I proceeded to remove part of the tumor-bearing right lobe of the liver, and performed radiofrequency ablation of the central tumor near the hepatic veins. This grossly treated all of the cancer we could detect. He recovered and received additional chemotherapy. But his cancer did not cooperate with our plans; it recurred. Within a year he had new liver metastases, including some at the edge of the radiofrequency-ablation zone, indicating that the tumor at this site had not been completely destroyed.
I performed a second liver operation. Once again, removing some tumors and destroying others with the heat generated during radiofrequency ablation. Based on the ultrasound used to examine his liver during the operation, all of the detectable cancer was removed or destroyed. I’ll evoke a Jaws analogy, since swimming is part of this tale. Cancer is like the ocean, what’s hidden beneath the surface can be dangerous. As already mentioned, the potentially deadly aspect of cancer is centered on the microscopic areas of malignant cells that remain and develop resistance to chemotherapy and other drug treatments.
The swimmer had these hidden clusters of cancer cells in his liver, and after lurking undetected for a few months, they grew to a size sufficient to be seen on CT scans. Bad words were muttered in the clinic. My colleagues and I responded with another barrage of chemotherapy, after which I performed a third liver operation. For the third time, I successfully removed or destroyed every tumor I could find in my patient’s liver. He had no malignant lymph nodes or tumor nodules in his entire belly cavity. I should have been buoyant and hopeful, but I admit I was guarded and worried because three major liver operations and months of chemotherapy had not eradicated the swimmer’s cancer.
Here was this former NCAA Division I athlete, skilled and self-motivated to compete at the collegiate level. He was intelligent and driven to complete graduate degrees and begin a career in a high-functioning environment, yet diagnosed at a relatively young age with stage IV colorectal cancer. Wouldn’t it be nice if this story had a happy ending? Cancer causes many unanticipated, unplanned, unwanted, unhappy endings. This is a story about diligence, endurance, and persistence.
The fourth time metastatic colorectal cancer reared its ugly head in the swimmer was more complicated. He had recurrent liver tumors that were in difficult locations near blood vessels or bile ducts. Some could be removed, and others could have been treated cautiously with thermal ablation. However, more liver surgery was contraindicated because he had several small metastases in both of his lungs. We surgical oncologists have data that shows we improve a patient’s chance of long-term survival when we are able to remove completely all primary and, for some cancers, all metastatic disease. My aquatic patient had too many lung tumors to remove, so he and I had several long conversations in which I explained why liver-directed surgery was not the optimal option. The swimmer was healthy and fit and received aggressive systemic chemotherapy instead. He searched and read extensively about novel approaches and different ways to treat cancer. He and I had numerous discussions about some of my laboratory research regarding the use of electromagnetic fields to fight cancer. My studies were all in the very basic stage of investigation, using cancer cells or animals with malignant tumors. Nonetheless, he was very interested and was motivated to find alternative methods to battle cancer.
The swimmer and his family initiated a swim-a-thon called Drown Out Cancer to raise money and awareness to fund cancer research. He did this of his own volition because he believed better approaches to treat cancer and reduce the side effects and toxicities of standard therapies were needed. My patient and other swimmers in his Great Plains community held a one-day swim event and raised thousands of dollars by swimming lap after lap to earn money people had pledged. The first year my patient swam to drown out cancer was about four years after his initial cancer diagnosis and well over a decade since his career as a competitive swimmer. When he informed me he had completed ten miles, I was speechless, an exceedingly rare state for me. I would have drowned myself after a few hundred yards had I attempted this feat.
The swimmer spent more time on rather than off chemotherapy after developing colorectal cancer. He received a variety of intravenous chemotherapy drugs, and realized the side effects were making it impossible for him to function in his medical career. Rather than despairing and decrying his bad fortune, he reinvented himself in an entirely different profession. He not only succeeded, he excelled, all while being treated with toxic chemotherapy agents. He had a clear set of priorities and made sure he spent time with family, friends, and others important to him. He was one of the most sanguine and focused individuals I have ever encountered.
Intravenous systemic chemotherapy was not working. The tumors continued to grow, particularly in his liver, where the majority of his cancer was located. So he entered an intensive experimental-treatment program. This required him to be hospitalized for three to four days every six weeks. A catheter was placed in the femoral artery in his groin and snaked by an interventional radiologist all the way up to the hepatic artery supplying blood to his liver. This allowed drugs to be delivered through the hepatic artery directly into the vessels going to the tumors. This increased the dosage of drugs delivered to the tumors while theoretically reducing the exposure of normal liver cells. The downside of this treatment approach was that for three or four days every six weeks the swimmer was confined to a hospital bed, unable to move to prevent the catheter from shifting or being displaced and causing bleeding or infusion of drugs to organs other than the liver.
