In My Hands

by Steven A. Curley

  All in all, a darned good week loping like a carefree dog and leaving a positive mark on the world.

  But the following Monday I quickly became the tree. My first patient was scheduled for an operation at 8 a.m., and I had planned to do a straightforward, small-wedge liver resection. All of our detailed, state-of-the-art preoperative imaging studies showed only a single two-centimeter tumor at the edge of the liver. Depending on the type of cancer, I occasionally start some procedures with a diagnostic laparoscopy to view the entire peritoneal cavity, and I ultrasound the liver to make certain there are no additional or small tumors not detected on the preoperative imaging studies. In most patients, I will start with a small mini-laparotomy incision just big enough to allow me to inspect and palpate the organs. I made such an incision in my first patient and upon entering the belly cavity immediately encountered hundreds of tumors smaller than a grain of rice. I biopsied several and while awaiting a frozen-section analysis by our pathologist, I performed an ultrasound of the liver. More shocking news: there were dozens of liver tumors scattered in every portion of the liver, each only three or four millimeters in size. I biopsied one near the surface of the liver and went to the frozen-section room to look through the microscope with the pathologist. All of the tumors were the same type as the one we had already planned to take out. The operation was over because there was no way to remove all of the malignancies.

  My resident and I closed the small laparotomy incision. I went out to deliver the grim news to the family. It was not received well. The patient had more than a dozen family members present, and they expressed a full gamut of emotion, from anger to disbelief to sobbing sadness. I waited for approximately an hour after the operation, and once the patient was awake, I repeated the conversation with the patient. Again, it was not well received. How could it be? I felt sad, frustrated, and stuck in place because I had not been able to help the patient.

  I started the second operation that day in the same fashion, with a small incision. Thankfully, I found no tumors in the peritoneal cavity. My relief was short lived, however, because once again ultrasound revealed that instead of only two tumors in the right lobe of the liver that could be easily removed surgically, there were dozens of small tumors scattered throughout every segment of the liver. Again, biopsies confirmed diffuse malignant disease throughout the organ. The incision was sutured closed. I took the seemingly interminable, long, shuffling walk to the surgical waiting area and delivered the unfortunate news. It was not even noon on Monday and I already felt physically and emotionally drained and bedraggled.

  On Tuesday the clinic started well with a new patient who was a surgical candidate and follow-up patients with assessments revealing they were tumor-free. After I delivered the good news, there were sighs of relief, smiles, and hugs in each room. Then the roof caved in. A young patient, whom I admire greatly for her determination and grit, came in for a follow-up visit three years after I had removed a primary cancer from her liver. This lady had amazed her medical oncologist and me by running two miles to and from her weekly chemotherapy sessions before and after her liver operation. She told us, “I feel like hell, but pushing through the sickness gives me purpose and hope.” She has impressive spirit and willpower. Her tumor blood marker, which had been normal for three years, was now elevated. I opened her scan images on a computer terminal and my heart sank. There were several new tumors in the hypertrophied liver and numerous enlarged lymph nodes near the blood vessels in her abdomen. I entered the examination room, and she and her husband knew immediately I was about to drop bad-news napalm on them. I maintained a calm and professional facade and quietly explained the findings indicating her cancer had recurred. After I finished describing the situation, there was uncomfortable silence in the room.

  Dumbfounded, she looked into my eyes and said, “How can this be? I am one who was supposed to beat cancer.”

  I had no response.

  We talked for another fifteen minutes or so, and I called her medical oncologist to let him know the situation. He was disappointed and deflated, too. He started her on a new chemotherapy regimen and we will follow closely and see what happens. My patient had asked me during our clinic visit if she would ever again be a candidate for an operation to remove any remaining cancer. I answered honestly; it was not likely, but with a dramatic response to chemotherapy, I was willing to push the envelope and give her every chance. A true statement for every patient I see. But sadly, far too many patients have cancer my colleagues and I cannot treat with surgery.

  When I arrived at my office Wednesday morning I looked at my schedule and I audibly groaned. The day was packed with nine hours of back-to-back meetings and committees. I don’t mind administrative duties if something is achieved and progress and decisions are made. But I knew from the list of meetings that that was not going to happen. I girded myself emotionally and sat through a day of verbose entropy. I participated actively, but, as predicted, no tangible success, decisions, or plans were made. I was far more exhausted at day’s end than I would have been after a similar day in the operating room. Thankfully, my single complex, six-hour operation on Thursday was successful, and I was pleased to be released from three days of bad karma. Nonetheless, I walked out recognizing the operation was for a cancer with a high propensity to metastasize and leave microscopic deposits of malignancy elsewhere in the body. More treatment will be needed for this patient, and then we will begin the process of nervous watchfulness. It is a tough existence for patients, family, friends, and the medical team. On Friday the clinic was completed uneventfully and with no more bad news to drop on patients. Whew! I met with my research team Friday afternoon and we reviewed several manuscripts and laboratory results. We planned a set of experiments needed to finish projects, knowing a long period of our work was coming to an end. It was time to move on to new ideas and new research to find (hopefully) better treatments for our patients.

