When Life Gives You Lemons

When I was about ten years old, swimming on a Texas swim team, I remember hearing that the child of one of the local coaches had been diagnosed with leukemia.  The idea of a kid dying of an untreatable disease was so foreign to me that I am sure that I have blocked out most of the details.  I do know that the child died, and it didn’t take very long.  In the fifty years since, the landscape of childhood cancer has changed dramatically for the better.  Today, most children diagnosed with acute lymphocytic leukemia—the most common type—survive.  But in the past, we oncologists significantly underestimated the cost of that survival.

For the last six months, I have been taking care of one of the earliest survivors of childhood leukemia.  In her late forties now, she was treated with life-saving combination chemotherapy when she was six years old.  A couple of years later, she relapsed with leukemic cells in her brain and spinal cord, and received cranio-spinal irradiation—radiation therapy to her entire brain and spinal cord, a toxic treatment associated with short stature due to reduced growth of the spine, lowered IQ, and a depressed immune system.  Again she survived, and grew up to be a teacher of disabled children—the ultimate in “giving back.”

In 2005, she was diagnosed with breast cancer, likely a consequence of the radiation exposure she had as a child.  She underwent a mastectomy, and then did well until last fall when she noted a lump in the medial aspect of her breast reconstruction.  A staging work up revealed a benign appearing brain tumor which, again, was likely a late effect of her brain irradiation.  Since she had no symptoms from her brain tumor, her medical oncologist forged ahead with chemotherapy for the breast cancer, followed by removal of her reconstructed breast and its residual cancer, followed by radiation to her chest wall and lymph nodes given by me.  All of this she bore without question, without complaint.

I saw her in follow up on Friday and she was doing well, but she knew she needed to undergo more testing for an enlarged and nodular thyroid—possibly a thyroid cancer, also radiation induced.  She also needed to have a follow up MRI for her brain tumor, to be sure that it is not growing rapidly.  She was matter of fact about the inconvenience, not to mention the anxiety, of having multiple additional tests and procedures over the next few weeks and months.

I am continuously amazed by her grace and equanimity.  I said to her, “You are my hero.  How do you just keep going, day after day, month after month, year after year, dealing with cancer, one cancer after another?”  She said, “When I was a child, dying was NOT an option.  My parents never even mentioned the possibility, so I was never afraid.  I just did what I had to do.  Now it’s the same thing—I know that this is the price I have paid for the wonderful life I have led.  I just keep putting one foot in front of the other, one day at a time.  I know that I will be okay.”

Here’s the thing about oncology folks:  It puts everything else into perspective.  If this brave woman can take the lemons life has given her and make lemonade, so can you and I.   This is the crux of the matter; this is what has kept me going in this field for over thirty years.  If this woman considers herself lucky, so should we all.

Fire and Ice

“Some say the world will end in fire, some say in ice…..”     Robert Frost

Sometimes there is a very fine line between doing too much, and not doing enough.   I have been thinking about this lately as I watch patients go through radiation therapy.  It’s not  just the acute side effects that worry me with radiation, it’s the late effects also.  One only needs to have known a few patients who were treated for Hodgkin’s Disease in the 1970’s, with now archaic radiation therapy techniques, to realize the havoc that can be wreaked  later, in the form of breast cancer, coronary artery disease and other secondary malignancies.  And yet I always counsel patients who need the treatment to take it, because as hard as it is to say this, the cancer that the patient already has is far more likely to kill him than the theoretical risk of something bad happening 25 years down the line.  For some reason, patients have a hard time understanding this concept.

When it comes to an individual patient, the radiation dose is sometimes the issue.  Most cancers have a clear dose-response curve, where the higher the dose, the more likely the tumor will be obliterated– up to a point, and that point varies from individual to individual and from tumor to tumor. At the highest doses, the complication rate starts to rise, and some complications can be quite severe indeed.  So one of my duties is knowing when to stop, when enough is enough.

When I was a young doctor, just out of residency, the first year of practice was the hardest. One of my very first patients was a 50 year old Polaroid executive with a very advanced form of nasopharyngeal cancer.  I had the sudden and startling knowledge that I alone was responsible for curing this man—in those days chemotherapy and surgery played no role in treating this type of cancer.  It was terrifying to have that responsibility, even though I had been well trained.    I asked one of my mentor/ teachers about the total dose that he would use.  He gave me a rather conservative number, stating grandly that “A tumor recurrence is an Act of God, but a complication is YOUR fault”. I went with the conservative approach; the patient was cured, and seven years later I named my third child after him.

Many years later, I was chatting with a colleague and we were talking about philosophies of treatment.  I drew myself up, and in my most senior, most pompous and most commanding voice I said:  “A tumor recurrence is an Act of God, but a complication is YOUR fault!”  He laughed.  I had ten years experience on him and he actually laughed at me.  And he replied, “Well, my own mentor always said to me, the WORST complication is a tumor recurrence!”

Are you, my readers, fire or ice people?  I’ve discovered through the years, that “cooling it down a bit” has served me well.  But then again, I’ve never been a risk taker.  Not with my life, and not with others.