He recovered over the next few days and left the hospital. I saw him back in the office weekly and checked his wound, which healed well without any further difficulties or problems. His medical oncologist initiated a six-month course of a second combination of chemotherapy drugs. But the patient was only able to complete four months of treatment because of the severe side effects that developed. When I saw this man six months after his liver operation, he looked tired, haggard, and dejected. “Rode hard and put up wet,” as my grandmother would say. Anxiety and depression are common problems in cancer patients, and should be addressed as part of their total care package. So I engaged my patient in a thirty-minute amateur-psychotherapy session that ended with me encouraging him to seek proper, professional mental-health counseling. He admitted he was not eating well or exercising regularly, he felt lethargic, and his sleep patterns were abnormal. These are common and expected symptoms of depression, but too frequently they’re overlooked by physicians treating patients with chronic, debilitating, or life-threatening diseases.
“You know I wouldn’t have no luck at all.” Treatment of his depression and tincture of time improved the attitude and outlook of my still-under-forty-year-old, stage IV colorectal-cancer patient. Two years after his liver resection, at a routine office visit, I noticed immediately that his serum CEA level was again elevated. I quickly pulled up his CT images. His liver, belly cavity, and lymph nodes were normal. I switched over to the CT scan of his chest and observed two “new” lung metastases in the right lower lobe. I quietly uttered a couple of four-letter words at the images on the screen, collected myself, and entered his room.
He sat on the exam table, smiling, until he got a glimpse of my face. His smile turned into a frown, and I told him what I had seen on his lab studies and CT scan. He seemed to deflate before my eyes. Taking the proverbial bull by the horns, I told him he was otherwise in excellent health and would be a candidate for surgical removal of these tumors. After staring at the floor for about thirty seconds, he looked up and said resignedly, “Okay, what choice do I have?” I explained we had other options and alternatives available, but I believed surgical removal was best. He agreed, and a colleague in thoracic surgery saw my patient the same day. Two weeks later, my patient underwent a thoracotomy and surgical removal of the two lung metastases. No additional tumors were discovered during the operation. This time he recovered quickly and well, with no complications or problems.
When I saw him back in the office a month later he expressed mild surprise that the surgical procedure and hospitalization had gone so well. The patient’s wife jumped in, “Stop whining! You’re alive and for now you’re cancer-free, let’s get on with it!” All right then. The patient and I stared at one another, and we burst out laughing. I remember this conversation clearly; her remark was a verbal slap into thankfulness for my patient.
Two years after his lung operation, I saw him back in the office and it was clear he had lost weight. He remarked, “I decided to get serious about being healthier so I finally took your advice and I’m eating right and running every day.” He mentioned that because he had lost about twenty-five pounds, he noticed a lump in his neck while shaving. I examined his neck; he had a palpable nodule in the right lobe of his thyroid gland.
Seriously? I explained we needed to evaluate this tumor. I ordered an ultrasound, which showed a 1.2-centimeter, solitary thyroid nodule. A fine needle aspiration biopsy confirmed a papillary thyroid cancer. When I saw him to discuss results, he looked at me bemusedly and said, “Okay, now what?” One of my endocrine surgery colleagues removed his thyroid gland the next week and my patient has been taking thyroid tablets every day for the last decade.
He doesn’t talk about being cured of cancer anymore, but it has now been twelve years since my patient’s lung operation for metastatic colon cancer. He received no additional chemotherapy, and no type of cancer has recurred since his thyroid was removed. He is appreciative and upbeat about being cancer-free for more than a decade now. During their visit with me last year his wife mentioned they have learned that patience and optimism can help to endure any tribulation they face. She is right. There is no serum blood test for a positive attitude, but in cancer care we have noticed that patients with an upbeat approach and a stable support system are able to bounce back from their treatments faster.
Not quite a decade ago, a fortysomething-year-old woman was referred to me with a diagnosis of a rectal adenocarcinoma and numerous liver metastases. When I entered the room to meet her, she immediately stood up, clasped my hands, and started crying. “I am too young to have this cancer doctor. How could I have such bad luck?” I sat her down in a chair next to me and spent forty-five minutes speaking with her and her husband. After she composed herself, I was able to perform a physical examination. Her rectal cancer was very low and clearly involved the sphincter muscles of her rectum. Surgical treatment would require complete removal of the lower colon and rectum, and a permanent colostomy. The rectal cancer was causing her pain and bleeding with bowel movements but was not obstructing her intestinal tract. She had a fifteen-centimeter liver tumor involving the right lobe of the liver extending into the medial left lobe, and abutting the right and middle hepatic veins. There were more than ten additional small tumors in the right lobe of the liver and one located in the caudate lobe. This was bulky and extensive metastatic disease.
