In My Hands

by Steven A. Curley

  Many types of cancer are emphasized during specific months of the year. Nearly every month is designated to raise awareness for one or more cancers. This is intended to remind Americans of the importance of prevention, screening, early diagnosis, and research to improve treatments, survival rates, and quality-of-life outcomes for a particular cancer. For example, April is Testicular Cancer Awareness Month and it includes the graphically named Get a Grip campaign. Let’s be gentle with the grip. Can we agree on that?

  A patient of mine I saw recently caused me to think about October.

  October is National Breast Cancer Awareness Month, and it is one of the most highly visible and publicized awareness months assigned to a specific cancer diagnosis. It is great fun for me to watch very large men wearing tight uniforms, heavy pads, and football helmets crash into one another while wearing pink shoes, pink wristbands, and pink towels. Smash-mouth, grind-out-a-few-yards running plays seem a little less ferocious when the 310-pound pulling guard, the 230-pound running back he leads into the six-hole, and the 250-pound outside linebacker he collides with are all wearing bright pink cleats. Even the officials get into the act by wearing pink armbands and blowing pink whistles. While it may seem enigmatic to see football players prancing in pink, it actually makes perfect sense.

  All of us, including professional athletes, have a mother. Often a sideline television camera will capture a close-up of a football player who just completed a great play as he looks into the camera, waving and says, “Hi Mom!” Despite our many advances in cancer research and therapeutics, breast cancer is still one of the three most common causes of cancer-related deaths in women in America. (The other two are lung and colorectal cancer.) It is estimated that approximately one in eight American women will develop breast cancer during their lifetime. As a shocking news flash to the guys, breast cancer can occur, rarely, in men. It’s not just the ladies who are at risk, Lads. Unlike some deep body cavity cancers, this tumor is easier to detect with routine screening examinations. Mammography and ultrasound administered regularly can diagnose small, early-stage breast cancers and save thousands of lives. That’s why biannual screening mammography in individuals with no family history of breast cancer is currently recommended to begin at age fifty.

  The patient who induced me to muse about pink-footed football players is an outstanding young woman. When I met her she was an executive at a large firm in a major American urban center. Shortly after turning thirty, she noticed a painless lump in her breast. She astutely and immediately sought medical care and a mammogram confirmed the presence of a mass that was potentially malignant.

  This young lady had no family history of breast or any other kind of cancer. She was referred to a breast surgical specialist who performed a detailed examination and palpated several enlarged lymph nodes under her arm, an anatomic area called the axilla. An ultrasound-guided biopsy of the breast tumor and enlarged lymph nodes confirmed infiltrating ductal carcinoma of the breast with metastasis to the regional lymph nodes. Additional special stains of her biopsy slides revealed her tumor expressed estrogen and progesterone receptors and was positive for human epidermal growth factor receptor 2 (HER2). The presence of estrogen or progesterone receptors in breast cancer has been known for several decades to be useful information guiding long-term delivery of anti-estrogen drugs to help control and prevent recurrence of this tumor. The additional indication of overexpression of HER2 on the surface of the cancer cells is a more recent discovery. HER2 expression is one example of a modern molecular-profiling study that is now routinely performed to assess treatment options for patients with advanced malignant disease. The presence of this receptor on the surface of breast-cancer cells allows use of a specific drug, a monoclonal antibody called trastuzumab, in combination with other chemotherapy drugs to improve the killing of the malignant breast-cancer cells throughout the body. Conversely, the absence of these three receptors in breast cancer, so called triple-negative breast cancer, portends a more aggressive cancer and indicates that the use of anti-estrogen or trastuzumab therapy will not be helpful.

  The patient was referred to a medical oncologist who found all metastatic evaluation studies, including a positron emission tomography (PET) scan and CT scans of the brain, chest, abdomen, and pelvis were negative except for a single 2.5-centimeter tumor in the right lobe of her liver. This tumor had the appearance of a possible metastasis on the CT scan, and had a high uptake of the radiolabeled glucose molecules used on the PET scan, which was also worrisome as a possible malignant lesion. An interventional radiologist performed a biopsy of the liver tumor. The presence of stage IV breast cancer with a solitary liver metastasis was established.

  She received three months of systemic intravenous chemotherapy including trastuzumab, and the tumor in the upper, outer quadrant of her breast and the lymph nodes shrank markedly. Her liver tumor also decreased in volume by approximately one-quarter. She underwent a breast-sparing operation removing the malignant tumor and a surrounding zone of normal breast tissue accompanied by removal of all of the lymph nodes in the armpit. The pathology studies confirmed her cancer showed a major response to the chemotherapy, but there were still viable cancer cells in the breast tumor and the lymph nodes. At this point, all of the patient’s malignant disease except for the single liver tumor had been removed. That is when she contacted me.

