The human drama within the oncology world is a never-ending story of triumph, tragedy, and all of the valiant efforts and human emotions in between. The doctor-patient relationship in oncology is deeper and longer than in most medical specialties due to the life-and-death stakes at play after a cancer diagnosis is delivered. This relationship is deftly captured in When Blood Breaks Down: Life Lessons From Leukemia by Mikkael A. Sekeres, MD, who is also a frequent contributor to the Well column in The New York Times. Dr. Sekeres is Director of the Leukemia Program at the Cleveland Clinic, where he is also Professor of Medicine and Vice Chair for Clinical Research at the Taussig Cancer Institute.

BOOKMARK

Title: When Blood Breaks Down: Life Lessons From Leukemia

Authors: Mikkael A. Sekeres, MD

Publisher: The MIT Press

Publication Date: March 2020

Price: $26.95, hardcover, 328 pages

Patient Profiles and More

When Blood Breaks Down is a concise book, with an epilogue and notes. It is organized into seven chapters, telling the stories of three composites of patients Dr. Sekeres has cared for during his career as a leukemia physician-scientist: Joan (acute promyelocytic leukemia), David (acute myeloid leukemia with myelodysplasia-related changes), and Sarah (chronic myeloid leukemia in the setting of pregnancy).

Along with the patients’ stories, Dr. Sekeres adds historical references to the development of leukemia drugs, such as imatinib, and a fine description of stem cell transplantation. These scientific digressions are richly told and never interrupt the narratives of Joan, David, and Sarah.

Moreover, Dr. Sekeres accomplishes something that most authors in this genre fail to do: He wrote a book that will capture the imagination of the scientific and medical audiences, along with the lay public. “Leukemia cells proliferate in an unfettered fashion, making too many primitive, nonfunctional cells that make red blood cells and platelets die out completely…eventually filling almost 100% of the bone marrow space, that sometimes they can’t even be aspirated by one of our 4-inch–long, wide-bored bone marrow needles,” Dr. Sekeres stated.

Doctor-Patient Relationship

As the author focuses on the personal lives of his patients and their family dynamics, made more complicated by their hematologic diseases, he also demonstrates how developing a trusting doctor-patient relationship helps in better decision-making by patients and families, especially about end-of-life care. In the opening chapter, “Leukemia Arrives by Dark of Night,” Dr. Sekeres poignantly describes the murky road to a leukemia diagnosis. Joan was a surgical nurse in Wooster, Ohio, who had gradually become so fatigued every day that she was almost falling asleep while assisting doctors in the operating room. “It felt like someone stuck a huge syringe into me and sucked out the energy. I was a shell going through the motions of the day,” Joan related.

One of her colleagues, a doctor she’d worked with for years, insisted she have a blood test. She had a blood draw at the hospital, and, after her second OR case of the day, a surgeon asked her to come into his office. He’d just received the lab results.

“Joan noticed his hair was mussed from the surgical caps he’d been wearing all morning, and he made no effort to fix it,” writes Dr. Sekeres, so delicately phrased, yet catching the concern of the surgeon as he tells Joan, “I’ve never seen a white blood cell count as high as yours.” Joan’s clinical story elucidates the incredible teamwork involved in multidisciplinary care. Because her leukemia relapsed after initial treatment, she needed an allogeneic transplantation, and a donor was found.

The interplay between a very sick and vulnerable patient with leukemia, her stranger donor, as well as Dr. Sekeres and his team is one of the book’s highlights. Joan was discharged from the hospital after 24 days, when her blood cell count began to recover. She returned to work as a surgical nurse about a year after her diagnosis—a triumph of science and spirit.

The Cost of Cancer Care

The subject of financial toxicity is seamlessly woven into the narratives. By putting real faces on it, the author sheds much-needed light on the dilemma and also delves into the rising costs of cancer drugs that are vital to his patients. One of his patients, named Joe, marveled at the cost of imatinib at $12,000 a month: “Thank God for insurance! We only had to pay the copay of $50. What do people do if they don’t have coverage?”

The author pointed out that the cost of imatinib has risen at an approximate rate of 15% per year and then skyrocketed to its current levels for the 2 years prior to the drug coming off its patent, which occurred in 2015. To his credit, Dr. Sekeres does not fall into a polemic; he gives a well-rounded critique of a problem that oncologists and their patients face every day.

At times, the author runs a bit long is his sidebar discourses on history, clinical discovery, and methodology for the lay audience. However, that is a small gripe for a book that succeeds on many levels. Readers will be elevated by the grace and humanity on page after page. This book is highly recommended for readers of The ASCO Post.