The fact is, a significant portion of cancer patients take nonprescription medications while receiving traditional cancer therapies. Frankly, most of these nonprescription therapies are innocuous and produce neither harm nor benefit. Some may actually have a positive effect and improve immune function, appetite, nutritional status, or the difficult-to-measure mental well-being of the patient. But, sadly, there are documented examples of patients’ suffering serious side effects or even dying from using alternative approaches. Some patients who favor alternative treatments in lieu of standard therapies may have a shorter survival time when their cancer progresses rapidly.
A series of factors, including fear, hope, uncertainty, and a desire to try everything possible to improve the odds of defeating cancer leads patients to try all kinds of nonprescribed therapies. In my opinion, however, it is a mistake for medical professionals to denigrate or disdain alternative therapies because that attitude fails to recognize that most patients want to have input in their cancer treatments. I prefer to engage my patients in an open and honest conversation about all therapies they are using as part of their cancer treatment. It provides them reassurance that we can have an open-minded dialogue about all components of their cancer care. Sometimes I learn new and important information myself. Generally, I am able to validate that the tablets, teas, concoctions, or contraptions they are using are not toxic and may provide some unmeasurable benefit, and other times I can warn them when I find they are taking a substance or using a device that is dangerous.
It is impossible to measure the potency of hope and comfort that patients and families derive from trying everything they believe may help improve their chances of surviving a battle with cancer. Hope endures. And you can’t write a prescription for hope.
14
Go for It
“By having a reverence for life, we enter into a spiritual relation with the world. By practicing reverence for life we become good, deep, and alive.”
Albert Schweitzer
Reverence: Deep respect for someone or something
How long does it take you to make a decision about a major purchase? For example, a new car. Most people I know or have observed use a significant amount of time evaluating different manufacturers and models. Their research and calculated considerations include questions like, Do I go with a gas-guzzling SUV or an extended–crew cab truck certain to protrude a few feet into the parking lot driving lanes? Or am I feeling eco-friendly? Do I go with a hybrid vehicle? I was once a member of the Sierra Club, perhaps I should go totally electric. How far can I drive on a single full charge of the batteries in one of those things? And where do I plug it in once I reach my destination? People consider option packages and colors of the exterior and interior. They take different cars for test drives and consult the internet or consumer-information sources to learn which are the safest and most reliable. I daresay we humans will take hours, days, or weeks to come to a final conclusion before signing a contract for a new automobile.
A stark contrast is our response to well-placed, impulse-buy items at the ends of the aisles in department stores or near the checkout counter at the local supermarket. Trinkets, baubles, gadgets, flashlights, batteries, gum, candy, and magazines with titillating sagas about the woes befalling various celebrities are placed strategically to catch the shoppers’ (or their children’s) eye. Clearly, businesses have done market research on the spontaneous buying habits of the average consumer. We apparently don’t mind spending a couple of bucks on an item we may or may not actually need. Do I have enough AA batteries? Can I own too many flashlights? It has been a few days since I treated myself to my favorite candy bar so certainly another is a good idea. Poor impulse control + ready access to excess fat and carbohydrates = an increasingly obese population.
What astonishes me, however, is how little time it takes to discuss and convince a patient that a major surgical operation is indicated. This should not represent an impulsive decision-making situation. I realize there are caveats and disclaimers to be considered. The great majority of patients I evaluate for a surgical procedure are dealing with a diagnosis of cancer. Patients are educated and well informed enough to understand that for most solid tumors, surgery is a critical and established component of cancer treatment. Patients know from personal experience with friends or family that surgical removal of cancer is known to yield a chance for cure in subsets of patients, particularly those with early-stage disease confined to the organ of origin, that is, disease that has not spread to regional lymph nodes or other organs. People are still frightened about cytotoxic chemotherapy or ionizing-radiation treatments, and their fear is usually based on witnessed or recounted horror stories about terrible side effects and the painful demise of someone they knew. Yet when I walk into an examination room to discuss the details of a proposed surgical procedure I am frequently told, “I trust you, Doc, just cut it out. Tomorrow, if possible.” I cannot begin to count the number of times I have heard the three words that sound like a slogan for an athletic shoe and apparel company, “Go for it!”
Evaluating a new patient for surgical treatment of a malignant disease starts with the patient’s history and physical examination. The surgeon, or an individual designated by the surgeon such as a physician’s assistant, nurse practitioner, surgical resident, or surgical oncology fellow will query the patient about how he or she came to be diagnosed with a malignant disease. The practitioner obtains patient information about any other medical issues such as high blood pressure, heart problems, or diabetes, along with a history of all prior surgical procedures and response to anesthesia and pain medications. A thorough review of all body systems is noted (akin to a preflight checklist to assure that everything is green and good to go before take-off on an airplane flight), and a complete list of allergies and current medications is recorded. Personal habits such as cigarette smoking, alcohol consumption, and any previous illicit drug use are solicited. After completing the medical history, the patient’s vital signs (blood pressure, pulse rate, breathing rate, weight and height) are measured, and then a physical examination including visual inspection and manual palpation of the head and neck region, back, chest, and arms and legs is performed. The examiner listens to the patient’s lungs and heart with a stethoscope, pokes and prods the patient’s abdomen, and explores the lymph node–bearing regions in the neck, under the arms, and in the groin by touch. And if the physician is really thorough, a rectal examination is performed. This is particularly relevant if the patient is being evaluated for a gastrointestinal, genitourinary, or gynecological malignancy because the surgeon wants to determine if there is any trace of blood present and if a tumor can be palpated with the probing finger.