Imagine yourself prohibited from moving, sitting up, walking, or getting out of bed for any function for three or four consecutive days. The prospect would be maddening. For a former high-level athlete it was difficult, but he managed and endured the treatments. I would visit him in his hospital room, and we would talk about options, progress in my research, and other novel approaches on the horizon. I knew he was frustrated, but to me he always presented a stoic and calm manner.
Like most patients undergoing chemotherapy and other cancer treatments, this man suffered from significant fatigue and deconditioning. That did not stop him from swimming only weeks after receiving high-dose hepatic arterial infusion chemotherapy. I was mildly surprised when he called and told me he would be swimming in the annual Drown Out Cancer event. (He invited me to speak at the dinner that would take place after the pool activities. He knew my history as a kid from the desert and thankfully did not invite me to flail in the water.) He had not been training or exercising regularly because of his ongoing therapy, yet he swam ten and a half miles! He swam even farther than he had swum the first time he organized this fundraiser. Talk about an iron man! The night I spoke at the swim-a-thon event he was clearly exhausted, but he was exuberant. He had swum much farther than even he had predicted. I asked him how he had accomplished this feat. He thought a moment and replied, “This disease devastates too many lives. That thought kept pushing me to swim.”
After several years of almost-continuous treatment with systemic or liver-directed chemotherapy infusions, the swimmer’s cancer became resistant to everything available and he succumbed. His brother sent me a note thanking me for my efforts and for the time I had spent talking with the swimmer in the hospital room or on the phone. He also reported that the swimmer had believed better treatments for cancer would be found, and he asked me to keep working on new approaches to treat this dreadful disease.
I can’t swim more than a few hundred yards before hauling myself dripping and breathless out of the water. The swimmer, in the middle of tough chemotherapy treatments, and with no training, got into a pool and swam for miles. The spirit and endurance of cancer patients is an inspiration and testament to the willpower, resolve, and toughness of some people. And I do not forget the family members, friends, and co-workers of patients afflicted with cancer. They step up to support their loved ones, and endure watching the rigorous challenges, painful surgical procedures, side effects of medical and radiation therapies, fear, uncertainty, and depression
accompanying the shocking diagnosis and treatment of cancer. Everyone associated with a cancer patient is drawn into the process of treatment, living in the shadow of the disease, and, for too many, dying. They all are affected in some way, and they must cope with a range of emotions and problems.
There are several new treatments reported in the last few years making a big splash in cancer therapy. There are immunotherapies, drugs targeted to specific proteins or aberrant pathways in cancer cells, and personalized genetic testing to identify abnormalities that can be treated with new or available agents. Everybody—patients, family members, cancer clinicians, care-givers, and researchers—all hope for better methods to improve the survival and quality of life for those afflicted with cancer. We must continue to fund and investigate novel approaches to understand, prevent, and treat malignant disease. To allow more patients to survive and thrive. The swimmer knew that clearly, and he and his family and friends did something about it. They swam to fund cancer research and “drown out cancer.”
“Some days there won’t be a song in your heart. Sing anyway.”
—Emory Austin
Endure.
24
Things Get Complicated
“Life is a long lesson in humility.”
J. M. Barrie
Humility: The quality of having a modest, rational view of one’s importance
A surgical operation, whether major or minor, whether for cancer or for a benign condition, is not to be taken lightly. For an elective, scheduled operation, one human being is knowingly granting another human being, the surgeon, permission to cut him or her. Think about it for a moment. The implications are extraordinary. This represents an almost incomprehensibly high level of trust. It is incumbent on the surgeon to weigh and balance the risks, benefits, short- and long-term effects, alternative treatments, and possible problems associated with a planned surgical procedure. Patients entrust surgeons like me with their well-being and their lives, and ostensibly we all have the same goal: a good outcome.
Discussing a surgical procedure with a cancer patient is different from discussing an elective operation for a benign disorder. Cancer patients are staring down the long-barreled gun of their own mortality, usually they’ve been confronted with this frightening reality unexpectedly. Cancer patients feel cornered and anxious, so they are willing to accept a recommendation for surgical treatment more readily than those deciding to address a nonurgent condition. Often cancer patients want the procedure done as quickly as possible. Caution and rational reasoning are replaced by fear and willingness to accept higher risks.
The most common question I am asked by patients and their family members is, “How many times have you done this operation?” Once I provide an answer resulting in nods of approval and general satisfaction, they ask few if any other questions. After I have ascertained that a patient is a candidate for a major abdominal operation, we choose a surgery date and schedule a preoperative visit.
