A nurse in the clinic informed me that the patient was already in an examination room because he had arrived early. I rapped on the door and entered the room. The patient was a man in his late sixties sitting on the end of the ubiquitous, bland exam-room table. A woman, who I soon learned was his daughter, sat in a chair beside him. He was dressed in frayed but clean denim overalls; a faded, once-colorful, pearl-snap-button Western shirt; and well-worn cowboy boots. A sweat-stained straw cowboy hat lay on the adjacent desk, resting properly on the crown (never on the brim). The man was bent over at the waist and holding his chest tightly with his right hand.
Usually when I first meet a patient I shake his or her hand and introduce myself. With this gentleman my first words were a question: “How long have you been having chest pain?”
“It’s been getting steadily worse for the last ten minutes,” he replied. “I took a nitroglycerin tablet, but it is not letting up.”
The patient’s daughter informed me he had suffered a “minor heart attack” two years previously and he saw a cardiologist every few months. She reported he occasionally had chest pain when engaged in strenuous labor on their “farm,” but after a few minutes of rest and sometimes a nitroglycerin tablet under his tongue, he was usually good to go. I quickly examined him. His heart rate was ninety, his skin was cool and clammy, and he was clearly having severe chest discomfort.
Crescendo angina. I had seen it once before as a surgical resident. These symptoms indicate a critical obstruction in one or more of the major coronary arteries providing blood supply to the heart. An impending, potentially lethal myocardial infarction was unfolding in the man before me. I quickly walked out the door and yelled for a nurse to call 911 and get an ambulance. A seemingly odd request given we were in a clinic building physically attached to a hospital. However, the hospital was a dedicated cancer center, well equipped to provide care for patients with all types of cancer, but definitely not a complete one-stop shopping experience for all medical care. We were certainly not prepared to handle patients with critical cardiac disease or an acute myocardial infarction.
After realizing I was serious, the nurse dialed 911 and joined me in the room. Emergency medical technicians (EMTs) were in the clinic within ten minutes. An intravenous needle was placed into the patient’s arm, an oxygen cannula was inserted into his nostrils, and he was strapped into the wheeled ambulance stretcher and whisked to the nearby elevator. The patient was loaded into the ambulance idling in front of our building, and we drove, lights flashing and siren wailing, about a quarter of a mile to the emergency room of a major heart hospital across the street. I was impressed with the rapid emergency room response with blood specimens obtained, an electrocardiogram performed, and a cardiologist at his bedside within minutes. He was soon transported to the cardiac catheterization lab. Recognizing he had a higher-priority, life-threatening problem with his heart than with the rectal cancer, I asked his daughter to call and keep me informed of his status. The EMTs were disinclined to allow me to hitch a second ambulance ride across the street, so I walked back to the clinic building and picked up where I left off.
Well now, an eventful beginning to one of my first clinic days as a surgical oncologist. It took most of the morning for heart rates of the staff (and me) to slow down to normal.
About nine o’clock the same evening my pager beeped and displayed a phone number I did not recognize. It was the patient’s daughter. She reported that her father had undergone cardiac catheterization, which revealed several near-occluding plaques in three vessels of his heart. He had just been moved to the intensive care unit after urgent surgery to perform a three-vessel, coronary artery–bypass graft operation. The cardiothoracic surgeon had told her that her father was stable and he believed her father had not suffered heart damage.
Many patients have additional medical problems or disorders confounding their diagnosis and treatments for cancer. Frankly, it seems to me an increasing proportion of patients diagnosed with cancer have what we in medicine call co-morbidities. These conditions increase the complexity of cancer-treatment planning, and may increase the incidence or severity of treatment-related side effects and complications.
Diabetes is one example, but there are numerous medical co-morbidities oncology care providers must account for during the delivery of cancer therapeutics and surgery. High blood pressure affects one in three adults in this country. Hypertension increases the risk for heart disease, stroke, and kidney dysfunction. Approximately forty million Americans smoke cigarettes. This is a deadly addiction that causes numerous types of cancer, and is a major co-morbidity that increases the risk for pulmonary complications during cancer therapy, and impairs wound healing after surgery. This next statement is not intended as a bad pun, but as a grim warning: There is a growing problem with obesity in many countries in the world, with almost one-third of Americans classified as significantly to morbidly obese. Obesity is associated with increased risk for diabetes, high blood pressure, heart disease, liver inflammation leading to cirrhosis, and numerous types of cancer.
This is a reality of modern cancer care: patients have other medical problems or disorders. Even allergies to medications can become problematic. We may not be able to use a vital antibiotic to treat a difficult infection in a patient whose immune system has been compromised by chemotherapy treatments. Alleviation of pain or other symptoms may be limited by allergies to useful medications. Patients can develop allergic reactions to chemotherapy drugs, sometimes including a dreaded life-threatening reaction known as anaphylaxis. When allergic reactions to chemotherapy drugs develop, our ability to treat patients with the optimal combination of drugs intended to maximize the probability of long-term survival is necessarily hampered.