Strictly from a prognostic point of view, considering the probability of long-term survival, this was not a good situation. I was concerned about the size and volume of her liver tumors. Surgical treatment would become impossible if these tumors grew even a little bit while she was on chemotherapy or recovering from surgery for the primary rectal cancer. Other than having stage IV rectal cancer, this woman was remarkably healthy with no other medical problems or co-morbidities. I recommended, and subsequently performed, an aggressive surgical procedure the following week. I executed an extended right hepatectomy and caudate-lobe resection. This removed approximately 80 percent of her total liver volume. This large resection pushed her to the edge. She was in the hospital ten days after the operation and developed some transient jaundice. An operation to resect such a large volume of normal liver strains the functional and biochemical capacity of the liver. Some patients require infusions of fresh frozen plasma after an extensive liver resection because the small amount of remaining liver is not sufficient to produce clotting factors needed to avoid postoperative bleeding. In others, serum bilirubin levels rise temporarily and manifest as jaundice with the skin and eyes becoming yellow. Until the liver regenerates adequately, it is not able to process the bilirubin produced as a by-product of turnover and breakdown of red blood cells. Thankfully, while it was a struggle, this lady’s liver regenerated and her blood work normalized after a few weeks.
Four weeks after her liver operation, while she was still recovering, we gave her a combination of low-dose intravenous chemotherapy and radiation therapy to treat the rectal adenocarcinoma. This approach required her to wear a chemotherapy pump Monday through Friday to receive a continuous infusion of 5-FU, along with daily radiation treatments Monday through Friday for almost six consecutive weeks. Her rectal discomfort and bleeding ceased midway through the course of chemoradiation treatments.
A month after she completed the chemoradiation treatments, I saw her back in the office and reviewed her new blood tests and CT scan results. Her liver had regenerated to an almost-normal volume, her liver function and serum CEA tests were normal, and the rectal cancer had completely disappeared on the scans and on physical examination. You know what I mean, right? Don’t make me say it. All right then, on digital rectal examination. Sheesh!
Despite the apparent disappearance of her primary rectal cancer, there was a high probability that microscopic nests of cancer still remained in the wall of the rectum or adjacent lymph nodes. So the accepted, correct, standard-of-care next oncological step was to remove the lower colon and rectum and create a permanent colostomy, an abdominope
rineal resection. I had a lengthy discussion with the patient and her husband. This lady, who had told me to “be as aggressive as possible” with her liver operation surprised me by saying, “I do not want a colostomy, and I do not want the rectal operation. I am feeling lucky.”
I could not justify the patient feeling lucky as a bona fide reason to not pursue surgical and multidisciplinary treatments that were sound from an oncological point-of-view. But despite a prolonged and spirited discussion, the patient was steadfast in her refusal to undergo the operation. She did agree to six months of additional chemotherapy, which was subsequently administered. When I saw her back after she completed the additional chemotherapy, CT scans and blood work remained normal. I reiterated my belief that complete treatment should include surgical removal of the area that had borne the rectal cancer, and she repeated her refusal, telling me that she was certain that the rectal cancer was gone. In medicine, when treating patients, we provide our best recommendations, presumably based on sound clinical trials, evidence, and rigorous reviews of patient outcomes. We are human. And patients have free will and are not required to accept our treatment options. I recorded my recommendation and her decision to decline an operation, and we agreed that I would follow her closely.
This patient and her husband returned dutifully every three months for CT scans of her chest, abdomen, and pelvis, blood tests, and a physical examination. My colleagues in gastroenterology completed a sigmoidoscopy and endoscopic ultrasound of her rectal area every six months. There was no evidence of local recurrence of her rectal cancer. But eighteen months after completing chemotherapy, her CEA level rose slightly and a CT scan of her chest revealed two new lung nodules in her right lung. There was no evidence of tumor at any other site. She was, naturally, distraught, but she agreed with our multidisciplinary-conference recommendation to receive a second type of intravenous chemotherapy. She completed three months of the therapy and the two lung tumors shrank in size. After one of my thoracic surgical colleagues removed these two tumors, the patient completed another three months of chemotherapy and her follow-up resumed.
Initially, she did very well. For the next year blood tests, CEA levels, physical examinations, and CT scans revealed no evidence of recurrent or new metastatic disease. Unfortunately, a year after completing chemotherapy for the lung metastases, a CT scan showed two tumors in her left lung. There were no lesions in her liver, lymph nodes, or in the rectum. The word luck came up again. She stated, “I have not had good luck with chemotherapy, let’s just take these out.”
So be it. The same thoracic surgeon removed the two left lung tumors, which were confirmed by pathology analysis to be metastatic rectal cancer. She had already been treated with two complete standard courses of first- and second-line chemotherapy, so she declined any additional drugs or novel agents as part of a clinical trial. At her visit with me six months later, I happened to be standing in the clinic hallway speaking with one my colorectal-surgery colleagues. The patient and her husband were ushered from the waiting room into an examination room, and I introduced her to the doctor. He exclaimed, “Oh, you’re the lady who won’t allow us to remove her rectum! You are really pushing your luck.” She glared at him icily and ended any further conversation or unsolicited opinions definitively, “I’ll save my own ass, thank you.”
