Wise Guy

 

I don’t know if new patients meeting me are anxious about their diagnosis of cancer, fearful over the prospect of the pain and recovery associated with a major cancer operation, concerned regarding meeting a surgeon new to them for the first time, or, more likely, some combination of all of these factors. However, I do know that patients, their family members, or friends frequently try to diffuse the heightened anxiety by using a humorous remark. What is consistent and constant, and predictable actually, is the nature of the humor I hear. You can’t have my last name and not be prepared for a specific topic.

Not a month goes by where I don’t get treated to at least five or six allusions to the Three Stooges. Things like, “Nice to meet you Dr. Curley. Where are Moe and Larry?”, or “When do I get to meet the other two stooges?” I am never surprised or offended by these remarks. I expect and enjoy them. I understand their genesis based in the apprehension and uncertainty that goes along with talking about a major operation with a cancer surgeon. Furthermore, I like to use humor to relieve trepidation and worry in my patients (when appropriate; never flippantly or dismissively), so it opens the door for me when the patient or their family members nervously inject some puerile humor. Naturally, I have watched and know all the Stooges’ routines, so I am prepared for these comments.

Nyuk! Nyuk! Nyuk!

I’m remembering one of my patients in particular, a gentleman who was a colorful character, who started our relationship in this fashion. I knocked on the door to the examination room and walked in to have him immediately exclaim, before I could say hello or introduce myself, “Okay, here’s the wise guy! Are Moe and Larry going to be assisting you in the operating room?”

Good to have that out of the way, right away.

I mentioned this patient was a colorful character. I mean that quite literally. This gentleman had bright orange hair that was long, bushy, and sticking out in all directions. I looked at him and before I could say anything he exclaimed, “I know, I know, you’re thinking of Bozo the clown.” I don’t believe in mind readers, but he was right, that was exactly the character and visual that entered into my conscious mind. This man was quick on the draw and beat me to the punch. I liked that about him immediately.

This gentleman was in his late 50s when I first met him. He was loud and laughed often and boisterously, and observing his wife and adult children, it was clear they had given up trying to inhibit his extravagant personality long ago. My patient had been a hard working laborer his entire life and was thin, hyperactive and, as I would learn, indefatigable. He also smelled like a carton of smoked cigarettes. He had been diagnosed with a rectal cancer after he developed intermittent rectal bleeding. A colonoscopy was performed by his gastroenterologist, and a non-obstructing, biopsy-proven adenocarcinoma of the upper rectum was confirmed. The remainder of his colon had no tumors or other abnormalities. A CT scan of the chest, abdomen, and pelvis was ordered, which demonstrated two large tumors in the right lobe of his liver, several smaller tumors in the right lobe, and a single tumor in the left lobe of his liver. He had stage 4 malignant disease.

“Bozo” was referred to me by his medical oncologist before beginning systemic chemotherapy treatment. The doctor requested my opinion on potential surgical treatments for his liver metastases. After having a lively conversation with my patient, which included a few snippets exchanged between us from Three Stooges’ films (my nurse later asked if I had met this man previously because we segued seamlessly through the routines as though rehearsed), I reviewed his CT images with him and his family. I explained I believed it was possible to preform an operation to remove or destroy the tumors in the liver following three months of preoperative chemotherapy. He would also ultimately need an operation to remove the primary cancer in his rectum. I informed him that timing and sequencing of those operations would be dependent on his response to chemotherapy. This gentleman maintained a knowing smile on his face throughout our first meeting, and concluded the session by stating, “This is all good news, Doc. I know you, Moe, and Larry will take great care of me.”

Soitanly!

This patient completed three months of intravenous chemotherapy and then returned to see me in the office. Before entering his room, I checked his new CT scans and was pleased to see that his lungs still showed no evidence of tumors, his liver tumors had all decreased in size, and the tumor in his rectum was also smaller. I knocked on the door, entered the room, and involuntarily exhaled a laugh. My patient now had bright red hair. And by red, I mean Ferrari red. This was not a subtle auburn or natural red head color, this was bright, flaming red. I quickly regained my composure and decorum commented nonchalantly, “I see you’ve changed your hair color. Very subtle.”