The preoperative experience can be daunting. There are blood tests, electrocardiograms (EKGs), a brief physical examination, and consent forms to be signed—there are always several forms to sign during the preoperative visit. My approach during a preoperative examination is to review the patient’s scans and blood tests with him or her, and all who are present in the room. Then I use charts, diagrams, and hand-drawn pictures of the liver or other intestinal organs to explain in common, easily understandable terms what steps I will take during the operation. I next go through a long list of potential complications. I often try to allay some of my patients’ anxiety with an inane comment like, “Okay, now let’s discuss the risks. As you know, I must go through the written list of possible complications on the consent form with you. I’m surprised it doesn’t mention you could be struck by a meteor during the operation.” I don’t know if I relieve anxiety or cause more, but most people at least emit a nervous laugh or grin briefly. The number of potential complications is sufficiently unnerving and it amazes me that people don’t exit the room visibly trembling. I explain the problems listed, and possibly some that are not included, are difficulties that may arise but have a low-to-moderate probability of occurrence—based on the patient’s overall health status, presence of other medical disorders and medications that may increase the risks, previous surgical procedures causing scar tissue and alterations in anatomy, and the degree of difficulty of the proposed operation.
Once I have answered all questions and explained everything to everyone’s satisfaction, the patient signs consent forms granting permission to proceed with the operation. At this point I have completed a surprisingly succinct discussion of the operation including the potential risks, outcomes, possible complications, and imponderables. This is a delicate euphemism linked to the other question I am occasionally asked, “What are my chances of dying, Doc?” Part of elective-surgical risk assessment and judgment includes choosing patients who have a low probability of a lethal event during or after the procedure. I inform my patients that the possibility of the ultimate bad outcome is exceedingly low, and assure them I will maintain a high level of vigilance and caution. I tell them, “I hope you will be stuck coming back to see me for a long time.” This is the desired outcome, but not always the one achieved when cancer is a variable. After the visit with me, the patient is sent on for an evaluation by the anesthesia team with yet more discussions of risks and complications and, of course, another consent form to sign.
Surgery has frequently been compared to flying an airplane. Everyone wants to take off, proceed on the journey, and land safely at the planned destination, every time. When something goes awry, and someone is hurt or dies, it is always a serious, disturbing event, and all involved want to know what went wrong.
More than a decade ago, I performed a right hepatectomy in a fifty-year-old man who had two colorectal-cancer liver metastases. His primary colon cancer had been removed two years previously, and he had received no chemotherapy because the primary cancer was small and had not spread to regional lymph nodes, which were removed during the operation. During routine follow-up with his physician, however, two liver tumors were discovered on his CT scan. He was an active gentleman who walked daily. On weekends he rode his bicycle twenty to thirty miles. He admitted he liked a glass of wine or beer with dinner once or twice a week, but had never been a heavy drinker. He had never smoked cigarettes. He told me he was ten to twelve pounds heavier than he had been in college but he had recently purchased a gym membership and was working out. He certainly was not significantly overweight. Other than stage IV colorectal cancer, his only medical problem was mild hypertension, which was well controlled with a single medication. He had no symptoms, medical issues, pain, discomfort, or other disorders, and he seemed like an ideal, low-risk candidate for surgical treatment followed by chemotherapy.
I performed the scheduled operation, and the procedure went perfectly. The anesthesiologist and his team communicated with me effectively during the process, the surgical fellow working with me was skilled, and the entire operating-room team worked harmoniously and seamlessly. We were humming along on all cylinders, as my grandfather used to say. The intraoperative ultrasound showed no additional liver tumors so the tumor-bearing right liver lobe was removed in less than two hours. He lost less than a hundred milliliters of blood during the surgery, and all of his vital signs were stable.
During operations, I always send word out to the patient’s family members and friends in the waiting room to give them an update on how things are going. I know they are concerned and fretting while I am working to remove the malignant disease from their loved one. For longer operations I might transmit two or three updates through the circulating nurse. But for a two-hour operation I provide a progress report approximately halfway through and then go out to the waiting area to deliver a full report in person after the procedure is completed and the patient is safely in the recovery room. In this fifty-year-old gentleman, I sent out a report about one hour into the operation to let his
wife, children, and family members know all was going well and he was stable. As we completed the liver resection, I asked the circulating nurse to call out to the waiting room to let all assembled know things were “great” and that I would be out to speak with everybody in about ten minutes. The surgical fellow and I sewed up the muscle layers of the abdominal wall incision we had made to access the liver.
When we finished tying the sutures and started to close the skin incision, the anesthesiologist said, “What are you guys doing down there? His blood pressure just dropped.” I looked up, over the sterile drape separating the surgical team from the anesthesiology team, and saw a blood pressure value of only sixty over thirty on the monitor display. The anesthesiologist asked, “Are you guys pressing on something or doing something?” I replied, “No, we just closed the abdomen, but something is clearly wrong.” The fellow and I immediately cut the sutures holding the abdominal wall muscles together because I assumed a blood vessel or the liver edge was bleeding actively and causing his blood pressure to fall suddenly.
Nothing. The liver edge and the entire belly cavity was as dry as the Mojave desert on a summer morning. No active bleeding, no blood clots, no surgical issue to explain a rapid drop in the patient’s blood pressure. At this point, the anesthesiologist called for assistance and said, “We have a big problem.”
In My Hands: Compelling Stories From a Surgeon and His Patients Fighting Cancer Page 18