No further comment needed. This patient’s luck has not run out. She is almost a decade out from her initial diagnosis and has undergone and endured three major oncological operations and a year of chemotherapy. She has never required the recommended operation to remove her rectum and evidently the chemoradiation therapy completely eradicated her primary tumor. This is not unprecedented. Carefully conducted clinical trials with several types of cancer, including rectal adenocarcinoma, indicate complete pathological response and killing of all cancer at the primary site can be achieved with chemoradiation therapy in a subset of patients. However, we surgical oncologists have no way to distinguish preoperatively between patients who achieve a complete response following chemoradiation therapy from patients with subclinical areas of cancer still present. While it was not the standard of care, it is hard to argue with the outcome; my patient has survived almost a decade in spite of liver and lung metastases from her primary rectal cancer. And she has not had to live those ten years with a colostomy. Saved her ass, indeed!
Fate is fickle, fortune is uncertain, and luck changes. In surgical oncology and all cancer care, we strive always for excellence, but we like it if good luck is on our side. It goes along with the old saying “Better to be lucky than good, but best to be lucky and good!”
23
The Swimmer
“I know of no higher fortitude than stubbornness in the face of overwhelming odds.”
Louis Nizer
Fortitude: Courage in pain or adversity
Growing up in the high Sonoran desert of New Mexico afforded my brother and me plenty of opportunities to run, play games and sports with friends, and bicycle across the mesas and arroyos around Albuquerque. Riding our banana-seat bikes on the sun-baked trails through creosote bush and piñon trees, struggling to pedal through the sandy bottoms of the usually dry arroyos, and pushing up into the foothills of the Sandia Mountains to then coast down at high speed was excellent aerobic exercise—particularly considering we were at an altitude of almost one mile. As an adult I continue to love running and cycling, and even competed for a couple of years in duathlon events that combined both activities.
I have never competed in a triathlon. There is a very simple reason: swimming is a not a forte of mine. New Mexico has an arid to semi-arid climate, depending on your location and proximity to the mountains. Until I was a teenager, the largest body of water I had ever seen was that great strip of mud known as the mighty Rio Grande River. Originating in Colorado, it courses north to south through New Mexico before becoming the natural border between Mexico and Texas as it flows into the Gulf of Mexico. I remember times when it flowed freely, particularly during springtime after a heavy winter of snow in the mountains, but for most of the year there was little water in the Rio Grande as it was diverted for the many irrigation needs of farmers along the river valley.
That is not to say I was not exposed to swimming as a child. My parents enrolled my brother and me in swimming lessons when we were very young, and we became adequate swimmers. Four or five times every summer we would be treated to a trip to the local community pool, called the A pool. The pool was constructed in the shape of a large, one hundred–yard long capital A. The flattened top of the A was the deep end and featured a spring board and a high dive platform. The end of one of the A legs was the “kiddie” pool, which we fastidiously avoided, and the opposite leg was the four-to-five-foot-deep swimming and playing area.
To my brother, my friends, and me, the most interesting feature was the center concrete island situated perfectly in the middle of the pool connecting the two legs of the A. This was an area to swim to, climb on, and cannonball or dive off in an attempt to splash our neighbors. This cavorting in the water was the extent of my aquatic skill and experience. The island was also a source of unending aggravation for the lifeguards. It was popular to play Capture the Island when two or more spontaneously assembled teams of kids would swim to the center of the pool and tussle to climb onto the island and claim ownership. This inevitably produced angry whistle-blowing from the lifeguards and shouts of, “Hey, you kids on the island, knock off the pushing and shoving!” Those clinging on to the side of the island would sullenly slide back into the water, while those already on top would cannonball into the pool as a wordless protest. There would be ten or fifteen minutes of relative peace as the groups of children would quietly reorganize, only to launch another assault for dominance of the island. The angry whistle-blowing and threats from lifeguards would recur numerous times a day. I don’t know how they tolerated it; we were relentless nuisances.
In contrast to me, with my inefficient water-thrashing technique, I had a patient who w
as an excellent swimmer. He swam competitively for a top-ranked major Midwestern American university. He wasn’t offered a scholarship, he walked on (or swam on, to be accurate) and showed enough talent and drive to earn a place on the team. After completing his university swimming career, he went on to earn graduate degrees and to work in the medical field. He was married with children and was enjoying his profession when he developed stage IV colorectal cancer.
This active and athletic gentleman was in his thirties when he was diagnosed. Another surprisingly young patient on the left side of the somewhat asymptotic age-distribution curve for time of detection. He had no family history of cancer, and during testing of his cancer and normal cells no genetic abnormalities were observed that would explain this early-age diagnosis. Nonetheless, he was faced with colon cancer and liver metastases. As is often the case with patients referred to me, he had already undergone surgical removal of his primary colorectal cancer and was receiving systemic intravenous chemotherapy. He had several metastatic tumors in his liver, including one that was unfortunately situated, abutting all three of the hepatic veins draining blood out of the liver.
In My Hands Page 17