At the risk of sounding superstitious and nonscientific, I have observed in oncology practice we sometimes have “streaks.” Some of these are positive winning streaks where our patients are responding well to therapy, their operations are successful and they recover uneventfully, and on follow up examinations nobody in clinic has recurrence of their cancer. It is similar to a hitter in baseball who is seeing and striking the ball well every time at bat and getting on base much more frequently than average, or like a basketball player who gets hot from the 3-point line and can’t miss. Conversely, every now and then we hit a bad losing streak when our patients’ cancer recurs rapidly despite all our efforts, tumors that cannot be surgically removed are encountered during an operation, or the number of patients receiving bad news during a clinic visit is unusually high. Back to the sports analogies, it is like a baseball hitter during a 0 for 30 slump or a basketball player who can’t make a layup, much less a 3 point shot.
I’ve been on a sour streak for the last three weeks. Half of the patient’s I have operated on for a planned liver or pancreas resection have been found to have small deposits of cancer spread throughout their belly cavity. A condition called peritoneal carcinomatosis. This finding indicates the cancer cells have broken loose and been shed into the belly, or peritoneal, cavity and an operation to remove a tumor in the pancreas or in the liver will not benefit the patient. Even though patients and their families are warned this is a possibility before the operation, it usually occurs in less than 5% or 6% of our patients given the quality of our highly sensitivity imaging studies these days. Nonetheless, for the past several weeks I have had far too many emotionally difficult conversations with patients and their families as I described the findings that caused me to not proceed with a planned operation. People understand this is not a good prognostic finding, and indicates they will need treatment with chemotherapy. Even if unspoken, they recognize they will likely ultimately succumb to their malignant disease.
I was sitting in my office today wondering sullenly what I needed to do to break out of this current slump (delusional, I know, like I have the ability to control fate). I reviewed all of the CT and MRI scans on patients who were found to have unexpected and unwanted intraoperative findings, and I was unable to detect a hint or clue that would have indicated spread of disease into the belly cavity. I was frustrated because I hate not being able to help my patients with an operation intended to rid them of their cancer. As I scrolled through radiographic images on my computer screen, my office phone rang.
I immediately recognized the voice of the wife of one of my long-term cancer survivors. Generally, she and her husband are among the most positive, upbeat, grateful, and happy people I have ever met. A warning claxon went off in my head because of the clearly sad tone to her voice. “I am sorry to call and tell you this, but my husband died last Friday.”
Pow! A gut punch delivering more bad news. I audibly exhaled, but quickly collected myself, “I am so sorry and sad to hear this. What on earth happened?”
This ladies’ husband is among my most remarkable cancer success stories. He was diagnosed with colon cancer over 23 years ago when he developed constipation and abdominal pain. A surgeon in the western city where he lived successfully removed the colon cancer and surrounding lymph nodes, but found that he also had tumor metastases peppered throughout his liver. He was referred to a medical oncologist who treated him with chemotherapy drugs intravenously for 3 months, but a subsequent CT scan revealed his tumors were resistant and growing despite the chemotherapy treatment. Approximately 50% of his liver was replaced by the several dozen tumor nodules spread throughout his liver. At this point he was referred to me.
This man had too many tumors scattered through every area of his liver to be considered for surgical removal or ablation of the tumors. However, he did not have any evidence of cancer at any other site but his liver. Therefore, I discussed with this man and his wife placing a hepatic arterial infusion pump to deliver chemotherapy directly into the blood vessels supplying the tumors in his liver. A quick anatomy and physiology lesson: all organs in the body receive oxygenated bright red blood from arteries that arise at some point from the aorta. Dark red venous blood is then returned to the heart through veins ultimately draining into the vena cava. The liver is interesting in that it receives oxygenated blood from the hepatic artery, but most of the blood supply comes from the portal vein. The portal vein is made up of blood vessels draining from the intestine to distribute the nutrients and substances that are absorbed from our gut to the liver for processing and metabolism. Malignant tumors in the liver are like malignant tumors anywhere else in the body; they survive and grow by deriving blood supply from the oxygen-rich arterial blood.
Hepatic arterial infusion chemotherapy had been used for about a dozen years by the mid-1990s to treat colorectal cancer liver metastases. Studies suggested a high proportion of patients had tumor shrinkage with the therapy, but long-term survival rates were not significantly improved. Nonetheless, we had several active clinical protocols using this approach, so the patient and his wife agreed to use this treatment. This required an operation with an incision under the ribs on the right side, removal of the gallbladder (the artery to the gallbladder comes from the same artery that goes to the liver so we did not want to poison and kill the gallbladder), placement of a catheter into a blood vessel that would release chemotherapy into the hepatic arteries without occluding the arteries, and then placing a device slightly larger and significantly heavier than a hockey puck in a separate incision on the right lower abdominal wall. This pump device could be accessed by puncturing a membrane underneath the skin on the pump and filling the pump with chemotherapy agents that would then be continuously dripped into the hepatic artery.
At the time I placed the hepatic arterial infusion pump, this gentleman was in his late 50s and was otherwise in excellent health. The operation was performed, he recovered quickly, and he was discharged three days after his surgical procedure. Two weeks after the operation, we loaded his pump for the first time with a chemotherapy drug called Floxuridine (FUDR) which was continuously infused into the blood vessels going to his liver tumors for the next week. Once a week for the next three weeks we gave a rapid bolus dose of a different chemotherapy drug, 5-Fluorouracil (5-FU), and then kept repeating this cycle for the next three months. This gentleman suffered no side effects or abnormalities in his blood tests during the three months of hepatic arterial infusion chemotherapy. Some people receiving this treatment developed significant inflammation of the liver necessitating cessation of therapy. This gentleman returned to his normal activities and full time work. He also reported an unexpected positive benefit to the approximately one pound device implanted in his right abdominal wall; he claimed his golf swing had been changed by the device and he had dropped approximately seven strokes from his average. I don’t know if this is causation or happy coincidence, but he was pleased with the outcome.