  Within ten minutes of meeting this highly intelligent, well-educated, articulate young woman in the clinic, it was clear to me she was focused and well informed. She had already read reports from the surgical oncology literature describing the long-term survival probabilities of women who underwent surgical resection of breast-cancer liver metastases. In addition to inquiring about resection of her liver metastasis, she wanted to know if ablation techniques, including radiofrequency or microwave thermal ablation, would be indicated in her. I had ordered a high resolution CT scan of her abdomen the day before her visit with me, and I pulled up the images on the computer screen in the examination room.

  Scrolling through the scans, I immediately realized ablation techniques were not an option for her because the single tumor was nestled between the anterior and posterior branch of her right portal vein. The liver has both arterial and venous blood supply, and coursing along the hepatic-artery and portal-vein branches into the liver are large bile ducts. Performing thermal destruction of a tumor in that location would kill the tumor, but would also destroy major bile-duct branches and produce significant and dangerous injury to normal tissue. I showed the patient and her family the CT images and then used pictures and drawings of liver anatomy to explain why ablation was not appropriate. She replied with a nod and asked me to describe the operation needed to remove her liver metastasis. I believe it was a rhetorical question, more for her family than for her because as I described the anatomical rationale for performing a formal right hepatectomy removing approximately two-thirds of her liver, she again nodded her head while her family members gasped. The location of this single metastasis abutting the blood supply to the right lobe of the liver necessitated removal of the entire lobe to assure a tumor-free margin would be attained.

  We had an approximately sixty-minute conversation about the potential benefits, alternatives, and risks of a major surgical procedure. The patient’s family appeared rather frazzled, but she calmly announced at the end of our conversation that she was ready to proceed.

  The next week I performed an uneventful right hepatectomy on this young lady. The procedure was completed in less than two hours with minimal blood loss, and she was awake, alert, and asking me questions in the recovery room within thirty minutes of finishing the operation. Generally after major liver resections, patients are hospitalized for five or six days. On the morning of her third postoperative day, she was fully dressed in her civilian clothes and reported that she was ready to go home. Her laboratory values and overall performance status confirmed she was ready to go, so discharge orders were dutifully written. I saw her back in the clinic a few d
ays later, and we reviewed her pathology report. As with her primary breast cancer and axillary lymph nodes, there was evidence of a significant response to her chemotherapy regimen, but some viable cancer cells remained. The resection margins were clear.

  While sitting in the room with the patient and her family, I called her medical oncologist and discussed the findings. We agreed in a real-time tumor board that she should receive additional chemotherapy and targeted therapy with trastuzumab. She returned home to her life, work, and ongoing chemotherapy treatment. After completing a total of six months of cytotoxic chemotherapy, she continued to receive infusions of the targeted agent. This monotherapy went on for another year, during which time I saw her every four months and happily reported blood tests and imaging studies showed she was cancer-free.

  I’ve been seeing this patient twice a year now. She is more than five years out from her right-liver-lobe resection for metastatic breast cancer. I always saw her as a composed, reserved, decisive, professional individual. At her most recent visit things changed. When I walked into the room she was tanned and her hair had a sun-bleached appearance. Her usually serious demeanor was replaced by a wide smile and she rose from her chair and gave me a warm hug. She has never hugged me before. Laughing at my startled expression, she reported, “I decided it was time to enjoy life and lighten up.” I wondered if she was performing a feat of mind reading because she preemptively stated, “I know you’re going to say something about my tan. Don’t worry, I’m using a good sunscreen.” Melanoma prevention is important, too. And not just in May, during Melanoma Awareness Month.

  She went on to surprise me further. She told me her cancer diagnosis had initially driven her to do all she could to survive, but she realized she wasn’t enjoying her life. A few weeks after my previous visit with her, she decided to quit her job and do something she had always dreamt of doing. Specifically, she wanted to learn how to surf. She moved to the West Coast and rented a small house near a famous surf beach. She sought out local surfers and instructors, bought a short board, and began to ride the waves every day. She pulled a portfolio out of her satchel and showed me series of pictures. The first few photos were of her in a wet suit standing nervously on a surf board in two-foot surf. The pictures progressed to a final shot taken three weeks earlier on the north shore of Maui with her clad in a bikini, grinning widely, and successfully riding a nine-foot wave, several feet above her head. I looked at her and said, “Cowabunga, Baby!”

  She laughed heartily and assured me she did not plan to turn into a professional surf bum. She had started her own consulting business after realizing she was happy with a simpler, less-stressful life. She plans to continue her voyage, to become a better surfer, to live her life fully, to volunteer and help others, and to find reasons to enjoy every day. It sounded like a great plan to me. I complimented her on her decision and reported as an afterthought, “Oh yeah, all of your scans and blood tests are normal. Everything is looking great.” That news earned me a second hug. She promised to keep me updated on her surfing adventures and I promised to enjoy living vicariously through her experiences.

