Somber silence. There’s not much people can think to say after a monologue dripping with venom.
Sometimes people will ask how I deal with the angst and distress of patients who are diagnosed with a cancer I cannot treat surgically, or when their cancer recurs and metastasizes despite all of our multidisciplinary treatments. My response is rooted in a baseball analogy. The greatest hitters in baseball successfully get a hit and find themselves on one of the four bases approximately one-third of the time. This means they fail to get on base the majority of their at bats. They may strike out, fly out, or ground out to an infielder. Less effective hitters may have a success rate of only one in four or one in five times at bat. If your batting average is lower than that, unless you are a pitcher, you will likely find yourself shipped to a minor-league team. I go on to explain that with many cancers our success rate with surgical and other treatments falls in range of the batting average of a middling-to-elite major-league baseball player. For some cancers, our success rate is much worse, and we need to work diligently to find better treatments or ship ourselves back into the basic science laboratories to find something better to help people. Happily, for some cancers we now have treatment-success averages that are unimaginable for even the best major-league hitters. But we are still not anywhere close to batting a thousand.
Caring for cancer patients is not an easy job and can incite intense emotions. A few years ago, I met a woman in her early fifties who was astonished when she was diagnosed with stage IV colorectal cancer. She had been a busy and healthy individual, involved in numerous community and church activities and with no medical problems. Along with her husband she was engaged in raising two teenage children, who were soon to enter college. She was feeling less energetic than usual, and had noticed a few episodes of some bright-red blood mixed in with her bowel movements. A trip to her family physician was followed quickly by a referral to a gastroenterologist. The gastroenterologist performed a colonoscopy and discovered a circumferential but nonobstructing cancer in the left side of her colon. The gastroenterologist ordered a CT scan of her chest, abdomen, and pelvis to evaluate her appropriately for the presence of any metastatic disease. Unfortunately the scans revealed five lemon-sized tumors in the right lobe of her liver.
The patient was immediately referred to a medical oncologist who began intravenous chemotherapy. He administered six cycles of chemotherapy, a two-day intravenous infusion every two weeks. He then referred the patient to me. This woman and her husband were well-educated professionals who had read extensively about her disease. They came prepared with several pages of questions, and I dutifully answered all of them. She was no longer bleeding from the primary tumor in the colon, and reviewing a new set of CT scans showed that the colon cancer, which had been readily evident on her initial scans, had decreased in size markedly. The five liver tumors were also smaller, but one tumor was very near the right portal vein and hepatic artery providing the blood supply to the right lobe of the liver. Another tumor was draped around the right hepatic vein. We had a long conversation about the sequence of surgical treatment, and I recommended we proceed with removal of the right lobe of her liver first. Her primary tumor had decreased in size and was causing no problems, and I was concerned that taking her off chemotherapy for two or three months while she recovered from a colon operation would allow the liver tumors to grow back to a potentially dangerous size. The patient and her family understood the rationale and agreed to proceed.
A surgical oncologist must assess the timing, sequence, and specific operation to perform in each individual patient diagnosed with stage IV colorectal cancer. Multidisciplinary cancer care is not a simple formula; each person should receive a customized treatment plan. In some patients, we are able to remove both the primary colorectal cancer and the liver metastases in a single operation. In others, the volume of liver removed combined with the potential extent of an oncological colon or rectal resection is deemed too much for a patient to tolerate physiologically. If a patient has a malignant tumor obstructing the colon or rectum, the priority is to remove the primary tumor, and the liver metastases are dealt with later. Often, patients receive chemotherapy first, before any surgical procedure, and if the liver metastases are a greater risk than the primary tumor, the liver resection is completed before a colorectal surgical procedure. My patient had some mild inflammation in her liver related to her chemotherapy treatment. I felt it safest to perform only a liver resection, followed six weeks later by either another three months of chemotherapy or by removal of the colon cancer and then additional chemotherapy. We agreed to make the decision on the most appropriate next treatment step based on her pathology results after she recovered successfully from her liver operation.
