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The ASCO Post is pleased to reproduce installments of the “Art of Oncology” as published previously in the Journal of Clinical Oncology. These articles focus on the experience of suffering from cancer or of caring for people diagnosed with cancer, and they include narratives, topical essays, historical vignettes, poems, and photographic essays. To read more, visit jco.org and search “Art of Oncology.”

She came when the ice was still on the ground, having traveled from a place far removed from the frozen land that she would now call home. After her long trip, she immediately presented to the emergency room, hands and feet raw and peeling from the toxicity of chemotherapy.

Melanie D. Seal, MD, FRCPC

Melanie D. Seal, MD, FRCPC

Upon meeting her, I was struck by her vivacity. She was bright, pleasant, and engaging despite her physical condition. She told me of the tremendous suffering she had endured since her diagnosis of cancer but remained upbeat and hopeful that she would continue to fight against her illness. I reviewed the notes of how she was diagnosed while pregnant with her third child and was advised by her physician to have an abortion, given the locally advanced nature of the disease and the requirement for intensive therapy. Her pregnancy had been terminated, and she had experienced disease relapse shortly after. She had begun palliative chemotherapy but told me she only received a portion of the doses she actually required, because she did not have the money to pay for her full treatment.

As I examined her, she inquired about the nature of the lesions that covered her chest. They were angry and red, an outward presentation of the same malignancy that was growing uncontrollably in her liver and lungs. When she asked me what they were, I explained they were from her cancer. As her tears came, I wondered if anyone had ever broached the topic of prognosis with her in the past. I would come to know with time that this was a discussion we would have frequently during the course of her illness.

She had two young children, who would occasionally come to clinic with her when she attended appointments. They had her eyes; the family resemblance was clear. It was a pleasure to hear their cheerful voices in the waiting room, a place where the quiet anxiety of many is often palpable.

Permeating Presence in the Clinic

As the months rolled on, her disease began to progress, and we explored new treatment options. Chemotherapy took its toll, and, despite her young age, her bone marrow slowly began to lose its reserve. One constant, however, was her spirit. Her presence seemed to permeate throughout the clinic. When she laughed, her happiness filled the room; when she cried, her situation would weigh on us all.

When she laughed, her happiness filled the room; when she cried, her situation would weigh on us all.
— Melanie D. Seal, MD, FRCPC

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One day, during a routine appointment, she told me she would like to have another baby. I was surprised. Didn’t she realize the gravity of her situation? As I re-examined our conversations in my mind, I knew I had been very clear about the trajectory of her malignancy. Perhaps she felt I had not been clear enough. I knew she could understand the words I was saying, but I began to realize she did not believe them.

Ultimately, the cancer progressed during treatment with the latest regimen, and I held little hope we could keep things under control. Her performance status declined, and she was admitted to the hospital. She remained intent on conquering this cancer and would challenge any unsuspecting house staff who dared to suggest time was short.

‘It’s a Girl’

On the last day I saw her, she was quiet, calm, and frail. Weakened from the effects of her medications, she could no longer get out of her bed, and it was obvious to us both she would never see the outside world again. The days had turned colder now, and it would not be long before the ice returned. I struggled to maintain composure as we chatted, though I knew we were saying goodbye. I was pregnant with my third child and due to have a baby soon. As I went to leave, she softly said, “It’s a girl, you know.” I smiled and explained that my husband and I both thought we were having a boy. We had two little boys at home and felt destined to have another. She brightened, and I saw that flicker of determination I had come to know so well from our many visits. “No,” she replied, “it will be a girl.”

A week later, as I prepared for another sleepless night and waited for my baby to arrive, a message came. My patient had died earlier that day. Despite my knowledge of her prognosis, the news still felt shocking. I could not help but think of her children and how they had just lost their mother. Only a few hours later, I was in the case room. As my baby took its first breath, I heard my husband say the unexpected words, “It’s a girl.”

Resiliency of the Human Spirit

Time passed, and, with a promise of spring in the air, I went for a jog around the lake near my home. It felt glorious to be alive on that cool, bright day. As I lifted my face to the sun, something caught the corner of my eye. There they were, laughing and running; her two children, those unmistakable eyes shining. They danced around their father as he watched with adoration. They were without her, yet they could share this happy moment as a family.

It is the honor of being present during some of the most intense moments in the lives of patients and their families that drives our work....
— Melanie D. Seal, MD, FRCPC

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As I headed home, I thought of the darkness of cancer, what it takes from us, the coldness it can bring to the world. Oncologists bear witness to the many winters experienced by patients and their loved ones, the profound grief that sets in as a patient dies, and the struggle the family must face to cope in the aftermath. It is the honor of being present during some of the most intense moments in the lives of patients and their families that drives our work, which inspires us to search for answers to a disease that continually questions our knowledge and beliefs. On that day by the lake, I saw something that the cancer my patient endured could not destroy: strength and resiliency of the human spirit. I was reminded that, with the arrival of spring, comes a new hope. ■

At the time this article was published in the Journal of Clinical Oncology, Dr. Seal was Assistant Professor of Oncology (Medical Oncology) at Dr. H. Bliss Murphy Cancer Centre and Memorial University, St. John’s, Newfoundland, Canada.


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