After completing the history and physical examination, the surgeon reviews the results of any biopsies already performed on the tumor(s) and looks at CT or MRI results. If the patient has not yet had a biopsy or undergone adequate radiographic evaluation, the surgeon orders such tests and reviews the subsequent results with the patient and the patient’s family members at a follow-up visit. Finally, it is time to discuss an operation.
This is when things become surprising to me. I am primarily a hepatobiliary surgical oncologist. The majority of patients I operate on have stage IV cancer that has spread from organs like the colon, rectum, breasts, or other sites to the liver. Some patients have a primary cancer like hepatocellular carcinoma or cholangiocarcinoma that has arisen in the liver. To employ the vernacular, a liver resection is a big deal. Frankly, most cancer operations are major surgical procedures, and even relatively minor surgical oncology operations are not without risks or possible complications. Yet, despite the complexities associated with a liver resection and the mandatory discussion of potential risks, complications, and alternatives, the average conversation to reach an agreement to schedule an operation takes less than ten minutes. An average is an average, meaning some conversations are shorter and some are longer. Some patients literally tell me, “I don’t want to kno
w anything about the operation, I just want the cancer out.” I insist on describing the steps of the operation and the potential complications, but at times patients respond by shaking their head with an emphatic “No!” They ask for the consent form to sign and tell me to proceed at flank speed.
Sorry, not going to happen, they must at least listen to my basic recitation about the operation. For all my patients I use pictures and artwork of the liver to describe the location of their liver tumor or tumors, and to define the areas to be surgically removed. Even for those not wanting to hear it, I mention a frightening list of potential complications associated with major liver operations. Most patients listen intently and nod, and may ask only one or two questions.
At times I do come across patients who are prepared with pages of written questions on which they dutifully jot down my responses. They request detailed descriptions of surgical techniques and diagrams of liver anatomy. We discuss the regenerative capacity of the liver and the probability of various complications during or after the operation. Often they will leave to consult with family, friends, the internet, and other physicians. We agree to meet again or arrange a phone conversation to discuss their decision. However, this ask-lots-of-questions-and-take-a-long-time-to-decide group is a small minority of the patients I meet. Usually when I ask the patients and those accompanying them if they have any questions, the answer is no or a simple remark such as “I trust you and I just want to get this taken care of.” The other frequent comment I hear is, “I am putting my life in your hands.”
In my hands. No pressure, right? That is a heavy load of responsibility and belief in my abilities laid at my feet. It is a burden all surgeons and physicians pick up and carry every day of their professional lives.
Trust is not something to take lightly or dismiss. It is an honor and a tremendous responsibility for surgeons to be granted such faith in their abilities and care. We are accorded a remarkable degree of respect and deference for our training, commitment, and willingness to attack and seek to eradicate our patients’ malignant disease. At the same time, we want to achieve this goal without causing long-term side effects or problems for our patients. The trust is sacred to me; I feel an abiding obligation to all of my patients who believe in my skill and entrust me with their lives.
It is common for patients to ask for a prediction of the future. Many patients or a family member (the latter occasionally to the considerable annoyance of the patient) will have done research on their own. They have read about short- and long-term probabilities of survival with their particular type of cancer. How long any specific patient will survive is an impossible question to answer, but it’s one I get every week in the clinic. My overused line is to tell people that I do not have a crystal ball and I cannot predict the future. Parenthetically, two of my patients have given me the gift of a crystal ball (where the heck do you buy those?). Unfortunately, both are malfunctioning and have not provided me a glimpse of the future. What I do tell patients is that I am committed and available to provide care for them in the future regardless of what occurs. When performing surgical removal of malignant disease, the term surgeons use is operation with curative intent. Currently, the problem surgical oncologists face is the inability to detect subclinical or microscopic foci of cancer (though many of us are working on this limitation). So we remove all of the detectable cancer, realizing malicious malignant cells may be hiding elsewhere in the patient’s body, waiting to arise in the imponderable future.
In general, conversations related to a major decision about proceeding with an operation on the liver, pancreas, colon, lungs, or wherever the cancer is located are short. Nevertheless, I have learned that patients and their families do hear what is said. Perhaps this is because I reiterate key points several times and I ask them to give me feedback indicating they understand. This is particularly important for those patients who do develop a problem or a complication after an operation. Whether it’s an infection in their abdominal incision requiring antibiotics or opening the incision, or a major issue like liver insufficiency or a life-threatening pneumonia, when I discuss the treatment of the problem, patients and their families generally acknowledge that they were aware these complications might occur. Still, it is a difficult situation for the patient, concerned family members and friends, and the treating surgeon. No surgeon wants a patient to suffer any ill effects caused by the surgeon’s action. We are tightrope walkers performing procedures designed to rid the patient of malignant disease. We know there is always a risk of slipping and falling from the high wire and suffering an undesirable outcome.
