck the treatment itself will be anti-climactic.  I'll be hearing tomorrow about the details of what now follows.

And that's pretty much the way it is.  I'm not a nervous wreck, but I'm not a picture of calm, either.  I still have some gut discomfort, and see Dr. Wright this coming Wednesday for a follow-up assessment of my recovery.  Mainly I think I've just still got some lymph fluid running about my innards--something that is bound to happen when they have removed several of the glands for inspection.  I've been assured this will all clear up in a few weeks.  Fingers crossed.



January 26

It's been two weeks since I wrote about the Perils of John and the health care organizations.  The return to UWMC added a few days to the intermezzo, but not a lot.  Since that point I've been in for a contrastive CT scan, used for planning/calculating all of the locations, depths and so on for radiation inputs, a return appointment to double-check the CT scan and the calculations made from it, and, today, the first of the radiation treatments proper.  There will be a total of 28, delivered every weekday except for the Presidents' Day holiday Monday.

I think I've already explained that this radiation is "mopping up" therapy.  It may be the case that all of the tumor is already gone, but it is also just as possible that there are still cells lurking within which might later develop into more trouble. Radiation is supposed to be particularly good at zapping those cells, and so here we are.

Today's first treatment was easy:  no pain, nothing visible, just a hum that extends a few seconds, then repeats of same as a certain amount of radiation is applied from what I counted were six different points in a circle around my body, each focused on the same point inside my abdomen.  The idea as I understand it is to concentrate the cumulative effect on that one spot, hitting it from six directions, the result being that that single spot receives the full allowable intensity even though each of the six separate beams by itself is not high enough to have much effect.

The experience is a little weird--no other human being is in the room, since they need to be outside the range of any possible radiation.  The staff can hear you, and they can speak to you if need be via microphone, but there really isn't much to say.  The whole thing takes about 10-12 minutes.  One of the techs then comes out, announces you are done, and give you a hand up off the very hard, very flat table, and says, as you leave, "See you tomorrow!"

That last is spooky--it reminds you that this is only one of many days you'll be doing this.  They have forewarned about a number of possible side effects--diarrhea, weird feelings in your bladder, intestines, or colon, or all three, skin irritation, or, most troublesome, they say, fatigue.  No one understands exactly why the fatigue, but the hypothesis is that the radiation damages tissues, especially at the point of concentration, and that that means the body has a lot of repair to do, and doing that takes energy.

They give you handouts about the most likely side effects; the only control I have, other than various remedies for the pains and drains, is exercise.  They have assured me that keeping up with exercise is the best way to alleviate the fatigue.

So that's about it.  I will learn a lot more over the next six weeks.  Notes and calls welcome--I'm happy to update anyone on anything, but this is probably enough for now.

And thanks again for the help with meals.  I'm guessing I'm about 70-80% back to normal, though these next weeks may knock me back down a bit.  I certainly intend to keep moving--I actually managed with my friend Rebecca's company to make it around Green Lake yesterday.  That's my longest walk yet.  Double that mileage, and throw in some hills, and I'll be walking a golf course again....



February 8

The close of my great healthcare adventure may finally be in sight.  Yesterday I sustained the tenth of the 28 radiation treatments--that's just over one third down, and two-thirds to go.  To this point in the radiation sequence I'm doing better that I had feared.  Before you begin treatment the staff outlines the various side effects you may experience; so far I've been spared most of them.  The ones I have felt include a certain level of discomfort in my abdomen (low-level soreness, edema, inflammation of nerves), intermittent nausea, and fatigue.  Thus I find myself falling asleep in front of the TV early in the evening and, occasionally, in my office chair (I haven't fallen out, yet).

This is all explained, I've been told, by the basic mechanism of the radiation:  normal human cells are able to respond to the injury that radiation causes them by rebuilding themselves; cancer cells are not.  So the radiation inflicts a certain level of damage on the sites it treats, and your body's normal cells respond by repairing the damage while the cancer cells die.  The normal cells' healing process takes energy and it takes materials, so the oncologists encourage you to be eating good levels of protein as well as ensuring plenty of rest.  Exercise helps by promoting blood flow and oxygenation.

But many people experience a number of other side-effects, and since I have another four weeks to go, I can only hope that my ability to tolerate the treatments relatively well continues. Meanwhile, I go into campus each day, and I continue my admin work, though not as efficiently as usual.  After driving to school I then walk down from upper campus to the Med Center for my 10:50am appointment, and then back up to Padelford once the treatment is done.  That's a mile and a half, and thus long enough to get my heart rate up a bit.

All of this means that I'm pretty tired by the end of the day, which in turn means that the house is a little chaotic, to which I have been paying attention this weekend.  I'll also be looking for pause enough in the rain to make it around the lake again.



28 February 2015

Dear Friends and Colleagues,

I am near the end of my seven months of medical saga.  This past week I finished the "long" series of radiation treatments--23 days targeted on the general area of the surgery; that left me with a "short" series of 5 treatments each targeted on the area that the surgical team felt represented the most likely site for surviving cancer cells--the place where the lesion-spawning diverticulum connected with the bladder.  The first of those treatments took place yesterday, Friday; four more will follow next week.

When the radiation treatments all began I was warned about a number of its likely side-effects; many people end up utterly exhausted--the interior bruising and healing the radiation is designed to promote puts a heavy demand on one's body's ability to cope.  I've certainly felt some of that, but except for some intense but intermittent discomfort in my abdomen and an intestinal system that fluctuates between extremes unpredictably, making the managing of diet both  necessary and almost impossible, I've so far come through without physical and mental exhaustion.

