The following essay by Fadlo R. Khuri, MD, FACP, is excerpted from The Big Casino: America’s Best Cancer Doctors Share Their Most Powerful Stories (May 2014), coedited by Stan Winokur, MD, and Vincent Coppola. The book is available on Amazon.com and thebigcasino.org.
Life and hope are why we go into this most challenging and rewarding of professions in the first place.
Recently, as I was opening Christmas and other holiday cards, I spied an envelope with a name and address that I did not recognize. It turned out to be a note from the mother of a former patient of mine with a grand surprise: a picture of her daughter, whom I had cared for almost a decade earlier. The picture showed my former patient, KK, in her wedding dress, crossing Massachusetts Avenue, walking down Commonwealth Avenue in my native Boston, arm in arm with her new groom.
In the note, the mother thanked me for starting her daughter on the right course of therapy and let me know that, thanks to my clinical judgment (her words, not mine), her daughter had been able to obtain her PhD and had just gotten married! She also wanted to remind me that she thought it both ironic and pleasing that her daughter and her husband had in fact moved to Boston, where she knew I had done my training. She was sure I would remember her daughter and thought I would enjoy the picture. Of those two facts, there can be no doubt.
Never Give Up
My clinical judgment: If only that were the complete story! I will never forget the first time I saw this young woman, KK, a 23-year-old student studying for her master’s in public health, who noticed that her voice was getting raspier and that she was becoming increasingly short of breath. I saw her in my clinic shortly after she had a tracheostomy performed, after a major neck dissection and an operation to debulk her disease had proven necessary but largely futile.
She had, in fact, an aggressive form of medullary thyroid cancer and turned out not to have the hereditary component, but she did have a RET gene mutation (in simple terms, a mutation in a particular gene identified as a risk factor for this type of thyroid cancer). She was sent to me by a long-standing colleague, for whom I have nothing but admiration, a head and neck surgeon who has never said “no” to a patient in his 35-plus years practicing in Georgia. Bill Grist, MD [Associate Professor of Otolaryngology–Head and Neck Cancer at Emory Healthcare] called me and said, “Fadlo, I need you to take a look at this young girl. We really have nothing to offer her, but it’s hard for me to give up. I know chemotherapy is not much of a help for these patients, but I think she is willing to try anything, and so am I.”
When I first met our patient, she was as full of life as she would be in that wedding picture almost a decade later but was unquestionably scared.
“What could we try?” she asked.
Surely, with all the science and the clinical trials ongoing in cancer, there must be something we could try, she pleaded. I thought hard and remembered from my limited experience treating thyroid cancers at MD Anderson Cancer Center with Dong Moon Shin, MD, FACP [now Professor and Executive Vice Chair, Department of Hematology and Medical Oncology at Emory University School of Medicine], and Andy Burgess, MD [Deputy Chairman in the Department of Melanoma/Sarcoma Medical Oncology], that we had placed some patients with thyroid cancers on clinical trials of several new compounds, agents targeting the Ras/Raf pathway. At the time, we had a trial of one such agent, sorafenib (Nexavar). Although other agents targeting the Ras/Raf pathway act specifically on just one protein within the network, sorafenib acts on several proteins.
Being intimately aware of the progress seen with patients who had been treated with this class of targeted therapies, I thought it made sense to try to treat her with the “dirtiest” inhibitor that was available to me. I had no honest idea that sorafenib could target the Ret mutation, but I figured it was worth a shot.
Extending Life
We started KK on the drug, and within weeks, her tumor began to shrink. Still, I indicated to her that this was no cure, and we had no idea how long it would benefit her. After a year under my care, she moved to Maryland to be closer to her family, assuming that although the worst would happen, she would remain optimistic, always hoping for the best.
She wanted to spend more quality time with her family. Her disease had shrunk dramatically in the time I had treated her, and she had started to gain a little weight. Her mother, who had some training in science and joined her on several visits, also thought it would be best for her to be close to her family. She finished her master’s degree and moved north to Maryland.
I arranged for her to see Ed Sausville, MD, PhD, FACP, at the University of Maryland Greenebaum Cancer Center, a friend and colleague of many years and a thought leader in drug development throughout his career at the National Cancer Institute. Ed continued sorafenib and would send me occasional e-mails to tell me how well KK was doing. The years passed and I lost touch with her. I always wondered what had happened to her until I received the wedding picture.
The Most Meaningful Award
This past year was a remarkable year, ironic in that our work was recognized with an award from the American Association for Cancer Research named after the late Richard Rosenthal. Mr. Rosenthal was a philanthropist who died of lung cancer, making this a particularly poignant award for me, as I have spent the bulk of my career working on the prevention and treatment of lung and head and neck cancers.
I also received an award from the Arab-American community as the high-achieving individual in Georgia who inspired others by his work, also a deeply meaningful award for me. When I was asked toward the end of this past year what had been the highlight of my year, however, it was no contest. It was the wedding picture of my patient, sent to me by her mother, and a sign that even the longest of shots based on the best extrapolations we can make from science can pay off.
Life and hope are why we go into this most challenging and rewarding of professions in the first place. ■
Fadlo R. Khuri, MD, FACP, is Professor and Roberto C. Goizueta Chair in Cancer Research and Deputy Director of the Winship Cancer Institute of Emory University in Atlanta.