There are many clinical studies in the oncology literature indicating that medical co-morbidities have a negative prognostic impact on cancer patients. Some studies found cancer patients with one or more co-morbid conditions have a lower probability of long-term survival compared to patients with the same type of cancer and no co-morbidity. Additionally, some types of medical conditions reduce the safety of delivery of standard doses of chemotherapy or radiation therapy and may limit the options for surgical oncologists to perform a complete and appropriate oncological operation. Reports from the surgical literature worldwide have confirmed that postoperative complications and risk of death are significantly higher in patients with co-morbidities, and that these risks rise as the number and severity of medical co-morbidities increase.
When evaluating new patients with a diagnosis of cancer, we obtain information on all medical problems from childhood and adulthood, along with lists of any previous surgical operations, problems with anesthesia, unusual bruising or bleeding tendencies, and documentation of all medications and allergies. Treating cancer patients who have one or more concurrent medical conditions is commonplace; we focus on optimizing their cancer care while controlling and monitoring their other medical problems. The situation is what it is. When patients who develop cancer frequently have other medical problems, it is our job in oncology to develop treatment plans that account for the cancer and the additional conditions that exist or arise in our patients.
The gentleman in the well-worn overalls, Western shirt, and cowboy boots recovered well after open-heart surgery. I visited him several times in the heart institute while he recuperated from his operation. He was in the intensive care unit for two days and was discharged from the hospital nine days after the unplanned heart procedure. While he was in the hospital, I took his history and completed a physical examination. I also confessed to him that the single question and very brief examination of our first encounter were not typical, but his identified critical heart problem had become an immediate priority.
Fortunately, this man’s rectal cancer was not obstructing his colon. He was eating normally and was not anemic, indicating an absence of prolonged or major bleeding from the tumor. The cancer was diagnosed by his physician after the patient had
noticed some bright red blood mixed in with his bowel movements. Unfortunately, the tumor was very low in the rectum, overlying the sphincter muscles that allow us to control (hopefully) the passing of gas and bowel movements.
While recovering from his heart operation, my colleagues in medical and radiation oncology and I formulated a treatment plan for his rectal adenocarcinoma. Four weeks after his successful coronary artery–bypass graft operation, we began treatment with continuous intravenous infusion of a chemotherapy drug, 5-fluorouracil, or 5-FU, Monday through Friday, with radiation therapy to the area of the rectal cancer on the same days. He received this treatment five days a week for five and a half consecutive weeks, during which all bleeding from his rectal cancer ceased.
The cancer shrank after chemoradiation treatment but did not disappear. Four weeks after completing the intravenous 5-FU and external beam irradiation, the tumor was still readily palpable in a digital rectal examination and was visible when looking into the rectum with a proctoscope.
Cardiologists at the heart institute evaluated my patient and gave us the green light to proceed with an operation to remove his malignant rectal tumor. I performed an abdominoperineal resection, or APR, on this man six weeks after the final dose of chemotherapy and radiation and ten weeks after heart surgery. An APR involves removing a portion of the lower colon, the entire rectum including the sphincter muscles, and the tissue containing area lymph nodes. This operation requires creation of a permanent colostomy. For the rest of his life, this man, like all who undergo such a procedure, must wear a bag on his abdominal wall to collect stool exiting the colon.
This represents a really big, life-changing deal. Before the operation was performed, the patient, his daughter, a stoma nurse (an expert in managing the supplies, problems, and questions associated with a permanent or temporary exodus of bowel through the abdominal wall into a collecting bag), and I had a prolonged discussion about what a colostomy stoma would mean in terms of management and lifestyle changes. We also had him speak with other patients living with a colostomy. Undeniably, he was not happy about the prospect of a colostomy, but he understood the oncological and anatomical constraints that warranted this curative-intent operation.
The surgical procedure was performed successfully, and no heart or other problems arose to disrupt his recovery. By the end of his inpatient stay, the gentleman and his daughter were comfortable with management of the stoma.
The preoperative chemoradiation therapy had produced significant killing of the patient’s cancer. This major response to the treatment was good news and a positive indicator for the prognosis. The patient had stage III (lymph node–positive) rectal carcinoma, so he received six months of intravenous 5-FU and leucovorin. When I saw him for checkups during his chemotherapy treatment, he reported that the chemotherapy made him a little tired and his hands felt tender when he was driving a tractor on his ranch. Minor annoyances, he told me. Insufficient to slow him down, his daughter confided.
The man came to see me three times a year for a couple of years after his operation, and then every six months until we passed the five-year anniversary of completion of his cancer treatment. At that point we continued with annual visits. He told me unemotionally during several clinic visits that he disliked the colostomy. He had a wry approach about it, however, telling me a couple of years after the operation he had nicknamed the colostomy Bubba, because of its uncontrollable propensity to be loud and obnoxious at inopportune moments in public. He once told me, “Bubba has a lot more to say than I do.” Bubba became particularly outspoken, effusive, and embarrassing when my patient drank two or three beers. The gentleman chose to quiet Bubba by limiting himself to a rare beer at a baseball game or an occasional scotch on the rocks during dinner.