Credit for this belongs both to Kathi White, the Group Health Radiation Nurse who first counseled me on the need to keep exercising and moving, and to all of you who have helped with food, company, and patience.  I don't know how I would have gotten through these many weeks without that help.  Obviously it's also been a great advantage to have had all of these treatments at the UW Medical Center, to which I could walk back and forth each day (by my admittedly rough calculation I've walked 36 miles down and back--almost to Tacoma!--since the treatments began).  That got me going even on those days I didn't actually want to move.

My final treatment will be next Thursday, and they tell me it will be at least a couple of weeks before the side-effects subside.  To be sure, few encounters with cancer really "end," and my situation will be monitored closely for some time to come.  But as I've explained earlier, my doctors are as confident as they can be that I will recover fully--and that, in these circumstances, is as good as it gets.

With thanks and more thanks for all of your support,


And so the Updates end. I'm still dealing with some issues, but the radiation is over, healing is underway, and I look forward to beginning my teaching assignment in less than a week. As far as I am concerned, this story now needs to be put to bed.


Five Years Later:

Five Years Later: Addendum: That was the end of the biggest and scariest part of my cancer story, and now, five years later, I am hugely happy to be alive and able to continue my work as a teacher-researcher. Still, once you have gone through all of these modifications of your body's functions you are not actually done. Post-operative surveillance lasts for five years, and includes scan after scan and urological bladder scoping after bladder scoping. The schedule over the first year requires quarterly contrastive CT scans and bladder scopings, and after a year of clear scans, the next couple years drop to semi-annual scans and scopings. These involve a certain level of fear: as much as such close observation has done to be sure that there has been no recurrence, you still know that recurrence is not all that rare. My cancer was not a normal bladder cancer, which turned out to be a good thing. Still, each exam can seem an existential roll of the dice. But my final fifth year follow-up CT scan was done in November of 2019, and all was, again, clear; two weeks later, I had the bladder scoping, and this, too, was clear.

So—success! But am I as good as new? No. The series of operations I had beginning in 2010 to deal first with kidney stones and then with prostate issues kept me in danger, actually. They led, in 2011 to a seriously life-threatening kidney infection (acute pylo-nephritis), and a truly hellish hospitalization with fevers so high I learned that in extreme pain one can indeed say to oneself—more than just once: “I truly do not care at this point whether I live or die” (for me, actually a peculiarly reassuring discovery).

Then in 2012 I had a TURP (trans-uretheral resection of the prostate) procedure, but a few days later I found myself again in critical care with what was a life-threatening condition: a very quickly developing case of acute uro-sepsis. That's something that arrives as a kind of explosion in your body's effort to deal with a huge infection of the blood. Your body goes crazy, it floods your tissues with fluids and requires immediate saline infusions while the staff works to figure out what kind of bacteria has attacked your system. I arrived at the ER late in the afternoon, and overnight received 9 litres of saline, and that's a lot! I also had a friendly doc sitting up with me all night. I thought he was just a nice guy without much to do. But the next day while in critical care, with a surgeon hovering near me ready to install a direct line from my neck down into my heart to restart my body if it started to fail, I learned that one sign of that kind of failure is a loss of "mentation"—which essentially means the ability to make sense. So my friend the doc was there just to make sure I wasn't going to crash. Fortunately, I was able to make sense all night, and when the next morning came my vital signs had begun to improve.

Now it's just 5 months since my last urology appointment, and it's hard to look back at all of this and really acknowledge how difficult it has been. When I have traveled post-surgery, I've sometimes had trouble having confidence that I am in fact healed. Can one trust one’s body to a 12 hour encapsulation on an airplane? That was a problem for me. So on my first trip to China I not only brought with me a catheter to self-catheterize if I had to protect myself against the weird and (in my mind, at least) not at all unlikely possibility of another blood clot showing up, but I also packed a dozen adult diapers in my suitcase just in case my Kegel muscles gave out (I had just been to my urologist for a scoping, and for the first few days after that procedure there can be some urethral irritation that can make you worry about incontinence).

I have lost other abilities, too, and when you combine that with the effects of aging, I remind myself that I am in fact very lucky to be alive at all. Though I have lost some (most?) of my sexual life, I have been so fortunate in my family, my colleagues, and my students that all of that seems of little importance. It's been hard to bring myself to admit to all of this (and in fact this is the only place I've ever written about it), and I do know that at my age it would have happened in any case (I'm 75 now, and will turn 76 in a few months' time). And then there’s the effect the radiation had on my intestinal tract. I must now rely on laxatives, which is an astonishingly inexact science. Anyone’s bowels are actually pretty much a mystery. I am always doing my best to hit a midpoint between diarrhea and constipation. I have learned two things in this process. First, no one really can give you great advice. And second, each intestinal tract is different, and it takes 2-4 days to learn what the effects of any one day’s intestinal medication has been. But still, I am alive!

I hope I have no more entries to make in this set of Updates. My recovery really has been about as complete as anyone would have a right to expect (I threw the adult diapers away before boarding my flight from Beijing back to Seattle, and since then I have been around the world without such supplies!).

So has living with the after effects of the surgeries of the past ten years changed my professional life? I think it has. I know now that A's, B's and C's mean much less than I once thought. It still annoys me when people write on my Rate My Professor page that I'm an "easy grader," but in a way that is certainly true. For I also now see so much growth in my students--in confidence, in fulfillment, in self-respect--qualities that being a "hard grader" can, and often does, very quickly destroy. Last year, on the last day of what may have been my most successful class ever, I asked my students why so many of them had stayed and stayed in the classroom, hugging both each other and me. One of them replied: "because this is the first time I've felt good about myself as a student since I came to the UW." Easy grader? or someone who has learned the hard way that life is too short to spend it beating up on people who in almost every case are smart, highly motivated, diversely interested, and looking for ways to embrace their full humanity.