On July 16, 1975, at 26 years of age, after almost 6 months of observing a left epididymal mass slowly enlarge, with workup for epididymal tuberculosis, I finally underwent a left inguinal orchiectomy and resection of what proved to be a pure seminoma. A subsequent lymphangiogram was reported to be normal, and I proceeded to prophylactic abdominal irradiation.
All would be fine, I was reassured by my surgeon and radiation oncologist; no, there was no need to undergo sperm banking, and the radiation therapy would surely cure this most irradiation-sensitive of cancers. As a young pediatric resident, who was I to question my consultants? I rapidly learned the consequences of poor communication between physicians and their patients.
There I was, hospitalized on the open male cancer ward of a large university teaching hospital, about 12 beds lined up on either side of a very long central corridor and a great television room with armchairs at the end. It was there that those of us allowed out of bed would convene in the evenings, and when my roommates learned I was a doctor, out poured all the questions they had not dared ask their physicians and their physicians had not addressed with them in anticipation of their concerns. One assumed he would die of a completely resected indolent thyroid cancer, because no one had told him otherwise. Others had no idea they even had cancer.
So many colleagues and friends were supportive, from my fiancée and a few of my closest friends to the professor of surgery, who stopped by my bed and joked that because they had spent so much money training me, I needed to get better fast and “earn my keep.” Other colleagues and friends found it hard to visit or even speak about my cancer. I understood their discomfort, which I, too, would most likely have shared previously; it was my cancer, and I had to deal with it, not them. I took 4 weeks off residency for my radiotherapy, helped my dearest friends with their home reconstruction, and cooked meals for us all in the evenings (they somehow knew that distracting me with mundane tasks was good medicine), and I managed to maintain my weight with a little support from metoclopramide. And then I got on with my pediatric residency training.
Alas, my cancer had not read the textbooks. By March 1976, while undertaking a senior residency in pediatric oncology, I was experiencing significant reflux esophagitis, inordinate belching, and, after a negative workup for gallbladder disease, underwent a barium swallow. My radiology colleague supervising the study looked pale as he informed me there were mediastinal masses squashing my esophagus, and, oh yes, there appeared to be a solitary, left-lung parenchymal metastasis.
Now the conversation took on a different tone. I met with a senior radiation oncologist who tried to reassure me that he did, indeed, have one long-term survivor of recurrent metastatic seminoma over the course of his long career, a bassoonist from a prominent professional orchestra, who, alas, was unable to play the bassoon any longer after they finished irradiating his lungs. With this level of reassurance, I embarked upon mediastinal irradiation and focal left-lung boost to around 30 Gy, planned my bachelor party with a circle of friends in Paris before my departure for my marriage in the United States in June, and continued to work daily as a senior resident on the pediatric oncology ward.
I continue to embrace my fortunate life—fortunate not only to have survived recurrent metastatic cancer but to have learned so much from the experience. I honestly do not believe I would ever have aspired to or would have become the physician I am today without this experience.— Jonathan L. Finlay, MB, ChB, FRCP
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I remember distinctly, one day during irradiation, meeting with a senior radiation oncologist who sat me down and stunned me with crucial and unexpected questions: Did I realize I might die of this? (Of course, I had not!) Who were the sources of my emotional support? (I had not even informed my elderly parents of any of this, relying on my wonderful older sister to help me through). I realized these were the kinds of questions I should be asking the parents of the little children for whom I was currently caring on the pediatric cancer ward, especially the 9-year-old boy with pulmonary metastatic Wilms tumor, who thought it so cool that he was receiving radiation therapy at the same time as his doc. He did not survive the experience.
I made it to my bachelor party in Paris, despite an unmeasurably low platelet count and exhaustion for much of the 3 days; made it to my wedding; and returned to England on my honeymoon, where I felt a lump in my right testis. Sure enough, contrary to everyone’s expectations that this was some form of psychologic posttraumatic re-enactment, the lump was real, and, 1 year to the day after my initial surgery, July 16, 1976, I underwent resection of a second primary seminoma.
Now the conversation yet again took on a different tone: this time influenced by a young radiation oncologist who told me, no, I could not receive any more radiotherapy, but there were these two new drugs that should do the trick. Thereafter, I commenced a year-long regimen of chlorambucil, 5 days per week each month, along with 2 full years of levamisole, 3 days per week on the second and third weeks of each month. Although I have forgotten his name, I owe that young radiation oncologist a debt of deep gratitude.
I returned to the United States and got on with my pediatric immunology fellowship and with life in general, despite an Easter 1977 hiccup, when right upper extremity pain and transaminitis turned out to be likely transient radiation hepatitis rather than liver metastases. The fear of the other shoe dropping gradually receded, and my experience with metastatic cancer took on a far more constructive role in shaping my life, my innate sense of “cock-eyed” optimism, and my continuing and, indeed, growing enthusiasm to make every day count.
All the Things That Did Not Happen
Now 40 years since my last encounter with seminoma, my personal health-care focus is upon all the things that have not happened rather than those that have. I endeavor to minimize the risks of additional and cumulative late effects through careful surveillance and activity. I have no significant radiation-induced pulmonary fibrosis and can at least stumble through half-marathons in 3.5 hours, row competitively with a local crew when the Ohio weather permits, and recently trekked for 5 days in the Himalayas up to 14,000 feet. I have developed occult but not clinically relevant coronary artery disease, irradiation-induced primary hypothyroidism, a couple of likely irradiation-associated neoplasia (a parathyroid adenoma and a low-grade bladder carcinoma), and a pre-preneoplastic Barrett’s esophagitis but have avoided myelodysplasia or leukemia to date.
At 67 years of age, I continue to embrace my fortunate life—fortunate not only to have survived recurrent metastatic cancer but to have learned so much from the experience. I honestly do not believe I would ever have aspired to or would have become the physician I am today without this experience. I continue to be fully committed to my career and vocation as an academic pediatric oncologist, have a wonderfully supportive wife, and a 29-year-old adopted daughter with whom we share an ever-closer relationship.
I do not believe I ever truly experienced posttraumatic stress disorder, survivor’s guilt, or a Lazarus-like syndrome, nor even significant anger or disappointment at my infertility—only gratitude for having survived the experience from which my life has benefited so much. And herein, I believe, quite simply, and however seemingly corny, lies the message for all of us: “When life gives you lemons, make lemonade” (Elbert Hubbard, 1915)—loads and loads of the stuff!
Happy Ruby Anniversary, Jonathan. ■
Dr. Finlay is Director of Neuro-Oncology at Nationwide Children’s Hospital and Professor of Pediatrics at The Ohio State University College of Medicine in Columbus, Ohio.