Medical UPDATE: 30th AUGUST

For the past few months, I’ve shared only the essentials about Michal’s health — enough so that people could daven for her, but not the full story. From the very beginning, I was asked not to disclose the full diagnosis, to protect those who found it too difficult to confront. Out of respect for that request, and out of a genuine desire to keep the peace within the family, I tried to carry much of the weight quietly on my own. At the time, it felt like the right balance — allowing people to pray and to care, without burdening them with details that might have been overwhelming.

But carrying something like this alone is never simple. Illness does not only affect the patient, it reshapes the lives of everyone connected. In choosing to hold back, my hope was to give others the ability to continue with life as normally as possible, to shield them from some of the heaviness that we were already feeling. And for a while, that seemed possible.

Now, though, the situation has reached a point where silence no longer feels like honesty. And if so many of you are giving your time, your tefillot, and your support, then you deserve to understand the full picture — not out of sensationalism, but out of respect.

So this post is different. Not because I want to cause any anguish or upset, but because we are reaching a point where fundraising for experimental treatment options may become necessary. If we are going to ask for help, then I feel it is only right that those who might consider participating — whether through tefillah or through a financial contribution — should understand exactly what the money would be for and where it would be going.

I take no comfort in sharing this, and I am aware that not everyone will receive it kindly. But I ask that if you choose to read on, you do so with discretion and respect. Please, do not make this a topic of casual conversation. My goal is not to draw attention, but to give clarity to those who wish to support Michal in the ways they can. Above all, I am still trying to protect our young children from the full weight of this diagnosis. So I ask you to read it, but not to share it, so that it does not get back to them.

Michal’s journey began one Monday morning at Morningside Hospital. She had been admitted for severe gastric pain and nausea. The doctors thought it might be gallstones — uncomfortable, yes, but routine and manageable. We braced ourselves for what we assumed would be a short hospital stay and a fairly straightforward solution.

That same day, a gastroscopy revealed a clear gallbladder. A CT scan was scheduled for Tuesday to look deeper. When the results came back, they showed a large lesion on her liver. Still, the radiologist and gastroenterologist reassured us: most likely a liver hemangioma. Benign. Non-cancerous. A nuisance at worst, often left untreated unless it causes pain. We exhaled — relief flooding in. This was a bump in the road, nothing more.

But to be thorough, the doctor ordered an MRI for Thursday, along with a blood test for liver function and a tumour marker called AFP (Alpha-fetoprotein). For context, normal AFP levels in adults range between 0–10 ng/mL.

On Thursday afternoon, the results came back. Michal’s AFP was 217,000. The number itself told the story: this wasn’t benign. It wasn’t a nuisance. It was an extremely aggressive and advanced liver cancer — Hepatocellular Carcinoma (HCC).

The MRI report landed later that same day and stripped away any remaining hope. The primary tumour in her liver measured 20 centimetres — the length of a rugby ball. It had already spread to her lungs and lymph nodes.

At 3pm that Thursday, we were discharged from Morningside and told to be at Donald Gordon Hospital the next morning, where an oncologist had cleared his schedule to see us as an emergency. We walked into that appointment still dazed, still clinging to a naïve kind of optimism: okay, it’s cancer, but cancer can be treated, right? People survive. This is just the beginning of a fight we’ll win.

By 9:30am Friday morning — just 18 hours later — that optimism shattered. The oncologist told us, gently but firmly: this is Stage 4, incurable cancer. The oncologist also to me, when Michal had left the room; The two-year survival rate: 2.5%.

The shift from gallstones to incurable Stage 4 cancer happened in less than five days. That is the speed at which our world turned upside down. And the takeaway point here, as we approach Rosh Hashana is to realise that nothing is guaranteed and that our entire life’s plans and sense of security vaporised in 18 hours.

Every subsequent scan seemed to bring worse news. (Yes, as impossible as it sounds, things can get a lot worse than being told you have a 2.5% two-year survival rate.)

There was, for a brief week, a glimmer of hope. A gastric surgeon floated the idea of an aggressive operation — a liver resection to remove the tumour along with the entire left lobe of the liver, followed by chemo or radiation to address the nodules that had already appeared in Michal’s lungs, and then we would mop up by dealing with the affected lymphs.