  Some people are overwhelmed by fear and apprehension after being diagnosed with a potentially life-threatening, chronic disease. Others, like this young lady, use the experience to redirect their lives and goals. I understand and empathize with both mind-sets, but I use stories like the one about my young surfer to encourage patients I see who are encumbered by anxiety and uncertainty that keep them from enjoying their daily lives. The surfer understands her breast cancer may recur, but she does not allow that knowledge to prey on her well-being and happiness. Life is uncertain and, frankly, none of us know how many days we have left to walk this earth. Every day should be embraced with joy and hopefulness.

  Surf’s up.

  After all, every day is a holiday.

  29

  This Is Too Real

  “My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style.”

  Maya Angelou

  Compassion: Sympathetic pity and concern for the sufferings or misfortunes of others

  When we humans find ourselves in a new social setting with people we have not met or don’t know well, there are certain unwritten but accepted rules of engagement. Unless you are attending a rally supporting your favorite candidate, it is generally not a good idea to open conversations with strangers with a discourse on politics. Similarly, if you are not in church, it may not be an opportune moment to initiate a conversation about religion. Instead, we choose socially accepted, banal, safe topics:

  “Can you believe how hot it’s been this month?”

  “I had a foot of standing water in my back yard after all the rain we’ve been having.”

  “Do you think [name your favorite sports team here] will win this weekend?”

  “What do you do for a living?”

  The last is a very common inquiry when meeting an individual or group of people for the first time. It’s a reasonably prudent opener and usually leads to a set of nonthreatening and nonemotional follow-up questions or comments, such as:

  “Are there others in your family who do similar work?”

  “How long have you been doing that?”

  “Gee, that must be interesting.”

  But it’s not so when I am asked the question. Until five or six years ago, when someone queried about my vocation, I would respond directly, “I am a surgical oncologist. I operate on patients who have liver, pancreas, and gastrointestinal cancers.”

  I wish I had a video camera to record people’s responses and facial expressions after I gave my answer. Eyebrows would rise, rapid blinking would occur, smiles would disappear, and weight would be shifted from one foot to the other as the inquiring individual processed this information. After quickly contemplating the implications of my professional activities, people would cough affectedly and change the subject. Some would excuse themselves reporting they had just seen a person across the room they wanted to greet, allowing them to move rapidly away from me, as if cancer were a communicable disease. And others would say something like, “Oh, that must be difficult. How do you handle dealing with cancer patients and such an awful disease?”

  Currently, when new people I meet ask about my job I alert them with, “Are you sure you want to know? Careful what you wish for.” Inevitably they are intrigued; I am pressed for an answer. Despite being forewarned, I still get the same responses.

  It just makes it a little more fun for me.

  After recovering from initially being surprised, many people tell me stories about their personal experiences with cancer. It is rare to meet an individual who has not been affected by cancer in a family member, friend, or colleague. Or the person may be a cancer survivor him- or herself. It is a pervasive disease and a topic that invokes an emotional response.

  I recently spoke to a group of about seventy first-year medical students. Members of the faculty had been asked to talk with students about different career paths in medicine. I described my daily activities and then opened the floor to questions. The first one was another common question I’m asked: “What made you decide to become a cancer surgeon?”

  I often startle people with my ardent response.

  “It’s personal for me. I hate cancer. I hate what it does to people and their families. When I was a junior surgical resident, one of my cousins, then an eighteen-year-old girl beginning her senior year in high school, was diagnosed with stage IV Ewing’s sarcoma. She was treated in the university hospital where I was a resident. Over ten months I watched her endure terrible pain and horrific side effects from treatment. Her death was agonizing. I saw what the experience did to her and to my aunt and uncle, my parents, my cousins, and everyone who loved her. All these years later, I am still pissed off. It’s just not right, and we have to do something to find better ways to understand, prevent, and treat cancer.”

  Somber silence. There�
�s not much people can think to say after a monologue dripping with venom.

  Sometimes people will ask how I deal with the angst and distress of patients who are diagnosed with a cancer I cannot treat surgically, or when their cancer recurs and metastasizes despite all of our multidisciplinary treatments. My response is rooted in a baseball analogy. The greatest hitters in baseball successfully get a hit and find themselves on one of the four bases approximately one-third of the time. This means they fail to get on base the majority of their at bats. They may strike out, fly out, or ground out to an infielder. Less effective hitters may have a success rate of only one in four or one in five times at bat. If your batting average is lower than that, unless you are a pitcher, you will likely find yourself shipped to a minor-league team. I go on to explain that with many cancers our success rate with surgical and other treatments falls in range of the batting average of a middling-to-elite major-league baseball player. For some cancers, our success rate is much worse, and we need to work diligently to find better treatments or ship ourselves back into the basic science laboratories to find something better to help people. Happily, for some cancers we now have treatment-success averages that are unimaginable for even the best major-league hitters. But we are still not anywhere close to batting a thousand.