Two weeks later I performed an exploratory laparotomy and confirmed she had a tumor in the left side of her colon. It was small and did not obstruct the intestine. I felt no obviously abnormal lymph nodes anywhere near the primary tumor. Intraoperative ultrasound confirmed the presence of five liver tumors, and as happens in 5 or 6 percent of the patients I treat, the ultrasound revealed a single six-millimeter tumor deep in the left lobe of her liver. This tumor was, no doubt, present the entire time, but was simply too small to be detected on the CT imaging. I always warn patients that when I use the direct liver ultrasound I might find a few additional small lesions and that I will deal with them at the time of their operation. I proceeded with removing the entire right lobe of her liver as well as a small portion of the left lobe, to assure a tumor-free resection margin. I finished the operation by performing a microwave ablation of the single small tumor in the left lobe of the liver. The operation went flawlessly, she required no blood transfusions, and she was up, alert and walking the next morning. Her hospital course went smoothly and she was discharged five days later. She was feeling the expected fatigue associated with rapid regeneration of the liver, but was smiling and happy over the results.
But the single small tumor in the left lobe of her liver foreshadowed a problem. I saw this woman a few days after her discharge and she was doing well. I scheduled her to return five weeks later to see me and her medical oncologist with repeat CT imaging to assess her liver regeneration and to discuss the next steps in therapy. When the patient returned for her appointment, one of my surgical residents went in and talked to her first. She came out after a few minutes and reported the patient was feeling well, although she admitted she had a bit of a dry cough and her energy levels, which had been recovering nicely, had waned a bit over the past few days. The resident detected nothing unusual on physical examination, and the patient’s surgical scar was healing nicely.
I pulled up the patient’s CT scans on the computer and the resident and I gaped at the images. She had dozens of marble-sized tumors in her lungs, and her regenerated left liver was peppered with at least ten golf ball-sized metastases. Unbelievable! I had performed an ultrasound on her liver six weeks earlier and none of these tumors had been evident. An early and aggressive recurrence of cancer after liver resection does not happen very often, but when it does, it is a miserable conversation to have with the patient and family. Eyes initially downcast, I walked dejectedly into her room. The patient knew immediately from my demeanor something was very wrong. I sat and faced her and her husband, looked her directly in the eyes, and I began to describe and explain what I was seeing on her CT scans. She started weeping quietly, but was soon sobbing loudly. Suddenly, from behind me I heard my resident state, “This is too real.” I turned to see a stricken expression on the resident’s face, her eyes welling with tears. She fled from the room.
I sat with my patient and her husband for another forty minutes and explained further surgical treatment was off the table as an option. Her primary colon cancer was still small and not causing problems. I mentioned we needed to initiate chemotherapy as quickly as possible. I called my medical oncology colleague who was treating her and he kindly dropped what he was doing to come speak with the patient and her husband.
I walked out of the examination room emotionally and physically drained by the conversation and the unfortunate situation this patient faced. She asked impossible-to-answer questions about the probability of seeing her children graduate from college. Her children were still in high school. Given the behavior of her cancer, my medical oncology colleague and I knew we were dealing with a vicious disease running rampant. We hoped to rein it in for at least a while.
After I dropped the bomb of horrible news on the patient and her husband in the examination room, I went searching for my surgical resident. She was nowhere to be found in the clinic. I pulled myself together and went back to work to see some additional patients. About twenty minutes later, my red-eyed resident reappeared. I took her aside into a quiet corner and asked what I could do to assist and support her. She explained that she’d been overcome by grief because her own mother had died the previous year. Ten years prior, her mother had been diagnosed with stage III breast cancer. She had undergone surgical treatment and chemotherapy. For almost a decade, her mother had been cancer-free and living a normal life. Then, unexpectedly, the malignant beast reared its head again and she developed back and leg pain. Scans revealed she had metastatic breast cancer in her liver, lungs, and bones. Ultimately, it also appeared in her brain. She was treated with chemotherapy and radiation therapy but lived less than six months after her diagnosis of metastatic breast cancer. The resident admitted to me she had suppressed much of the emotion related to her mother’s death because she had needed to get back to work taking care of surgical patients.