We clung to that hope. For a moment, the impossible felt… possible.

Medically, the most favourable resections are when the tumour is less that 5cm. Extremely large hepatocellular carcinomas — giant tumours of 10 cm or more — have been resected in carefully selected patients, provided there’s a single tumour and no major vascular invasion. Surgical guidelines are not to do a resection if the tumour is greater than 10cm. Michal’s tumour was 20 cm. Double that.

Still, the surgeon was willing to consider it. A second gastroscopy was ordered to check if the cancer had penetrated through the stomach lining. If it had, it would mean not only removing part of the liver but also a partial — or more likely, a full — gastrectomy (removal of the stomach). It would be an extremely long, delicate, and high-risk surgery, and life after would be permanently altered. But at least it carried the promise of removing the cancer.

That hope lasted barely twenty-four hours. The next day, the full-body PET scan results came in. They revealed more metastases — including spread to the abdominal wall. And just like that, the surgical plan collapsed. What had been our fragile lifeline was gone.

With surgery off the table, the next avenue was science. A biopsy was performed, not just to confirm the diagnosis, but in the hope of finding something more — a genetic “Achilles heel” we could attack.

Certain mutations in hepatocellular carcinoma (HCC) have been shown to respond to newer, targeted immunotherapies. In some cases, when a mutation is identified, it can open the door to treatments that are far more precise than standard chemotherapy, giving patients a chance at a longer or better-quality life. We prayed for such a finding.

The tissue was sent for Next Generation Sequencing (NGS), an advanced test that looks across hundreds of genes for targetable mutations. We also ran immunohistochemistry (IHC) to profile the tumour’s biology.

The results came back:

• No actionable mutations were found. The cancer had given us nothing to target.

• The immunohistochemistry revealed no risk factors that typically support the development of HCC.

• Michal tested negative for all hepatitis strains. She is also not an alcohol drinker. Her liver showed no signs of cirrhosis

In other words, this was not only an aggressive and advanced cancer, but also one that defied explanation. There was no clear cause, no obvious medical “handle” to grasp onto. It was HCC at its most merciless — arising without the usual risk factors, and resistant to the therapies that sometimes offer a measure of hope. And yet, the very inexplicability of Michal's case has left many oncologists unsettled, for me has only underscored what we already believe: that this is not random at all, but a message directly from Hashem, calling us to listen and to respond.

I did not share that 2.5% statistic, not with Michal, and not with her family. I chose not to repeat it. Not because I was hiding from the truth, I know the truth better than anyone and carry more of it than I will be allowed to share, but because as Jews, we don’t believe in statistics.

If our people lived by statistics, we would have been wiped out long ago. From the moment of our inception, we have been persecuted, chased, exiled, and attacked. By every statistical measure, the Jewish nation should no longer exist. Far greater empires have risen and fallen, entire civilizations have vanished — and yet we remain.

That is why I have never doubted that Hashem can perform a miracle. That is not the part that troubles me. The question that has never left me is different: are we — am I, are we as a family — doing enough to be deserving of a miracle?

That is the thought that keeps me awake at night. Not the numbers. Not the percentages. But whether we are responding in the way Hashem asks of us — with enough tefillah, with enough teshuvah, with enough tzedakah — so that when the Heavenly scales are weighed, perhaps we may yet merit compassion beyond nature.

Back to the medical journey. We began an immunotherapy regimen known as Atezo-Bev — a combination of atezolizumab and bevacizumab. This is currently considered the global first-line treatment option for advanced hepatocellular carcinoma, based on the landmark IMBRAVE150 trial.

We consulted widely, including with overseas specialists, and through miraculous hashgacha, we found the very doctor who served as the global lead on the IMBRAVE150 study itself. Their conclusion was clear: despite Michal’s circumstances, Atezo-Bev was still her best first-line option.

But from the outset, we knew we were walking into this with the odds stacked against us. To put it in perspective:

• In the IMBRAVE150 trial, the average AFP level among participants was around 400. Michal’s AFP was 217,000.

• Her primary tumour measured 20 cm — many times larger than what is typically seen in successful immunotherapy responses.