  As I drove home Friday afternoon I reflected on the previous two weeks. One of the messages I had received from a patient the week of my birthday thanked me for being “the world’s greatest doctor” and for being responsive and caring. I appreciated the sentiment, and while comments like this may be great for the ego, they must be kept in some rational and realistic perspective. There is no world’s greatest doctor. The world contains lots of great, well-trained, hard-working, caring physicians. There are no Olympics for liver surgeons, oncologists, or other types of medical providers. No gold medals, no world records to beat, no objective measures of who is the best. All of us involved in cancer care should strive to do our best for each patient. It is critically important to have an honest and caring relationship with our patients, but such a goal is not always achieved. The demands, stresses, failures, complications, side effects, and sometimes brutal reality of cancer’s effect on patients, caregivers, and clinicians can conspire to produce frustration, angst, disappointment, and burnout.

  Too many times, cancer still defeats our attempts, no matter how great a job we do with our multidisciplinary treatments; the high-quality, complex cancer operations; the formulation and delivery of anticancer therapeutics; and the complicated three- and four-dimensional ionizing-radiation planning and delivery. Look at the statistics. Despite remarkable advances in basic science and clinical research over the past four decades, cancer is still the second most common cause of death in Western countries, and it is rapidly closing in on heart disease to become the most common. That is good reason to temper any egocentricity or arrogance among cancer clinicians; we have a painfully obvious high rate of failure. Cancer still wins the battle far too often.

  None of us can be the dog all the time.

  In 2021 we will mark the fiftieth anniversary of the war on cancer. The war will continue for many years after 2021. I am hopeful and optimistic that we will continue to make progress; continue to advance on the enemy; and through ongoing developments in research and understanding of this nefarious disease, our success rates will be higher an
d our patients will live longer, productive lives. We must maintain hope, courage, and commitment. I am reminded by my patients every day of the importance of working to sustain these qualities.

  I am grateful, and I am blessed to have the privilege of providing care for patients battling cancer. My colleagues and I will fight alongside them and help as we can. And I will offer the same four words to all: “Always happy to help.”

  ACKNOWLEDGMENTS

  I have written many surgical, clinical research, and scientific papers or book chapters during the course of my career. I have also edited a couple of textbooks. This first endeavor into a (hopefully) more readable, wider public audience–style of writing has been enjoyable, educational, and energizing. It has allowed me to honor the humanity, spirit, and journey of the cancer patients described herein and to recognize the highs and lows faced by every cancer patient and those who support them. It has helped me manage some of the emotional distress my colleagues and I face as cancer care providers. I have more people to thank for the gifts and blessings they have bestowed upon me throughout my life than can be listed in this brief section, but first and foremost, I thank all the cancer patients and their families who have entrusted me with their care over the years. I cherish the confidence they have placed in me, and I always respect the determination, endurance, and strength they show as they live and work through the diagnosis and treatment of cancer.

  I thank my mother for fostering and supporting my love of reading and investigation. Thank you to my father for teaching me the importance of hard work and the stubborn tenacity needed to overcome obstacles or problems placed before me. I am grateful for my son, Niel, and my daughter Emily. You were and are a constant source of joy and challenge for me—with the exception of the teenage years, which we will not discuss any further. Thank you to their spouses, Chelsea and Jess, for their love and support for my offspring. I am grateful to my two youngest daughters, Sarah and Katherine, because I come home every day to new adventures, wonders, and experiences seen through their eyes. Niel and Chelsea have blessed me with two grandchildren, Everly and Nash, who amaze me with their energy, rapid development, and endearing behaviors. And yes, Everly really did need a four-foot-tall stuffed unicorn for her birthday. You are welcome. It will only get worse; this is how Grandpa rolls.

  I am committed to teaching students at all levels of education, and I am fortunate to encounter undergraduate, graduate, medical school, and resident physician trainees on a regular basis. An opportunity to teach is always an opportunity to learn, and I thank them for their insightful and thoughtful questions. I teach to honor all who taught me throughout my educational career. I had the good fortune of having teachers throughout primary and secondary school who recognized that I needed extra work and projects to keep me occupied, and I appreciate all of those who took the time to ply me with additional work and reading materials. Medical school is an arduous experience, but Dr. Cheves Smythe and Dr. Benjy Brooks, in particular, provided critical life lessons about caring for patients and maintaining balance in life. Surgical residency was a six-year marathon, including one year of basic science research, and the residents I trained with were a brilliant and bodacious group. I have the utmost admiration for the surgical faculty who had major impact on my training as a young surgical resident, especially Dr. Raymond Doberneck, Dr. William Sterling, Dr. Dan Smith, and Dr. Sterling Edwards. Advanced surgical oncology training was made more rewarding because of the time spent teaching by Dr. David Hohn, Dr. Charles Balch, Dr. Mark Roh, Dr. Fred Ames, and Dr. Raphael Pollock. The latter individual is a dear friend whose support and assistance throughout the years has earned my enduring love and esteem.