When I was sharing the bad news with my colorectal-cancer patient, however, it had opened a personal Pandora’s box for the surgical resident. All of the unresolved feelings regarding her mother’s cancer had rushed out and momentarily overwhelmed her. It is a risk all of us face, balancing compassionate and thoughtful care with control of mental turmoil from our own personal situations and our experiences. After we finished the clinic, my resident and I went downstairs to the coffee shop. We talked for half an hour and I encouraged her to speak with me, other faculty, colleagues, or friends about the difficult emotions and to recognize and accept that it was okay to express feelings about her loss. Sometimes a tough facade is fine, even necessary, but not at the expense of true compassion for others and for ourselves.
Things were much worse than we anticipated for my patient who had precipitated the release of the surgical resident’s pent-up feelings. The patient’s medical oncologist called me the next week to tell me he had admitted her to the hospital. Her liver tumors had grown so rapidly that her liver was beginning to fail. I went to the intensive care unit and visited the patient, her husband, and children. Even the usually tough ICU nurse was crying softly by the end of the conversation. The patient and her husband graciously thanked me for my efforts on her behalf, and she told me how proud she was of her two children. Then she turned to her children and told them she was sorry she was leaving them and to always remember her love and devotion to them.
She died two days later.
Patients, family members, friends, and caregivers treating cancer patients ride a constant emotional roller coaster. There are occasionally thrills as we see patients back in the clinic who are long-term survivors living complete and fulfilling lives. Conversely, there are periods of gloom as we watch patients suffer from toxic treatments while their cancer progresses and ultimately claims their life. Even patients who are doing well years after a cancer diagnosis tell me they get wound up and anxious for a few days before their routine follow-up visit with me or other oncologists involved in their care. Treating patients with cancer is sometimes a viscerally painful, mentally draining, and powerful experience. You can only imagine the profoundly emotional experience for a cancer patient, unless you yourself have been such a patient.
It’s not an easy choice, but I choose to feel. I am engaged and involved with my patients, and I’ll spend as much time with them as they need. I have many patients whom I follow right up to the time of their death, some of whom I’ve never operated on. What I have learned is that patients don’t want to be abandoned. They want to know that someone will be present and will provide assistance when they have symptoms or fears and need support.
We need to support our own as well. The physicians, nurses, trainees, and all cancer caregivers are devoted to helping patients who are facing a frightening and potentially lethal disease.
We need to remember the emotional toll. We need to take care of all.
30
Be the Dog
“Modesty means admitting the possibility of error, subsuming the self for the good of the whole, remaining open to surprise and the gifts that only failure can bring. There are many ways to practice it. Try taking up golf. Or making your own bagels. Or raising a teenager.”
Nancy Gibbs
Modesty: The quality or state of being unassuming in the estimation of one’s abilities
My great-grandfather was a reserved, taciturn man. He was in his late seventies and eighties when I was growing up in New Mexico. When he did speak, it was worth listening, because his few words carried impact, perception, or wry humor. I always looked forward to our time together because it represented an opportunity to learn from a master observer who had been born in the late nineteenth century and experienced remarkable progress in the twentieth. He had been a miner, a builder, a hunter, a fly fisherman, an expert in surviving in the high mountains in all seasons, a self-taught mechanical engineer, and a keen commentator regarding human behavior. His statements on the last were invariably terse but remarkably insightful.
One day, I walked in to my grandmother’s house, where my great-grandfather sat at the kitchen table with a cup of coffee in his hand. I asked, “How are you doing today?” He took a sip of coffee and, never meeting my eyes with his gaze, commented, “Some days you’re the dog; some days you’re the tree.”