As I mentioned, there are caveats and disclaimers. I recognize most patients referred to me have already been thinking about surgical treatment. They have considered their options, had an operation recommended by their primary physician or medical oncologist, and are emotionally prepared to accept an aggressive therapeutic procedure. Cancer patients want the malignant tumors removed when data supports the operation and it can be performed with an acceptable probability of a safe and successful result. Acceptable probability is difficult to define; research has demonstrated cancer patients are often willing to undergo invasive or toxic treatments more readily than the physicians providing the treatment would recommend. Patients will accept the risks and pain connected with an oncological surgical procedure when there is an opportunity to eliminate their cancer. A tacit understanding exists between patient and surgeon recognizing that although complications might arise, the potential benefits outweigh the alternative of a cancer-related death.
I am compelled to reiterate an important point: Patients generally respect their physicians and recognize the hard work and years of training needed to develop their expertise and excellence. The level of trust granted to me as a surgeon is immense. I occasionally forget that the surgical acts I perform routinely are a source of amazement to patients, medically naïve individuals, or young acolytes like our medical students. Commonly I will ask a surgical fellow, resident, or medical student who scrubbed into an operation with me what they thought about the procedure. The usual response is an expression of surprise or astonishment. That makes me happy because I can use the emotion of the moment to teach a vital lesson: the respect and trust we are granted as physicians by our patients is a precious gift to be cherished and nurtured. Patients and their families and friends are awed by the procedures my colleagues and I can perform; I am awed by their belief and confidence in us.
Humans consider odds and risk-benefit ratios many times every day, albeit not always consciously. Can I make it through that yellow light before it turns red? Can I hustle across the street before that car comes through? This operation has a chance of ridding me of my cancer.
Go for it.
15
Good Morning!
“Balance, peace, and joy are the fruit of a successful life. It starts with recognizing your talents and finding ways to serve others by using them.”
Thomas Kinkade
Joyfulness: Feeling, expressing, or causing great pleasure and happiness
Early one morning last week my cell phone dinged notifying me of a new text message. This happens twenty or thirty times daily as I receive reports or questions from surgical residents, my secretary, patients, friends, or home. I opened the message and a smile quickly spread across my face.
Hi Dr. Curley. Today is the 9th anniversary of my Whipple operation. I’m still here! Thank you.
What a nice start to my frenetic day!
My grin was gradually replaced by a wistful expression. Pancreatic adenocarcinoma, also known as pancreatic ductal adenocarcinoma (PDAC), is one of the most lethal diseases we tangle with in oncology. Epidemiologists estimate there were approximately 54,000 new cases of pancreatic adenocarcinoma diagnosed in the United States in 2017. Of greater concern is the prediction that by 2030 there will be approximately 80,000 new cases annually. More than 41,000 Americans will die from PDAC this year; it is the fourth most common cause of cancer death in women (
after lung, breast, and colorectal cancer) and in men (after lung, prostate, and colorectal cancer). The long-term survival probabilities are daunting. In most countries, fewer than 5 percent of patients with PDAC will still be alive five years after their diagnosis.
PDAC is particularly deadly for several reasons. A key driver mutation in the development and propagation of PDAC is an alteration in the KRAS gene (KRAS encodes for a protein involved in cell-signaling pathways that control cell growth, cell maturation, and cell death. Mutated forms of the KRAS gene may cause cancer cells to grow and spread in the body). Cancer clinicians have not yet been able to do much with this information to help identify, detect, and treat patients at risk of developing PDAC, which may be present for years, growing insidiously in an unsuspecting and asymptomatic patient, before it becomes clinically evident.
If located in the head or uncinate process of the pancreas, these cancers are most frequently diagnosed when they obstruct the bile duct coursing from the liver through the head of the pancreas to drain into the small intestine. Patients will develop jaundice. Patients with tumors situated in the body or tail of the pancreas may present with mild or moderate abdominal or back pain, changes in gastrointestinal functions manifest as bloating or reduced appetite, or unexplained and unplanned weight loss.
Sadly, by the time the majority of patients develop these symptoms, to quote my grandmother, “The mare is out of the barn.” Most patients diagnosed with PDAC have advanced-stage disease. This means that either the primary pancreatic cancer has grown around critical blood vessels like the superior mesenteric artery, or has already metastasized to lymph nodes and other organs like the liver. Metastasis from PDAC is usually a harbinger of doom. PDAC is notoriously difficult to treat and modern chemotherapy or radiation only buys a few additional months of life for patients. Once this malignant serpent slithers out, making its presence known, it rapidly invades other areas and organs and evades attempts to push it back into a hole.
In My Hands Page 10
