Jonathan Flint

In March last year, at the age of 35, I was diagnosed with advanced stage III rectal cancer with a metastasis in my liver. This was a shock: I had no family history, and none of the doctors suspected it. In fact, I'd had a negative occult blood test when I went to ER with severe digestive symptoms a few months before. The first lesson I learnt from this was that there's no substitute for the proper diagnostic procedures: if you have any bleeding, get a colonoscopy, even if you don't have family history. I was treated with total neoadjuvant therapy at UCLA. I had 6 weeks of combination radiation and chemotherapy (Xeloda). The photo shows me after completing that first step of my treatment along with my parents in Yosemite. My mother has already survived two breast cancers, and my father had recently had a knee replacement (at the age of 70), so getting all three of us to the top of Sentinel Dome felt like an achievement. The chemoradiation was followed by 6 rounds of combination chemotherapy: oxaliplatin infusions followed by two weeks of Xeloda. I tolerated this unusually well. During this period, I managed to hike up to over 11,000ft multiple times in the Sierras, and I wrote the main text of a 72 author meta-analysis paper and submitted it to Nature where it has passed first round reviews (currently working on revisions). I showed a good clinical response, with the tumor in my rectum nearly completely disappearing and the liver metastasis shrinking substantially. At the end of October I had surgery: I was under for 9 hours, and they cut out a large bit of my rectum, 1/3rd of my liver, and gave me a temporary ileostomy. Waking up from this was probably the strangest experience of my life: I felt more machine than man, and I had wild hallucinations form such a large dose of anesthesia. It took a while to feel OK after that surgery. However, I still had the ostomy. I had that reversed at the end of January in another surgery, which took a greater toll on me than I expected. There's a cumulative effect of having so many major medical interventions, and it reveals anything weak in body or mind. Surprisingly, my mind held up well during this process. This was thanks to the love and support I received from friends and family and the great care I received from UCLA — in particular Dr Anand (medical oncology), Dr Kazanjian (colorectal surgery), Dr Agopian (liver surgery), and the radiation oncology team. I only just started to feel like I was starting to feel OK again and I got bad news: I got a positive circulating tumor DNA test (ctDNA), the signatera test from natera. Unfortunately, the second test I had done recently showed the level of ctDNA in my blood is increasing. This means disease recurrence is almost certain, likely within a year from the first positive test. Since then I've been put on celecoxib based on recent data indicating this can reduce risk of disease recurrence, although it doesn't seem to agree to well with my digestion. I've had CT, MRI, colonoscopy and there's been nothing to see, but it's only a matter of time. My oncologist thinks it is very likely (90%+) that it will be a local recurrence in my liver, which should be fairly easy to cure. But there's a small chance it is something worse, even potentially incurable. This is the reality of cancer for many patients: years of uncertainty. It's still not clear why this happened. Genetic testing returned nothing. My polygenic risk score (PRS) — something close to my own research — gave me totally average risk, at least according to 23andMe. I've always been slim, fit, eaten a pretty healthy diet. I was even raised vegetarian by hippy parents. I probably drank and partied more than is medically advised, but nothing extreme. However, there's been a well-documented uptick in cases like mine. A recent paper indicated this may be due to colobactin, a bacterial mutagen associated with E. coli among other bacteria. I may look at my Tempus tumor data to see if the somatic mutation in the APC gene they found (the only driver mutation) has a signature matching colobactin. If anyone knows anyone with a worthwhile expert opinion on how to manage my situation I'd be interested to hear!