The cancer journey well-traveled

Last summer I met with a patient in my clinic who had come to the hospital with leg weakness and his CT scans showed widespread cancer. His type of cancer is rare and treatable with a pill, which he had been taking for about a month. He was tolerating it without too much trouble.

During our first visit, he was insightful but overwhelmed. “I know how sick I am — just get me to December, that’s all I need,” he said. He had a family milestone coming and told me he would be happy if he made it just one day beyond. Toward the end of the appointment, we reviewed everything and for the first time his emotions came through.

“I don’t know what I did to deserve all this,” he said, meaning the weakness, and the pain, and the cancer in general. It wasn’t self-pity; it was honest confusion.

He made it to December. We celebrated with him and I started to look forward to his appointments as a highlight of my week. He told (purposefully) bad jokes and needled me every visit about not bringing him a danish and coffee. At the end of each half-hour he would say thank you and meant it.

A few months ago, we ordered a CT scan to check on how all of his different sites of cancer were responding, and one area was much worse so we switched to a newer pill that hadn’t been available when we started his treatment. None of his symptoms had become significantly worse. A few weeks later I ordered another scan to see if the new pill was working and that same spot had grown much more. Not working. His lab work was starting to reflect it as well, so decisions about the next step in his treatment would need to be timely.

The next step was chemotherapy. Here’s the conflict with chemotherapy in patients with stage 4 cancer: Most of the time, stage 4 cancer is incurable. Just thinking and writing that sentence feels like I’m squashing hope for a thousand patients to come, whom I have yet to even meet. Maybe soon a treatment will be approved that will cure metastatic cancer, but today this happens almost never. So we give chemotherapy to prolong someone’s life as much as we can, but the trade off is choosing among inevitable side effects. It can’t be a decision made without careful consideration.

I’ve already had more than one patient’s family member ask me if it’s ever worth going through chemotherapy for metastatic cancer after their family member had passed away. Sometimes yes, sometimes no, is the best answer I’ve been able to come up with so far.

We talked about it and my patient wanted to go ahead and try it. We scheduled it for the next week but for a few different reasons we postponed for another week when he came back in. Over the weekend he got much sicker and died the following week, never having had the treatment.

He will always represent for me the cancer journey well-traveled. It’s never a good road to walk, but he started off toward his self-ordained promised land and he was fortunate to have made it. When his disease progressed, he wasn’t bitter and he didn’t rage against the injustice of it. He got to where he wanted to go.

During our last visit, he said another thing. He had clearly been reflecting and had been thinking back to his months overseas in the service when he was young, on all the friends who weren’t fortunate enough to join him on the trip home, and he told me he felt like everything he had after that was a gift. His family, his job, his life.

Almost like he was saying that he didn’t know what he had done to deserve all this.

He died and I’ll miss him even though I never knew him in any capacity other than as my patient. I looked forward to seeing him because I knew I’d laugh at some point when I did, and because he didn’t fall into the trap of focusing on the injustice and inequity that advanced cancer sets for us.

He walked his road, and he made it to the end of it, and then he proudly and gratefully stopped walking.

Kenneth D. Bishop is a hematology-oncology fellow who blogs at Out Living.

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  • http://www.phoenixism.net/ Socially Extinct

    That’s beautiful.

  • elizabeth52

    It’s a difficult call and one that only the patient can make with their family and doctors. My sister-in-law had a stroke 2 years ago and has been making slow but steady progress until stomach pain started last December. She was referred to a gastroenterologist and treated for IBS, a misdiagnosis, and was diagnosed with advanced pancreatic cancer a month ago. Most pancreatic cancer is diagnosed at a late stage.

    Her oncologist said with a new drug regime they were getting better results, patients living for years, not just months. I don’t think we’ll be so lucky though, my already weakened SIL (after the stroke and not eating much over the last 5 months with the stomach pains and nausea) is fading fast and thinking of stopping the chemo.
    Sadly, chemo for some patients doesn’t help much and can make people very sick and miserable when time with family and friends is even more precious, but again, it has to be the patient’s call. When these hard decisions are made it’s often the family playing catch-up, it’s hard to let go even after your loved one has done that.
    I think some close relationships are made between patients and oncologists (and doctors generally) especially during these difficult times.
    I recall the oncologist who treated my MIL was cold and direct, I suppose he needed to be like that to cope with his work, but I’m pleased my SIL’s oncologist has found a way to be highly professional, but also, patient and compassionate.

    • http://kenbishop.wordpress.com Ken Bishop

      So sorry to hear about your sister-in-law, she has a very hard disease. I hope she can find some comfort at this stage, it sounds like she has good support from you and other family members. Please be sure to attend to your own emotions during the process as well.