• The genetic and biological profile of her tumour from the biopsy showed:

  • Moderate differentiation

  • PD-L1 CPS score of 0

  • Microsatellite stability

  • All of these terms may sound technical, but they essentially add up to one grim reality: prognostically, these markers are all considered “bad.” They are associated with a much lower likelihood that immunotherapy will succeed.

When you are fighting for the life of your wife and your loved one and the mother of your children, you don’t weigh hope in percentages — you take the hope that exists, however fragile, and you run with it.

IMBRAVE150 represents the best chance the medical world currently has at treating HCC. And while the numbers you’ll see below may appear discouragingly low, it’s important to remember that these outcomes were still considered a breakthrough — superior to anything achieved by earlier treatment regimens. For this disease, the results were nothing short of unprecedented:

• Overall Survival (OS): The median overall survival was 19.2 months (95% confidence interval 17.0–23.7).

  • Overall survival means the average length of time patients lived after starting treatment. For advanced HCC, this represented a remarkable extension of life.

• Progression-Free Survival (PFS): The median progression-free survival was 6.9 months (95% CI 5.7–8.6).

  • Progression-free survival refers to how long patients lived before their cancer grew or spread further. Holding the disease stable for almost seven months was a meaningful breakthrough.

• Side Effects: Among patients who could be evaluated for safety, about 43% experienced severe (grade 3/4) treatment-related side effects. Treatment-related deaths were uncommon.

  • In practice, this meant the side effect profile was considered significant but manageable, especially given the benefit in survival.

Starting Atezo-Bev was our hishtadlut, our obligation to act according to the best medical advice available. But alongside that, we knew that the real work was not in hospitals and scan rooms. It was in ourselves. So we turned inward and upward. We tried to perfect what we could spiritually — through tefillah, through teshuva, through tzedakah, and through initiatives aimed at le’zakot et harabim, bringing merit to others.

Like I have written before: illness is not random. Hashem can send sickness as a message, as a catalyst for Teshuva, as a Tikkun or as a push toward spiritual growth. The challenge is to listen, to search honestly, and to respond. And that has been our journey too — not just battling a disease, but asking what Hashem is asking of us in this moment. Alongside the medical journey, there has been a spiritual journey.

The science may speak in medians and hazard ratios, but living through treatment is something else entirely. Between each infusion of Atezo-Bev, Michal has carried more pain than I can put into words. The nausea that never lets up, the bone-deep exhaustion, the chills and sweats that leave her shaking. For three weeks between doses, her body feels wracked and broken, as if the cure is nearly as punishing as the illness.

And yet she has never given up the fight. Not once. She endures the pain, the nausea, the endless side effects — not because she is unafraid, but because she is unyielding. Because she refuses to surrender.

I watch her — the strongest person I know — forcing herself out of bed when every nerve in her body screams to lie down. I see her find a smile for the children when the treatment has stolen every ounce of strength. Her one refrain, spoken again and again in whispered determination: “I just want to be there for them.”

Our youngest is only four. Our eldest is not yet bar mitzvah. Every parent wants to see their children grow, but for Michal, that hope is not abstract. It is the fire that keeps her going through nights of shaking chills and days of relentless pain. This is not just her battle with cancer — it is her sacrifice, her fight to remain the mother our children so desperately need.

At this point, I need to pause and say something important: we have been carried by exceptional people. Friends, family, and even strangers have stepped in with kindness, with prayers, with support that I could never have imagined. That in itself is one of the greatest gifts this illness has revealed — how extraordinary people can be when they choose to show up.

My favorite tefillah has always been Aleinu L’shabeach, in which we thank Hashem for being Jewish, for having Him, the King of Kings to turn to, “While they bow down to nothingness and emptiness, and pray to a god who cannot save.”

In the shadow of this illness, that line has taken on new meaning for me. The greatest comfort is knowing that Hashem is here beside us. That He has a reason. That He has a plan. That our suffering is not random, but carries meaning, and is ultimately for our benefit — even if we cannot yet see how. That He hears every single one of our prayers.

I have sat in treatment rooms and looked around at the other patients. I have seen the lostness in their eyes. They have no one to turn to, no framework to understand their pain, no awareness of who the real Doctor is. Their prayers fall on deaf ears.

We, baruch Hashem, are different. However hard this is, however painful, we are never truly alone. And that — in ways I cannot explain — is what has carried us.