My patient guffawed. As I mentioned, loud and boisterous. He explained his hair color changed at least once a month, and this had been his habit for over a decade. He reported this kept his clients and bosses at work “on their toes”, and it was source of mirth and amusement in his work environment. I can only imagine. After discussing his hair color, I informed him the scans revealed a very good response to the three months of chemotherapy treatment. He and his family were pleased by this news. I called and spoke with his medical oncologist, and we agreed to proceed with an operation to remove and destroy his liver tumors before operating on the rectal cancer. The liver tumors were the most dangerous and pressing issue, and he was having absolutely no symptoms related to the primary colorectal cancer.

Two weeks later I performed an operation on this gentleman and removed the right lobe of his liver, the side bearing all but one of his liver metastases, and I performed a microwave ablation of the solitary tumor in the left liver. The ultrasound examination I performed on his liver showed no additional tumors. The operation went flawlessly.

As previously noted, this gentleman was a heavy cigarette smoker. I had implored him on several occasions to quit smoking and he looked at me each time and said the same thing, “Go ahead and tell me all about it, Doc. But I’m not going to quit. So let’s just accept that basic reality.” Not much I could do with such an unwavering stance. This gentleman did pay a price for his nicotine habit after his operation. Patients who smoke are at an increased risk for respiratory problems and infections like pneumonia after an operation. This man had pain, of course, associated with the operation, and was hesitant to cough and clear the thick lung secretions present in many smokers. Subsequently, he developed post-operative pneumonia five days after the operation. This cost him another twelve days in the hospital to receive intravenous antibiotics and aggressive respiratory treatments. Thankfully, he did not end up on a ventilator or in the intensive care unit representing a more prolonged and harrowing stay.

Once the patient was discharged, I saw him back in the office a week later. He was healing well and smelling like cigarettes again. Admittedly flabbergasted, I asked him how much he was smoking. “Somewhere between two and three packs a day,” he replied, matter-of-factly. We had a spirited discussion and I reminded him of his pneumonia. His wife sitting behind him shaking her head, finally noted that I was wasting my breath because many people, including her, had tried to convince him to quit smoking but had failed.

You can lead a human to the fountain of knowledge, but you can’t make them think.

My patient returned to his medical oncologist and received another three months of chemotherapy. The primary upper rectal cancer was associated with some enlarged, suspicious lymph nodes near the tumor on the initial CT scans. Thus, after completing chemotherapy, the medical oncologist and a radiation oncologist treated the rectal cancer and surrounding tissue for almost six consecutive weeks with ionizing radiation and low dose chemotherapy treatments. Four weeks after completing radiation, we repeated his imaging studies and the tumor in the rectum was even smaller. Unfortunately, he had a new tumor in the regenerated left lobe of his liver. This new liver metastasis appeared six months after his liver operation. I conferred with his medical oncologist and we agreed to proceed with an operation to remove the rectal cancer, remove the solitary liver tumor, and create a temporary ileostomy. An ileostomy is a loop of small intestine that is brought outside the abdominal wall and sewn to the skin to drain into a bag. This is routinely performed as part of the operation in patients who undergo pre-operative radiation to treat rectal cancer because the area where the colon is reattached to the rectum frequently does not heal well and has a high risk to leak, causing serious and potentially life threatening infection. Heavy cigarette smoking also impairs healing so I was not going to take a chance in this gentleman. I informed him pre-operatively he would unequivocally have a temporary ileostomy. With his now U.S. Navy Blue Angels blue hair (specifically chosen, he explained, because it is the ribbon color for colorectal cancer), he responded sanguinely, “No worries Doc Curley. You and Moe and Larry do what you need to do.” I performed the operation to remove the lower portion of his colon and upper rectum and reattached the remaining colon to the rectum, created the ileostomy, and then performed a wedge resection of the solitary new liver metastasis.

