“Never deny someone hope, Doctor.” If I ever had a crystal ball to predict the future, I obviously dropped it in the mud a long time ago. I was wrong about the minister. His cancer never returned. He spent only one week in the hospital after his surgery and his sliver of liver performed and regenerated beautifully. For the first five years I saw him every three to six months with lab tests and CT scans to check for the return of malignant tumors. For the next six years I saw him only for an annual visit. This man survived and enjoyed life for eleven years after being told he had only six months to live. He died at age eighty, as many of us would wish to die, in his sleep from a stroke. He gave his last sermon from the pulpit of his church three days before he died. His cancer never returned to prey upon his mind and hunt down his hope.
After thinking about it, I realize I learned one additional lesson from this patient. He taught me that it was acceptable to express a little clean, righteous anger and then laugh and move on. The minister and I developed a ritual we repeated at each of his visits after passage of the initial six months his medical oncologist gave him. Once I reviewed the results of his tests and CT scans and confirmed that all was well and the cancer had not returned, he would smile and say, “Let’s do it!” From the examining room, I would dial the phone number of the medical oncologist in Mississippi. The minister admitted to me he was angry that this doctor had needlessly denied him hope. When the oncologist came on the line, I would hand the phone to the minister, who would identify himself, and then he would say exactly the same words, each time, “Hey, Doc, you want to go fishing?”
As a surgeon, I confess I enjoyed witnessing the precision with which the preacher inserted this verbal blade, deftly turning it to maximize the impact of his statement. When I passed the phone to the minister, he always had an impish, perhaps even devilish, grin on his face. After he asked the doctor if he would care to join him for a fishing expedition, he would hand the phone back to me and a look of serenity would come over him. The ritual was completed when I would take the phone and speak to the doctor in Mississippi. In my first few conversations with the physician, I apologized for my obvious and indecorous breach in professional behavior. But to the credit of this man being regularly taunted by a Baptist minister, who wasn’t entirely forgiving, he would tell me that no apology was necessary and he believed he deserved, and benefited from, the brief but poignant verbal reminders. As the years passed, the doctor would be laughing when I put the phone to my ear, telling me that he really enjoyed the calls and his whole office staff looked forward to this annual event.
The doctor in Mississippi told me it was because of the minister that he never answered patients with a diagnosis of advanced cancer about their expected longevity. Instead, he would inform patients and their families he really couldn’t make such a prediction. Not only because of marked individual differences in responses to treatment, but because of the immeasurable will to live—even in individuals no longer receiving treatment for their cancer. Together, he and I learned the importance of leaving no stone unturned in treatment: to engage in multidisciplinary management and to consider all options for our patients. Great lessons from a great spiritual teacher taught to a couple of hardheaded doctors.
“Hey, Doc, you want to go fishing?”
2
Heroes Walking among Us
“I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.”
Nelson Mandela
Courage: The ability to do something that frightens one; bravery; strength in the face of pain, fear, or grief
Living among us, usually unbeknownst to us, are people who have experienced war. I am reminded of these men and women every anniversary of V-E Day, May 8. Victory in Europe Day commemorates the unconditional surrender of Germany to the Allies, and the end of World War II in Europe.
My grandfather and two of his brothers fought with the U.S. Army in Europe during the war. One of my great-uncles went ashore in Normandy on D-Day. My grandfather and my other great-uncle soon followed with the waves of Allied troops that arrived in France in the weeks after June 6, 1944. All three saw combat in France and Germany, and all three received commendations and medals, including a Bronze Star for my great-uncle who fought at Bastogne during the Battle of the Bulge.
None of these men ever talked much about their time in Europe in World War II. However, shortly before he died, one of my great-uncles told me, “I saw things you can’t imagine, and memories that I can’t wash away.” He then told me he’d been in the contingent of U.S. soldiers that liberated prisoners from Buchenwald in April 1945. When I looked at pictures in books of the emaciated Jewish prisoners, I couldn’t believe what I saw, and I knew he couldn’t either.
During my rotations at the Veterans Administration Hospital as a general-surgery resident I was honored to care for many veterans of World War II, Korea, and Vietnam. I listened intently to their stories, recognizing the opportunity to learn history from actual participants. While some, like my grandfather and great-uncles, did not talk much about their involvement, others told remarkable stories of harrowing survival and astonishing experiences. In my career as a surgical oncologist I have continued to learn from the firsthand stories told by veterans and their families. I always feel like I am walking a fine line in asking about what may be emotionally charged memories. However, sometimes when I ask the right questions, the most extraordinary stories come to light.
One such story came from an unassuming gentleman whom I treated in the late 1990s. His medical oncologist sent him to me when the only chemotherapy agents available had failed to shrink the more than twenty metastatic colorectal-cancer tumors in his liver. At the time we did not have many of the chemotherapy drugs or biologic agents that are now readily available to treat patients with stage IV colorectal cancer. Specifically, this man was referred to me to place a hepatic arterial infusion (HAI) pump that would deliver drugs directly to the malignant liver tumors through the hepatic artery. (For a brief synopsis on the rationale for HAI chemotherapy and on liver anatomy, please see the addendum at the end of this chapter, for those of you who are interested in such things!)