  I appreciate the friendship of some of the incredible surgical oncologists with whom I trained, particularly Dr. Merrick Ross and Dr. Mark Talamonti. I had the very good fortune to serve as the surgical oncology fellowship program director at the University of Texas MD Anderson Cancer Center for nineteen years. I am honored to have worked with spectacular fellows from 1990–2014. In 2014, I was granted the marvelous opportunity to work with medical students and surgical residents at the Baylor College of Medicine. These inquisitive and talented people keep me on my toes and inspire me to achieve excellence in all my endeavors. My colleagues in surgical oncology, the department of surgery, and the Dan L Duncan Comprehensive Cancer Center at Baylor are a remarkable and dedicated group of master clinicians.

  I have maintained a translational basic research laboratory throughout my career, and the opportunity to work with college undergraduate and graduate students, postdoctoral fellows, and young faculty has pushed me continuously to find better treatments for patients with malignant disease. Working alongside my colleagues in all disciplines involved in the diagnosis, treatment, and care for patients with cancer has been an integral component in the successful development of state-of-the-art multidisciplinary treatment programs. I appreciate the commitment to excellence embodied by each of you in the care you provide for our patients. The thousands of nurses, physician’s assistants, nurse practitioners, other medical practitioners, support staff, and administrative staff involved in care for our patients deserve a prolonged and heartfelt standing ovation. We could not achieve the desired outcomes in our patients without your commitment and assistance. I thank, in particular, Veronica Smith for sticking with me for many years now and for providing a level of communication and compassion to our patients that is extraordinary.

  Finally, this first-time foray into book publishing has been shepherded by my agent, Jan Miller. Her humor and energy, along with very direct evaluation of my work, has been just what this surgeon needed. Grazie, Jan! Delysia Aldana and Ivonne Ortega at Dupree Miller have always graciously answered my inane questions and have patiently responded to emails. I am indebted to Becky Nesbitt and Dorothea Halliday, who have assisted in editing this book. Grace Tweedy Johnson readily responds to my inquiries to the publisher, and I am grateful to the editorial director at Center Street, Kate Hartson, for her unwavering support. And finally, to Kristine Ash and Sandra Palacios, a massive thank-you for your assistance in typing the numerous drafts of chapters in this book. My fingers would not have survived unscathed without your assistance.

  ABOUT THE AUTHOR

  Dr. Steven Curley is professor of surgery, chief of surgical oncology, and director of clinical programs in the Dan L Duncan Comprehensive Cancer Center at the Baylor College of Medicine in Houston, Texas. He has been an academic surgical oncologist for almost thirty years. His surgery practice focuses on patients with gastrointestinal malignancies, particularly cancers involving the liver and pancreas. He maintains a translational basic science laboratory directed toward developing, testing, and performing clinical trials on novel devices to treat patients with malignant tumors. His work led to use of thermal ablation techniques to destroy liver tumors that could not otherwise be removed surgically. His research group is working to develop less invasive, less toxic, and more effective treatments for patients with highly lethal malignant diseases such as pancreatic and primary liver cancer. He has been active throughout his career initiating screening programs to diagnose cancer at early, more treatable stages of disease and in improving multidisciplinary treatments for patients with gastrointestinal cancers. He lives in the Houston area with his wife and two youngest daughters. His son and older daughter are successful young professionals. He shares his space with four dogs, six chickens, and a horse.

  1. More than 90 percent had chronic hepatitis C.

  2. The overall incidence of liver cancer in the entire group of patients we screened was less than 10 percent, but the incidence in patients with hepatitis C and cirrhosis was almost 50 percent.

  3. In patients who did not have cirrhosis, we reduced the screening interval to only once every three years.

  4. Registry of Hepatic Metastases. “Resection of the liver for colorectal carcinoma metastases: A multi-institutional study of indications for resection,” Surgery 103, no. 3 (March 1988): 278�
�88.

  5. T. M. Pawlik, E. K. Abdalla, L. M. Ellis, J. N. Vauthey, and S. A. Curley, “Debunking dogma: Surgery for four or more colorectal liver metastases is justified,” Journal of Gastrointestinal Surgery 10, no. 2 (February 2006): 240–48.

  6. S. A. Curley, F. Izzo, P. Delrio, L. M. Ellis, J. Granchi, P. Vallone, F. Fiore, S. Pignata, B. Daniele, and F. Cremona, “Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies: Results in 123 patients,” Annals of Surgery 230, no. 1 (July 1999): 1–8.

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