And then there is the other truth that humbles me every single day: “Mi Ke’amcha Yisrael” — who is like Your people, Israel?

From the moment of Michal’s diagnosis, we have been lifted by a community that has not stopped giving. Meals have arrived at our door without pause. The generosity has been overwhelming — gifts for the kids to brighten their days, offers of medical advice and expertise, people stepping in to help fast-track treatment approvals with the medical aid, others ready to fight the medical aid on our behalf when claims were rejected.

We’ve had holiday accommodation at Magalies Park offered to us, a group of women joined together to sponsor a new sheital for Michal, and a psychologist offered therapy at no cost. There are so many people holding us up in all different ways. You expect it from family — and even then, the way most of our family has stood with us has been beyond words — but what has stunned me most is how often it has been total strangers who have become our biggest saviours.

There is so much more I could mention, and I ask forgiveness if I have left anyone out — but please know, we see it all, we feel it all, and we are forever grateful.

And of course, even more important than the meals and gifts and practical help, there has been the army of prayers. Literally hundreds of chapters of Tehillim being said around the clock, people telling us they have gone to tzaddikim for brachot, placed notes in the Kosel, poured out their hearts at Kever Rochel, visited the Ohel. Our suffering has become their tefillah. Our pain has been carried by countless voices storming the heavens on Michal’s behalf.

This, too, is part of the miracle: that in our darkest days, we have discovered just how luminous Am Yisrael truly is.

Chazal tell us that a person who sees the place where Moshe Rabbeinu stood on the mountain during the war with Amalek makes a special beracha. But think about it: the actual fighting, the physical miracle of victory, took place down below, in the valley, where Yehoshua was battling Amalek sword against sword. Why then is the blessing made not on the battlefield, but on the mountain?

Because that mountain revealed the deeper truth. The real war was not fought with swords. It was fought with Moshe’s uplifted hands, with the prayers and faith of Am Yisrael. The battlefield only reflected what was happening above.

So it is with us. The scans, the infusions, the medicines — these are physical battleground. But the real war, the one that determines the outcome, is being waged on the mountain: through tefillah, through mitzvot, through the cries of Klal Yisrael storming the heavens on Michal's behalf.

Again, let me go back to our medical journey. The standard practice with Atezo-Bev is to repeat scans (CT, MRI) after three infusions. That first reassessment is critical: it shows whether the disease is shrinking (best case), holding stable, or progressing further (worst case).

Even before those scans, though, the bloodwork — drawn before every infusion — was already painting a grim picture. Michal’s AFP, which had been 217,000 at diagnosis, rose to 396,000, and then to 846,000 across three successive results. Other liver enzyme markers climbed higher and higher. Every number pointed the same way: progression.

Sure enough, the scans confirmed what the blood was already screaming. The primary tumour had grown 32% since diagnosis. The metastases had multiplied. And perhaps most devastating, there was now macrovascular invasion — meaning the tumour had spread into the major blood vessels of the liver. This places Michal in the highest risk category of all.

It was the outcome we had dreaded, and yet no less crushing for having feared it.

At this point, we were forced to confront the reality that in South Africa there are no real treatment options left. And even the word “treatment” feels cruelly ironic. It suggests the possibility of getting better, of being cured. But with stage 4 HCC, treatment doesn’t mean cure. It means: can you slow the runaway train just enough to eke out a few more weeks, a few more months?

There is very little solid data on what to do after immunotherapy fails. Some oncologists recommend focusing on supportive care — easing symptoms and shifting toward palliative measures. Others suggest circling back to older first-line drugs, the very ones that Atezo-Bev had replaced: drugs like Sorafenib or Lenvatinib. These are grasped at not because they are expected to cure, but because sometimes — in rare cases — they might buy time. Oncologists measure time in days and weeks, sometimes months, hardly ever years.

It is a bitter place to arrive at. To sit in front of doctors and realize that the cutting edge of global medicine has already been exhausted, and that everything now is uncharted, uncertain, without promise.

And this is where we are now. After exhausting the standard of care, we turned again to global experts in liver cancer. The same specialist who had guided us at the start suggested that Michal’s best chance at achieving a durable response would be to try a regimen called Ipi-Nivo — a combination of Ipilimumab and Nivolumab.

