Rules for rumination

by Brian on September 30, 2018

in Cancer,Travel

The results from my latest PET CT were good. Excellent in fact. My hematologist sent me a two-line update by WhatsApp.

“No uptake in no lymph nodes! Well done!” she wrote (exclamation points included).

“Uptake” in medical language refers to whether the radioactive material injected into my veins prior to the PET CT had found its way into any of my lymph nodes. That would have indicated that I still had cancerous tumors in my body. It didn’t and I don’t.

My doctor followed her message with a pair of clapping hands. (You’ve got to love a doctor who communicates using emojis.)

I was less ebullient, however. Yes, I was officially now in remission. But as good as the news was, it was still “expected.” Most people with my kind of cancer respond very quickly to treatment. Moreover, my positive PET changed absolutely nothing. I still had another three chemo treatments to go and then 12 immunotherapy “maintenance” sessions over the next two years.

That’s because, with a chronic recurring cancer like follicular lymphoma, there are two battles: knocking out the cancer and then doing everything you can to ensure as long a remission as possible before the disease returns.

That put me in a bit of a Catch-22: I wanted to keep friends and family up-to-date, but if I said I was “cancer free” without a caveat, I’d be deluged with “congratulations” and “way to go” responses.

Even worse, my mind had already gone in a different direction. If I was now cancer free, did I still need all the remaining treatments? Maybe I could just stop. And the two-year treatment plan I’d settled on – was it even the “right” one? Could I have achieved the same positive result with less chemicals?

I was ruminating.

Rumination is when you essentially re-play in your mind a decision you’re not sure about, maybe even one you regret, to the point where you’re not able to be fully present in the current moment.

Rumination is not the same as reflection. That’s where you return to a decision but, rather than get lost in it, you evaluate it objectively in order to learn something new. For example, let’s say you sold your car for a certain price without doing a lot of research and later found out you could have gotten substantially more. Next time you’ll know better what to charge.

My worst case of rumination happened in 2011, when our family set out on a two-week trek in Nepal for my 50th birthday. One of the highlights of the hike was a pre-dawn 350-meter climb to a place called Poon Hill from which you could see all of the spectacularly snowy Annapurna range at first light.

But I was worried about being too tired to handle the long trek we had planned for the rest of the day. So I passed on Poon Hill.

As we hiked towards Tatopani, though, I couldn’t get what I imagined I would have seen atop Poon Hill out of my mind. With each of the hundreds of steps to the hot springs awaiting us at our destination, I beat myself up, over and over, missing out on the breathtaking real-time scenery unfolding all around me.

I needed some rules for rumination.

The key is separating what goes into making a decision with what comes after.

I’m a naturally analytical guy – that’s perfectly fine. If I’m going to buy a new smart phone, I’ll look at every possible model, listing all the pros and cons, prices, features and functionality.

But once I’ve bought it, assuming it works, looking back will only cause unnecessary pain. I can reflect (“next time, I’ll buy more storage” or “I’ll get the one with the better screen”), but rumination and reproach (“I should have bought the model with the bigger screen,” and “I’m such an idiot”) are off-limits.

That doesn’t mean you have to stick with a decision when new data becomes available. Let’s say you choose to go to a concert or a movie. Half way in, you realize you’re not enjoying it. Do you have to wait it out just because you paid for the tickets?

I had a clean PET scan – did that qualify as new data such that I should reevaluate? How about my physical response? After several months of treatment, I could see how my body was handling the chemo. Did that suggest a change of direction? Had the neuropathy – a common chemo side effect – been too intense?

Those kinds of discussions are entirely legitimate. What’s not OK: obsessively second-guessing whether the original decision was a mistake.

Another way of looking at the difference: reflection is looking back at a situation. Rumination is more like taking an actual step backward.

When I was debating whether to climb Poon Hill, I was worried I wouldn’t sleep that night. Guess what? I didn’t anyway – I was too busy “pre-ruminating.”

Years later, when my wife Jody and I took a similarly adventurous trip to Sri Lanka, one of the top recommended outings required a 4 am wake up.

I reflected on Poon Hill, deflected any rumination and we did it.

It was glorious.

I hope I can make a similarly glorious, non-ruminative decision on the coming months of my cancer treatment.

I first created my rules against rumination in The Jerusalem Post.

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