The referring oncologist informed me that his patient was a jovial, successful, highly respected, and beloved member of his community. I walked in to meet this man, along with his wife and daughter, who had accompanied him. He was of slight build, in his late seventies with brilliant blue eyes and a firm handshake. He maintained eye contact with me at all times in a manner that was initially unnerving. He spoke with an accent I couldn’t quite identify, so I asked where he was from originally. He stated that he was Dutch and had grown up in Holland and had immigrated to the United States soon after the end of World War II.
I began to ask the usual array of questions about his cancer treatment and medical history. He reported he had been in excellent health throughout his life and had only been in the hospital once prior to his diagnosis of colon cancer. When I asked when that hospitalization occurred, he quietly said it was in 1944. I inquired why, but before he could answer his daughter blurted out, “Because he is a war hero!” My silver-haired, slender patient noticeably blushed and then shushed his daughter. Unfortunately for him, it was too late. I immediately asked him to tell me of his experiences in World War II and he recounted an amazing story.
During the war my patient and his family were members of the Dutch Resistance. His parents took considerable risks hiding people who were fleeing Nazi Germany. He said at various times they had anywhere from two to four members of Jewish families hidden in false rooms or passages of their home. However, he and his brother wanted to take a more active role in fighting the oppression they witnessed every day.
Late in 1944, my patient knew there were German munitions trains in the depot outside Rotterdam near his home. In an effort to disrupt the flow of these weapons back into Germany, he led a band of Dutch Resistance fighters to the rail
yard. My patient, his brother, and four companions managed to dig under a fence and elude the guards. They proceeded to a train car and were surprised to find the door open. The rail car was filled with high explosives and artillery shells. They poured gasoline inside the train car, lit it on fire, and then, as he said, “We ran like the devil was chasing us!” After they’d sprinted a little more than a hundred meters, German guards discovered their presence and began firing at them. At that point, he stated, “All Hell broke loose!” The rail car exploded, knocking all of the Resistance fighters to the ground. There followed a series of tremendous blasts throughout the rail yard.
My patient and the other Resistance fighters looked for an escape route. Seeing an opportunity, they jumped onto a moving flatbed train car heading out of the rail yard. Unluckily, this exiting train passed directly in front of a guard post. German soldiers opened fire on the six men. Bullets hit my patient in the shoulder and the leg. His brother and one other fighter were killed.
The soldiers then pursued them on foot, and my patient saw another train rapidly approaching on the adjacent track. With no further thought, he ran along the flatbed rail car and jumped from one moving train to the other. Despite his wounds, he and the remaining men managed to escape. My patient was hospitalized briefly, but after recovering he and his comrades continued to fight alongside French Resistance forces and Allied troops.
I listened to his story, admittedly impressed by his matter-of-fact demeanor in recounting his harrowing experience. It was a remarkable tale of heroism. I asked if he’d ever been recognized for his role in this encounter. To my incredulity, his wife handed me a folder that included a picture of my patient as a young man in 1946 being awarded the Legion of Honor at the level of Chevalier by Charles de Gaulle himself. The folder included a complete history written to accompany the medal describing the importance of the raid in destroying a large cache of weapons on train cars throughout the rail yard.
I read the account, mouth agape, amazed that this unassuming, quiet man had been involved in such an exploit. I would never have guessed that he and his family had risked their lives to assist people fleeing from Germany. I was impressed by his bravery in leading such a daring attack against a garrison of well-armed troops.
But that was not his last act of courage. Try to envision undergoing an operation that creates a six-to-eight-inch-long cut on your belly just below the ribs on the right side, removes your gallbladder, places a catheter into the artery going to your liver, and implants an approximately two-pound metal device slightly larger than a hockey puck under the skin on your right lower abdomen. After I explained this procedure and possible risks to my patient, without hesitation he said, “Let’s get it done, Doctor. I have lots of living to do!” I performed the operation the following week, and he was discharged three days later.
After six months of HAI chemotherapy my patient’s liver tumors had reduced in size by more than 80 percent. He continued to receive HAI chemotherapy, but two months later his liver became inflamed by the drugs and I told him we could not safely continue with treatments.
He accepted this information with his usual calm stoicism and reported that he would simply carry on and enjoy his life. He did exactly that for another thirty months and at every check-in he was always grateful and upbeat. He again impressed me near the end of his life when I saw him in the clinic, “I am a happy man doctor. I have lived a long and productive life and I have a wonderful family. Why would I ever complain?”
During his clinic visits my patient and I had many long conversations about his involvement in World War II. He was clearly affected by his memories and admitted that he was haunted by people he had not been able to save or help. I was awed by how he and his family had lived during the war, but more so by the man he was after his experiences. He was a man who had the courage and resolve to do the right thing and help others while combatting those who oppressed them. And he had the courage to fight a hard disease with dignity and grace.