Ipi-Nivo is not officially approved for HCC. It is being used off-label, but some patients have seen encouraging responses. I don’t want to overpromise: the reality is that in a retrospective study, about 3 out of 10 patients responded. For the others, it did not halt the cancer. The average progression-free survival was just 2.9 months — meaning that for many, the disease continued advancing quickly.

And yet there are exceptions. There is one patient at Sheba Medical Center in Israel who received Ipi-Nivo after progressing on Atezo-Bev. That patient achieved a complete response and is still cancer-free, now two years on.

It is not a guarantee. It is not even close to a certainty. But it is something. And right now, “something” is more than we have.

And there is a catch. Nivolumab is not registered or available in South Africa. The only way to access it here would be through a Section 21 SAHPRA application, on a named-patient basis, and that would be built on very limited documented evidence for HCC.

Overseas, however — in countries like Israel and the United States — Ipi-Nivo is available. Privately, of course. And it comes at a staggering cost. I am awaiting the Israeli quote but in the U.S., each infusion costs around $20,000 (R350,000). Because the regimen is given every three weeks, it would mean a monthly cost which alternates between R350,000 and R700,000. That is the monthly cost of simply staying on treatment. Of the treatment itself. Excluding all the other secondary costs.

Which is why certain family members have already begun investigating what fundraising or crowdfunding might look like if we reach that point. We are not there yet. We are still comparing costs between Israel and the U.S., and also exploring whether there is any oncologist locally who would be willing to administer the regimen here — if there is any way to bring the drugs into the country.

Because it’s not just about importing medication. It’s about the management of the patient — monitoring, bloodwork, knowing how to recognize and treat the potentially severe toxicities of the drugs. Experimental drugs can be as dangerous as they are promising, and they cannot be given in isolation.

This is where we stand: between limited options at home, extraordinary costs abroad, and the uncertain path of how to make any of it possible.

I know this has been a lot to take in. I have tried to lay out the medical landscape as clearly and as accurately as I can, not to cause anyone distress, but so that those who are walking this road with us — through their tefillot, their chesed, their support — understand where we truly are.

More than anything, I ask that you continue to daven for Michal Chava bas Feiga Aviva. Every kapitl of Tehillim, every whispered tefillah, every mitzvah taken on in her merit is felt and cherished more than words can ever say. The way to win this battle is on the mountain, by turning heavenward.

I share all of this now not to burden, and not to despair, but to be honest and upfront. If you are giving us your time, your prayers, and your assistance, then you deserve honesty in return. And while until now I held back some of the details out of sensitivity to others, it has weighed heavily on me to do so. At this point, transparency feels not only right but necessary.

And despite where we are, we still know with absolute certainity that this is the will of Hashem. We accept that Hashem has a plan; that He can overturn decrees in an instant; that suffering has meaning even when we cannot see it, and that miracles are never beyond reach for those who make themselves worthy. We live in hope, strengthened by your tefillot, and we continue to believe that the same Ribbono Shel Olam who has carried our people through exile, persecution, and survival against all odds, can carry us through this too.

And so we come now to Elul, to the days that lead into Rosh Hashanah. Every year on Rosh Hashanah we daven for life — but we usually think of it in the broadest sense, “another year.” This year, I know what it means to daven not for years but for months, even for weeks. To realize that every single day of life is a gift that requires prayer.

I have come to see how fragile everything really is. That all the things we work for and save for — the careful planning, the retirement fund, the hard-earned money — can be taken in an instant. Or worse, that Hashem does not have to take away our money at all; He can take us away from it. I have learned how in just 18 hours, a whole world can collapse. My wife had not seen a GP for anything since 2016 — she was never unwell. And then, without warning, she had Stage 4 HCC. There was no medical history in between.

So if nothing else, let this Rosh Hashanah change the way you daven. When you stand in shul, think of us. Think of Michal Chava bas Feiga Aviva. Let it remind you that nothing in this world is guaranteed. Let it fuel your tefillah with urgency, with sincerity, with fervency — the awareness that every moment of life is fragile, every breath is a gift, and everything we have comes only from Hashem.

May Hashem inscribe all of us in the Book of Life, with health, strength, and only besoros tovos, and may we merit to see miracles and salvations speedily in our days.