This time the patient recovered much more quickly, and because he worked hard at coughing and walking beginning the day after his operation, he was discharged from the hospital after less than a week with no complications or problems. We had talked about reversing his ileostomy 6-8 weeks after the colorectal operation, but he underwent a radiographic study, called a barium enema, which revealed a small leak in the anastomosis, the area where I had reattached his colon to the rectum. I explained until this area healed, it was not safe to reverse his ileostomy. As good-natured as ever, and now sporting bright lime green hair, he noted he was working full time and having no problems managing his ileostomy, so he was content to wait. He went on to receive an additional year of chemotherapy with an oral drug daily two weeks out of every three and an intravenous injection of a medication that reduces blood vessel formation in cancers every three weeks. I saw him every four months during that year.

Approximately six months after he completed his year of chemotherapy treatment, a repeat barium enema showed complete healing of the rectal anastomosis. I performed an operation where the ileostomy was reversed and the small intestine was sewn back together. He was able to have normal bowel movements again and was no longer wearing a bag on his abdominal wall. He was quite happy with the outcome. For this operation, he presented himself with tri-colored hair. This included a bright purple streak down the middle, canary yellow hair on the right side, and a turquoise blue patch on the left side of his head. When I inquired about the purpose of the mixed color hairstyle, he replied bemusedly, “I like to mix it up Doc.”

Straight and simple, I like it.

This gentleman did well for another 18 months or so. His medical oncologist then called me to report that two new small liver metastases had been detected on a CT scan. This is the nature of cancer, microscopic nests of cells that have not been eradicated by chemotherapy eventually grow to a size where they are detected. My patient returned to see me. Now he had a kelly green hair color, obviously dyed that color since it was a few days before St. Patrick’s Day. He also showed me a picture of his red, white, and blue striped hair from the previous July in support of Independence Day. I like a man who coordinates his hair color to correspond with important holidays. My patient had directly told his medical oncologist he was not going to do any more chemotherapy treatments and he wanted me to address his two new liver metastases. I scheduled him for an operation the next week. The operation would have been uneventful were it not for an unfortunate finding. I performed an exploratory laparotomy through an upper abdominal incision and the ultrasound of his liver confirmed the presence of two small, approximately 1.5 cm liver tumors. It was possible to completely destroy these tumors with microwave ablation. Unfortunately, palpation of other organs in the abdomen revealed multiple small, grain of rice sized nodules. I biopsied several of these and the pathologist confirmed they represented metastatic colorectal cancer.

I trudged out to the waiting room and informed his usually cheerful wife and family that the liver tumors were successfully treated, but that he also had tumor nodules peppered throughout his peritoneal cavity. They were appropriately stunned and disappointed by this news. When my patient was awake and alert enough that afternoon, I shared the same news with him. He was unflappable. He looked at me and stated quietly, “I know you’ve done your best work and done everything you could for me, I appreciate everything you, Moe, and Larry did for me. Let’s just see what happens.”

What happened is he did well, still working full-time, chain smoking, and changing hair colors monthly, for about nine months. Then he came to the emergency room with an obstruction of his small intestine. He was unable to eat or drink and had intractable nausea and vomiting. An emergency operation was performed and I was removed a loop of small intestine that was completely blocked by a now golf ball size tumor in the abdominal cavity. There were multiple other tumors of various size scattered throughout the abdomen. Fortunately, this operation, though palliative, did allow him to resume eating. He steadfastly refused any further chemotherapy or other anti-cancer treatment.

I received a call from his wife less than 90 days after I had performed the final operation on him, informing me that he had passed away quietly at home with his family around him. Graciously, she expressed her gratitude for all I had done for him. She also emailed me one last picture. He was again sporting bright orange hair. She included a final message from him. It stated simply, “Thanks for everything Doc. You and Moe and Larry are the best!”

It’s hard to feel like the best, along with my imaginary partners Moe and Larry, when cancer recurs and claims the life of an animated and interesting man like this. Or any other patient, for that matter. But these patients fuel the fire. It keeps me looking for new and better ways to treat this heinous and dreadful disease. And maybe one day, all of us worldwide driven by a desire to find improved treatments to control and defeat cancer will succeed. Recognizing preventing cancer would be the optimal goal, but would require true political and societal courage to do things like banning cigarettes and tobacco products, ending pollution of our environment with toxic substances, and encouraging and incentivizing healthy diet and exercise. Then we can poke cancer in the eye, knock it’s heads together, and give it a good full force Moe slap.

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