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Fine-Tuning an ‘Airport Diagnosis’


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HIS HEAD WAS DIFFERENT from those of the other people in line. He bore a matrix of white rows of circular patches on his shaved scalp like a wig. The patches were electrodes, connected by cords to a power supply in a satchel around his shoulder. I was able to make an instant and unfortunate “airport diagnosis,” a term I learned in my first year of medical school. Airport diagnosis is the recognition of a medical condition based on a physical sign such as proptosis or jaundice, and the name indicates that it usually happens in a public place. The irony of our location—the Sea-Tac Airport car rental facility—was not lost upon me.

Maxwell M. Krem, MD, PhD

Maxwell M. Krem, MD, PhD

This particular diagnosis gripped me and would not let go, perhaps because it fell into my specialty. The man standing in line behind me was wearing a tumor-treating fields device, which generates alternating electrical fields and is used to treat glioblastoma multiforme, the most aggressive brain cancer. Casual people-watching had suddenly thrust me into the intimate medical world of a stranger.

I had too much time to contemplate the man’s situation. It was August, the height of cruise season in Seattle and the worst time to rent a car at Sea-Tac. Tourists thronged at the car rental facility, forming a line that snaked out from the rental counter and continued deep into the facility’s lobby.

Breaking the Ice

THE LINE’S glacial progress gave me time to ponder the scenario and the possibilities of how to open a conversation with him. How would I start? Cancer couldn’t be the opening act. You don’t ask, “Do you have a glioblastoma?” It was too intrusive and too presumptive.

I felt sheepish, but I was irresistibly drawn to a conversation that would inevitably be centered around life and death; no one gets out of glioblastoma multiforme alive. We made eye contact.…What would come out of my mouth?

“Is that for seizure monitoring?” is how I weaseled into the conversation, an incorrect but plausible explanation for the electrodes. I might have asked him simply, “What are those electrodes on your head?” but that version of the question rang too dishonestly, since I recognized that those electrodes were pathognomonic for glioblastoma multiforme. My cowardice and indirectness did not remain an issue for long. The man was direct and responded without irritation or indignation, “This is for treating a brain tumor.” Now at ease, and to explain my curiosity, I quickly told him that I was an oncologist. With the ice summarily broken, he gave me the privilege of getting to know him.

“I felt sheepish, but I was irresistibly drawn to a conversation that would inevitably be centered around life and death; no one gets out of glioblastoma multiforme alive.”
— Maxwell M. Krem, MD, PhD

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“John” [not his real name] was married and had two young children. The glioblastoma multiforme had started with headaches. They became progressive and then unbearable, and when the images came back, there was an 11-cm tumor in his left temporal lobe.

He sought treatment at an oncology Mecca, and the surgeons resected as much as they could. Radiation therapy combined with temozolomide followed. He pointed out the stigmata of his illness: scars on the left side of his head and hair loss, not to mention the device that had been our conversation-starter.

The physicians at the Mecca who initially treated him hadn’t listened much, and when he asked if he should incorporate the tumor-treating fields device into his first line of therapy, they had been dismissive. (It is currently included as a category 1 recommendation for glioblastoma multiforme in version 1.2019 of the National Comprehensive Cancer Network® Clinical Practice Guidelines in Oncology for Central Nervous System Cancers.1) Now, though, he had a local oncologist who talked to him, listened to him, and had researched any new treatments that were available for glioblastoma multiforme. He held him in the highest regard and was grateful for his efforts.

Life With Glioblastoma

HIS DISEASE followed the usual, ill-fated pattern of glioblastoma multiforme: tumor progression after initial improvement. He had proceeded to treatment with two other drugs used for relapsed or refractory glioblastoma multiforme, lomustine and bevacizumab. He chatted with me about the dosing, schedules, and side effects he had experienced. He knew his subject well. Finally, at about the same time that he began his most recent line of chemotherapy, he belatedly started alternating electrical field therapy.

He and his wife were visiting Seattle for a vacation together and to spend time with family. As the conversation temporarily flowed away from oncology, he came directly to his personal philosophy and told me the reason for his vacation. He would not allow his medical problems to take over his life any more than they had, and he refused to consider his cancer diagnosis terminal. He planned to stay on treatment and continue his regular activities as much as possible. He was willing to consider any clinical trials that were sufficiently accessible or feasible.

John was motivated primarily by his school-aged children. Of course, he wanted to prolong his time with them, but it was substantially more important to serve as a positive role model for dealing with adversity. “I will not let them see me give up,” are the words that continue to ring in my memory. He was concerned about the lessons his kids would take away if he “surrendered” to his cancer.

“On that day in a car rental line, I did not make an airport diagnosis of an illness, but instead, one of a person who refused to be defined by his disease.”
— Maxwell M. Krem, MD, PhD

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Suppressing Pity

HE WAS A family man in his mid-30s with a terrible cancer diagnosis, and he was doing his best to carve out a life, to minimize the stigmata and impacts of his disease. He did not want anyone’s pity, but wearing the tumor-treating fields device had brought him mine. I struggled not to pity him. I knew what he had endured from his disease and its therapies, and I knew what he did not: what he would yet endure. 

To suppress pity, I had to push my medical knowledge aside, forget that I was an oncologist, and consider this man simply as a person. Beyond that, he was close to my age, and I could imagine myself one position farther back in that line, wearing an electromagnetic field device on my scalp.

In that hour in line with John, I refined my airport diagnosis. The tumor-treating fields device was much more than a visible cue to a glioblastoma diagnosis; it was the mark of a man’s perseverance, a husband’s love, and a dad’s example. On that day in a car rental line, I did not make an airport diagnosis of an illness, but instead, one of a person who refused to be defined by his disease.

Dr. Krem is Assistant Professor of Medicine, Division of Hematology and Blood & Marrow Transplantation, Markey Cancer Center, University of Kentucky College of Medicine, Lexington.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.

DISCLOSURE: Dr. Krem reported no conflicts of interest.

REFERENCE

1. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology. Central Nervous System Cancers. Version 1.2019. March 5, 2019. Available at www.nccn.org/professionals/physician_gls/pdf/cns.pdf. Accessed March 19, 2019.


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