I had learned from previous experience never to ask for an explanation of his somewhat abstruse remarks. He had told me once that I should, “Think it through.” So this time I sat in a chair next to him and pondered for a moment. I looked up at him, and said, “So some days you feel like you’re rooted in place and must endure whatever problems arise and deal with whatever is dumped on you, while other days you are running happy, free, and able to leave your mark on the world.”
He took another sip of coffee, still staring out the window, and a small smile played at the corners of his mouth. He gave an almost-imperceptible, affirmative nod. He then patted me on the arm and said, “Smart boy.”
It was the most emotion I ever saw him express. I was thrilled to have earned high praise from this occasionally curmudgeonly, genuinely thoughtful and experienced man. He lived alone in a small stone house in the Jemez Mountains northwest of Albuquerque. It had a wood-burning stove but no central heating or air-conditioning. It did have central plumbing that my great-grandfather had rigged up himself. He had no telephone; if he wanted to make a call he had to amble down the mountain to the nearby home of his niece.
In addition to his other skills, my great-grandfather was a master furniture maker. He created amazing pieces from wood he milled and shaped himself. He was also able to carve beautiful figures of animals and birds out of wood or stone. Several of his skillfully cut and polished sculptures are included in the Americana collection at the Smithsonian Institution. I will always display and cherish the wolf he carved for me out of lilac-colored lepidolite. The raw material came from one of the many mine claims throughout northern New Mexico and southern Colorado where my great-grandfather had worked. When he died, I was bequeathed his complete set of hand-carving tools. Sadly, I did not inherit his skill in working with wood and stone, although I am very handy when it comes to carving malignant tumors out of my human patients.
About a month ago, I had a great week. I was the dog. On Monday, I successfully completed a wonderfully symmetrical day by first performing a left hepatectomy for colorectal-cancer metastasis,
followed by a right-lobe liver resection in a patient with an intrahepatic cholangiocarcinoma. Both operations went perfectly with minimal blood loss. Both patients were up walking the halls on the surgical ward the night of their operations and asking when a dinner menu would be delivered. On Tuesday I had a splendid day in the clinic. My schedule was full, and I saw several new patients who were candidates for surgical treatment of their malignant disease. The patients and their families were relieved to know I could potentially remove their liver tumors and give them hope of controlling and possibly beating the cancer. As lunchtime approached, the day was interrupted when my physician’s assistant tapped me on the shoulder and asked if I was having a good day. I replied I was indeed, and I turned around to see the entire clinic staff and all of the surgical residents with a birthday cake. Somebody had leaked the date! I protested (unsuccessfully) that it was false news. They embarrassed me completely by loudly singing “Happy Birthday to You” and I blushingly endured teasing and further birthday songs from my patients for the next several hours. On Wednesday I attended an energizing education session for the residents, and I spent some time individually teaching students and residents about the process of thinking through options and evaluating patients with various malignant diseases. Any chance for me to teach or learn makes for a great day. On Thursday, I completed two more liver operations that went smoothly, and, again, both patients recovered quickly and uneventfully. Friday saw another clinic day following up on patients who were recovering well after liver resections and with no need to drop bad news on anyone. I also met with two patients who were scheduled for operations the next Monday, I answered all questions and went over the details of their procedures to their satisfaction.
Unexpectedly, I received five birthday notes from patients or their family members during the week. The information leak from my staff was worse than I had imagined. One card read, “Hello Dr. Curley. You treated my husband twelve years ago for colon cancer spread to his liver. I am happy to say he is still cancer-free and we have raised our family. Thank you for giving us over a decade more than we were told we would have with him.” The five patients—all cancer survivors—were initially told they had “incurable” disease. All had undergone major liver resections and chemotherapy and were enjoying life and family, cancer-free eleven to sixteen years after their surgical treatment.
In My Hands: Compelling Stories From a Surgeon and His Patients Fighting Cancer Page 24