I am looking out of my window on a cold and cloudy Boston afternoon and find myself pondering about life: How unpredictable it is, and how one minute can hold no assurance for what happens after. Before I left for vacation, I saw Joan.* She has been under my care for a number of years, living with and thriving despite metastatic disease. Each regimen has worked, at least for a while, and the nontrivial toxicities they have caused have not stopped her from doing what she has to do — as a mother, wife, and caregiver.
We had recently reviewed her last tumor markers and scan. Her markers were not normal, but they had been stable for the past few months, and her CT scan showed that the disease had not grown; though they had stopped shrinking, it appeared she was in a new “steady state,” alive with stable disease. We discussed next steps. Should she continue on her current combination regimen? Stop therapy now, knowing that she will likely require new treatment sooner than later? Simplify her regimen as “maintenance” therapy by using single-agent chemotherapy or even tamoxifen? We talked at length about each option, the pros and cons, and I sensed her anxiety. I knew she did not want to make the “wrong” choice.
After some time passed, she looked at me and said, “I know one thing for sure — I am tired of being on treatment for this cancer. I think I need a break. I need to be with my kids, to celebrate Christmas and New Year’s without worrying about my next appointment, the side effects of treatment and trying to schedule an infusion while they are on break. I know there are no guarantees here, but if you think I’ll be okay without treatment for awhile, I’d prefer to take a break.”
“I wish my crystal ball was working,” I told her. “But, you look fine, the cancer seems to be stable and your bloodwork supports that. I think it’s okay to take a break. I’ll see you in four weeks, and we will see where we are. You know you can call me if something comes up.”
With that, I sent her on her way, hopefully, to enjoy a wonderful Christmas and to ring in the New Year. I too left for vacation — to Sedona, where I met with my mom and my sisters and their families. Immersed with my family in Red Rock country, I let myself forget about oncology for a while.
On my return, I perused my first clinic list. Joan was there, and I was excited to see how her holidays went. I pulled out some labs she had done, and, unfortunately, her tumor marker had climbed significantly. My heart fell. Although I knew that a blood test does not predict what a patient feels or what a tumor looks like when imaged, I was anxious about her, worried that we had made a mistake, that I should have recommended she continue treatment and not taken a break.
I worked my way through clinic, cognizant that Joan was coming in early that afternoon. My medical assistant came to me then, informing me Joan was in room 32. “How does she look?” I asked.
“She looks a little tired — barely smiled when we saw each other,” she said.
I walked in and greeted Joan. My assistant was right; she was tired. Her eyes were bloodshot as if she had been crying or not sleeping (turns out, it was both). “Are you OK?” I asked.
“No, not really. I lost my husband right before New Year’s.”
“Oh, Joan, I am so sorry. What happened?”
“It was his heart. He was at the gym and collapsed on the treadmill. They pronounced him in the emergency room. I didn’t even get a chance to say goodbye.”
She started crying then, and I just held her hand in silence.
“Funny, in a way we had prepared ourselves for the eventuality that I would die first. I mean, I have this horrible cancer that won’t go away. We both knew it would kill me someday. Heck, we even joked about who he’d marry next,” she went on. “But, never did I fathom he would die before me. He was my rock, always so solid. Never even thought this could happen.”
We talked for a while as her tears slowed and eventually stopped. She asked about her CA-125, and I told her it had increased significantly.
“Oh, well,” she said. “You told me I wasn’t going to be able to stay off of treatment for too long. Turns out, you were right, but at least, I got to be with Tom these last few weeks at home, not shuffling between the cancer center and the house. We got to be with our kids, just being a normal family. It was our last Christmas with him, and it was the best one by a long shot.”
We ordered a new CT scan to better assess the cancer, and after a few more minutes, we both got up to leave. “I am so sorry, Joan. I am at a loss for words.”
“I know,” she said. “I think I am still in a state of shock. But then, that’s life, huh? What do you tell me? There are no guarantees, no predictions. We just have to do it.”
I guess that’s what I learned from Joan. As I think about her and the start of a brand new year, I realize yet again, that all we have is here and now. And life — you just have to live it.
* The attributes and details of this patient have been changed to protect her identity.
Don S. Dizon is an oncologist who blogs at ASCO Connection, where this post originally appeared.