I am truly fortunate to have a career that allows me to help people every day and to hear their stories. I am blessed to have cared for this man and many other veterans who chose to make a difference.
Addendum
In the decades leading up to the new millennium, we had very few drugs to treat patients with advanced colorectal cancer. Patients with stage IV disease, meaning the colon cancer had metastasized to organs like the liver or lung, were usually treated with 5-fluorouracil (5-FU) and leucovorin. These drugs generally did little to improve long-term survival for most patients, and dramatic responses rarely occurred.
One of the biological fascinations and peculiarities of colorectal cancer is that it will metastasize only to the liver in some patients. These patients may also have lymph node metastases removed at the time their primary colon or rectal cancer is resected, but in patients with liver-only disease, surgical removal of the tumors can be curative.
Unfortunately however, most patients have too many liver tumors, or tumors too near critical blood vessels or bile ducts, for it to be possible to consider surgical removal of the tumors. For that reason, I have been involved in studying other types of treatments to destroy or to treat the malignant liver tumors directly.
The liver is my favorite organ for many reasons, most of which are irrelevant to my current musings, but one interesting fact is that it has a dual blood supply. Specifically, the liver gets blood from an artery called the hepatic artery, which carries oxygen-rich blood from the heart. In addition, the majority of the nutrient blood flow to the liver comes from a large blood vessel called the portal vein. Everything we eat or ingest through our intestinal system passes into veins that flow into larger and larger veins, in a pattern like that of branches on a tree, until the vein-branches form into a single large “trunk,” the portal vein. Thus, all digested food, medications, and other chemicals ultimately pass through the liver.
While the liver is unusual in the presence of this dual blood supply, it is like any other organ in the body when it comes to malignant tumors. A malignant tumor survives in the organ in which it originated or spread by a process known as angiogenesis. This means the tumor derives its blood supply from arteries feeding the organ. A colon-cancer liver metastasis obtains the majority of its blood flow from the hepatic artery, while a normal, nonmalignant liver gets most of its blood flow from the portal vein, with an admixture from the hepatic artery. Cancer clinicians take advantage of this feature of malignant liver tumors to deliver drugs or other treatments directly to the tumors in the liver through the hepatic artery. One such treatment that gained some popularity in the 1980s and 1990s was a device called a hepatic arterial infusion (HAI) pump.
Parenthetically, as a liver surgeon, when I consider removing malignant tumors from the liver I must always be mindful to leave the patient with enough residual liver to maintain function while the liver regenerates. The liver is the only organ in the human body that grows back after a major portion of it is removed. Clearly, the ancient Greeks knew this, as indicated by the story of Prometheus. His punishment by the gods on Olympus for giving fire to mankind was to have his liver eaten by an eagle every day, only to have it grow back, so he could suffer the same fate daily. Unfortunately, a human liver does not grow back in one day; it takes six to eight weeks!
3
Good News, Bad News
“The price of success is hard work, dedication to the job at hand, and the determination that whether we win or lose, we have applied the best of ourselves to the task at hand.”
Vince Lombardi
Determination: The quality of being determined; firmness of purpose
One of the things I love most about being a surgical oncologist is seeing my patients for years after I have treated them. However, those visits are inevitably like the opening scenes from the old Wide World of Sports television program I watched on Saturdays when I was growing up. For those patients who receive good news during their clinic visit, the images are of athletes crossing
the finish line in a first-place “thrill of victory.” I tell the patients I am confident I can perform an operation to remove their cancer; or I confirm that their blood tests and scans show that tumors have not recurred after surgery, chemotherapy, or other treatments. Or they pass some major chronological milestone without evidence of cancer rearing its ugly head again. (Many patients still believe the five-year cancer-free anniversary means they’re “cured.” If only that were always true.) In contrast, “agony of defeat” scenes, like the ski jumper falling off the end of the ramp and bouncing hard on the slope, represent the distress and depression patients and their family members feel when I deliver bad news.
I would never make it as a professional poker player because I can’t bluff when I’m holding a bad hand or keep from grinning when I have a good one. My patients can tell by my face when I enter the clinic room what the news is going to be. When all of their blood tests and scans reveal no evidence of cancer recurrence, I walk in smiling and immediately tell them everything looks great and I see no evidence of any cancer. The remainder of the visit becomes a combination of medical checkup and social enterprise. I inquire about the well-being of their children, grandchildren, parents, other friends, and relatives I have met. We discuss their pets, their gardening, their recent travels, and sundry snippets of their lives. Patients frequently bring pictures of children and grandchildren, or travel photos of places they have been since their last visit with me. Often they ask for medical advice on conditions totally unrelated to their cancer as they get farther and farther away from their original diagnosis. My patients also know tidbits from my life. They ask about the status of soccer teams I coached, how my son or daughter are doing (both graduated college and moved onto successful careers, thank you), and whether I have progressed from owning a Ferrari lanyard to hold my medical badge (I’m a fan of Ferrari F1 racing) to actually owning a Ferrari automobile (I have not).
In My Hands: Compelling Stories From a Surgeon and His Patients Fighting Cancer Page 2