After three months of hepatic arterial infusion chemotherapy, a repeat CT scan was truly impressive. Almost all of the liver tumors had disappeared from his liver. His serum CEA tumor marker, which had been over 1,000, was now only 12. I walked into the examination room with this excellent news and was quickly given bear hugs simultaneously by the patient and his wife. Given the dramatic anti-tumor response to the direct liver chemotherapy, we decided to continue with another three months of the same regimen.
Three months later repeat bloodwork and CT scans revealed a CEA of 8 and a total of 3 tumors still evident in the liver. Two of these tumors were in the left lobe and one was deep in the right lobe. I believed there was a high probability that other areas of tumor were still present, but nothing was evident on the CT images. Unfortunately, the hepatic arterial chemotherapy was starting to affect the patient’s liver and his blood tests showed that his liver was inflamed and a little unhappy. The gentleman asked an interesting question, “Why don’t you just take these remaining tumors out?”
Some patients do have dramatic responses to neoadjuvant (pre-operative) chemotherapy that is intentionally given before an operation. In this man, I had never considered surgically removing his tumors given the number and volume of lesions. I administered the hepatic arterial chemotherapy in an attempt to shrink and control the malignant liver tumors for as long as possible. However, now, only three tumors remained. We discussed the pros and cons of an operation and four weeks later, after his liver blood tests had normalized, I performed an operation that removed the left lobe of the liver, completed a radiofrequency ablation of the solitary tumor deep in the right lobe of his liver, and scanned the remaining liver thoroughly with an intraoperative ultrasound probe. I was not able to detect any additional tumors. I readily admit I was surprised but pleased. Upon learning the surgical findings later, the patient and his wife were ecstatic.
The gentleman recovered from his liver operation well and returned home to full time work and his numerous outdoor leisure activities in his western city. I came to learn from his wife and the numerous visitors who came in a steady stream to see him during his hospitalizations that he was beloved and active in his community. He worked for a number of volunteer organizations and volunteered a significant amount of time and energy in his church community. Everyone spoke of him in glowing terms and remarked what a kind, thoughtful, and generous soul he was at all times.
We had decided not to do any additional chemotherapy given the early stages of inflammation caused by his hepatic arterial chemotherapy. Instead, we chose to watch and resume chemotherapy only if his cancer recurred. After two years of watching every four months with blood tests and scans, the patient informed me he was tired of, “lugging this thing around under my skin” and requested I remove it. I could not argue with him so the next week, using only local anesthesia, I did exactly that.
This man’s cancer never recurred at any site in his body. He graduated from two or three visits every year with me to annual visits for the past 18 years. Every time I saw his name appear on my clinic list, I would automatically smile knowing I was in for 30 minutes of great conversation catching up on his and his family’s life. He was always polite and thoughtfully asked me how my children, various pets, and research projects were coming along.
As happens with most of us, as this gentleman entered his mid to late 70s, he began to suffer from other medical problems. High blood pressure and diabetes arose and he required medication to treat these conditions. Years of being active and working in strenuous jobs caused wear and tear on his joints and back. Apparently, over the past year he developed back pain so severe and unrelenting it could not be effectively controlled with medication. A surgeon in his home city recommended an operation to deal with a bulging disc compressing his nerves and to fuse his spine. Appropriately, the surgeon forewarned the patient, his wife, and family that complications could arise after such a major surgical procedure, and his diabetes and high blood pressure could pose a higher risk for complications to develop.
When my patient’s wife called today she informed me his spine operation had lasted over ten hours. He did reasonably well for the first two days after the operation, but on the third post-operative day while walking with a physical therapist, he collapsed to the floor. He was immediately transferred to an intensive care unit and placed on a ventilator. Sadly, over the next 24 hours one organ system after another started shutting down. As my patient’s wife was telling this story, past scenes from my career flashed through my mind as I remembered a few patients who developed complications after an operation, or others whose cancer advanced despite all treatments and they developed relentless organ failure.
After thorough consultation with the treating surgeon and intensivists, the patient’s wife and family decided to not pursue any heroic measures to maintain life. Within a few hours he suffered a cardiac arrest and was allowed to quietly and painlessly pass away.
These are heart-wrenching decisions that patient’s family members and the treating medical team must make together. As my patient’s wife told the story, she struggled to maintain composure as she choked back tears. I was deeply saddened by the news, but then she said, “I want you to know my family and I cherished every moment of the more than twenty years we had with him because of your operations. Your skill and passion for what you do was always evident to us, and we love you. He loved you.”
What a blessing to receive from this woman in her time of grief after the death of her husband of almost 50 years. This couple was a source of joy every time they visited me in the clinic. Selfishly, I am sad I will not be seeing them for our pleasant annual visits. But his wife’s phone call and recalling his story punted me out of my funk because he represents a major victory against cancer.
Blessings occur in my life every day. Some must be carefully sought because they are not obvious or are taken for granted, but others, like this woman’s heartfelt appreciation, are an unexpected gift at a time when I needed to be reminded I am blessed to have the career I have. And as I was taught by my parents to do when receiving a gift, I said to my patient’s wife, “Thank you very much.” I then added, “It was always an honor and a privilege to help in any way.”
And that is true with every patient I see.