Every time I saw my patient in the clinic, his outfit was similar. His standard attire was denim overalls, a Western shirt, well-worn cowboy boots, and a cowboy hat. I admit I assumed he was a proverbial good ol’ boy from central Texas. He was a man of few words and expressed little emotion. He never put on airs and was deferential and impeccably polite to every member of the staff.
About seven years into our follow-up routine, his daughter invited me to an event in Fort Worth honoring her father. It fell on a weekend when I was available, so I accepted. I wondered what group was honoring this seemingly simple and soft-spoken man.
The event turned out to be a party for more than a thousand people involved in the cattle business in Texas. My patient arrived wearing a tailored tuxedo, a black Stetson cowboy hat, and a pair of shiny Lucchese black lizard cowboy boots. From the look on my face, he could tell I was surprised and amused. He laughed and said, “I run a few head of cattle, Doctor.” A few thousand head on several thousand acres, it turned out. This unassuming, undemanding, true gentleman owned one of the largest cattle operations in the state of Texas. Who would have known? We had a great time and raised money to support his two favorite charities, cancer research and a center for troubled young people in west Texas.
The gentleman rancher came to see me in the clinic for more than ten years. His daughter called me as he was approaching his eightieth birthday. The wear and tear of years riding in the saddle on working cow horses, bumping around in pickup trucks, and driving tractors and backhoes on his ranch had taken their toll. He wasn’t getting around as well as he once did, so we agreed he would see his local physician. I received a Christmas card from this man every year for another five years until a note arrived from his daughter announcing he had passed away. His cancer never recurred. His daughter reported that while they’d had a tenuous and quarrelsome relationship at times, he had learned to coexist with Bubba.
I urge my patients with medical co-morbidities to do everything possible to manage their conditions well. Patients can take certain measures to help improve their outcomes after a diagnosis of and treatment for cancer: taking prescribed medications to control their high blood pressure, monitoring their diabetes closely to keep their blood-sugar levels in good control, exercising regularly and losing weight to avoid the problems related to obesity, and especially quitting smoking cigarettes if they are afflicted with that particular addiction. Coexistent medical conditions and unhealthy behaviors do more than increase the risk of complications and toxicities associated with cancer therapy; many medical disorders and personal choices directly produce conditions that cause cancer. Preventing cancer is always better than treating cancer.
Even Bubba wouldn’t argue with that point.
20
It’s Not Fair
“When you show deep empathy toward others, their defensive energy goes down, and positive energy replaces it. That’s when you can get more creative in solving problems.”
Stephen Covey
Empathy: The ability to understand and share the feelings of another
For a dozen years spanning the 1990s and early 2000s I had an avocation in addition to my career in surgical oncology, cancer research, and medical education. I coached my son’s and daughter’s soccer teams. My daughter was an avid player until she went to middle school, when she decided basketball, track and field, and music were more interesting. My son played soccer from the age of four through his college years. On his team, I had a core of the same players for a decade. A few came and went as parents were transferred to new jobs or as the players developed different interests, particularly once adolescence arrived. It happens. But by and large I had the same group of boys the entire time I coached.
When children are four or five years old, they play what I call piranha ball. The ball rolls to an area of the field and a group of eager children wearing uniforms in two different colors descend upon it, kicking madly. The ball eventually squirts out, the piranha follow, and the furious kicking resumes. Great fun with lots of laughter, and nobody cares about goals’ being scored. The occasions when the ball ends up in the back of the net are usually random events amidst the chaos.
As my son grew older, it became clear that he was a good
athlete and skillful player. He began competing on teams designated for more advanced players. Two evenings a week and every weekend in the fall and spring involved his soccer practice and games. His games took place throughout south Texas, and during his teenage years, included several trips annually to tournaments around the country. To assure I was up to date on the latest soccer coaching techniques, for two consecutive summers I accepted the extreme measure of living in a dormitory room for a week at the University of Oklahoma to obtain my United States Soccer Federation national coaching licenses.
The players who were on my team for many years came to know my idiosyncrasies. I had one notable pet peeve. When one of my new players committed a rough foul and was shown a yellow card, or conversely, when he believed he had been fouled but the referee failed to agree, he would come over to the sideline at halftime and complain, “It’s not fair, Coach.” The veteran players would moan, avert their eyes, and quietly creep away. Parents would clear their throats, grab their lawn chairs, and scatter. They knew what was coming: “The Lecture.”
I would sternly ask the young man if he’d been granted a contract at birth stating life would be fair. Confused, wondering why he was deserted by his teammates, he would stammer out, “No.” I would then affirm that life is indeed not fair and would provide examples of atrocities committed on innocent populations throughout history. I would go on to mention the fact that people, including children, without any good reason are diagnosed and die from cancer, and I’d state that there are children born with defects or who develop disorders that do not allow them to run and play on the soccer field. The Lecture would invariably end with, “Is any of that fair?”
In My Hands: Compelling Stories From a Surgeon and His Patients Fighting Cancer Page 14