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.”
I was asked to see a 64-year-old man in the coronary care unit (CCU) 4 days after he collapsed in his driveway after a seemingly normal day at work. His wife told the paramedics that he had been having episodes of chest pain in the past 2 weeks leading up to his dramatic homecoming, and he was diagnosed with a myocardial infarction in the emergency room. An urgent cardiac catheterization revealed critical three-vessel coronary artery disease; and based on an otherwise pristine medical history, he was recommended to undergo coronary artery bypass surgery.
Daniel Rayson, MD
His admission blood work, however, revealed a hemoglobin level of 91 g/L, much lower than the last available value of 137 g/L roughly 1 year before. When questioned, he described having difficult bowel movements over a 3- to 4-month period with occasional blood-streaked stool. A computed tomography scan quickly diagnosed his second critical problem: locally advanced sigmoid colon cancer with multifocal hepatic metastases.
Inside the CCU
I was asked to see him urgently to help adjudicate the appropriateness of proceeding with the cardiac surgery in the face of a second competing life-threatening condition and to help the cardiology team elucidate the goals of care in the context of his oncologic prognosis.
I had not been inside a CCU since the depths of my residency days and walked in awkwardly while trying to convince everyone that I belonged amid the ventilators, central lines, and constantly pinging monitors. Shuffling through the nursing station, I passed a bank of video surveillance screens that would not have looked out of place in a high-security prison; despite being completely disoriented, I managed to find my patient.
As I squeezed into a chair between the intravenous pole and the movable side table upon which lie the prized possessions of the hospitalized, I took mental note of the photo of his beaming family gazing up at him. I introduced myself and tried not to let the pinging cardiac monitor distract me from the discussion or add to the headache that was already beginning to pound. He seemed to become paler before my eyes, as I slowly explained the scan findings to him. His liver was peppered with variably sized metastases, too many to reliably count, I explained in answer to his question. Although there was no biopsy confirmation of his disease, the constellation of clinical symptoms, blood work, and imaging left no room for doubt.
Competing Timelines of Two Life-Threatening Illnesses
“So, what am I in for,” he asked.
I carefully explained why all therapies for his cancer would be noncurative in intent and why surgery would be limited to an urgent need to remedy bowel obstruction but would not change his overall prognosis.
“Can’t they just fix this at the same time they’ll be fixing my heart?” he then asked.
I circled back to why surgery could not deal with all of his diseases and then spent the rest of the discussion talking about chemotherapy and the goals of treatment, which were to help him live as long and as well as he could with his cancer.
“Until…?”
“Until you die of the cancer,” I responded bluntly.
“So, let me get this straight…. They want me to have surgery on my heart so I can end up dying of my cancer? Do I have that right, doc?”
Oncologists are experts in reframing prognosis and expectations in the face of metastatic, incurable disease. It is an important part of our jobs to be able to convince people that the median survival time of 2 to 3 years for metastatic colon cancer is something to cheer about. It is equally important that we can clearly explain that a median is just a point estimate, without direct relevance to those in front of us, and that we are often unable to predict how close to and on what side of that median the future holds for them.
“I guess that’s right,” I replied, my eyes not leaving his.
“It’s a question of what would get me first,” he stated.
I nodded, “In a sense, you know the answer already.”
“Yes, I could have died in my driveway, that’s true. I guess I just about did.”
“As close as anyone can come to just about dying in their driveway, yes, you just about did.”
“But, if my heart does it, it will be quick, right? No pain. No drama. Just an ending, like almost happened?”
I nodded.
“But cancer—that’s a whole other thing. Pain, vomiting, chemotherapy, weakness. Suffering. For me and my family.”
I explained the lengths to which we try to control pain and other symptoms, from both disease and treatment, and reviewed the medical and supportive care that is designed to minimize suffering.
“But, doc, how often does that happen? How many times can you truly say you were able to minimize suffering? And not just for your patients. What about the suffering you don’t see? For my wife, my kids. How do you take care of their suffering, as they spend the next 2 to 3 years, if I have that long, slowly watching me die of cancer?”
By then, my headache was screaming at me. A hammer behind each eye was slamming down on chisels angled to the center of my brain. The incessant pings, beeps, and buzzes of the monitors and machines were laughing at my discomfort. We kept circling back to the competing timelines of two life-threatening illnesses, the dramatically different trajectories they take to death, and the different types of fallout and collateral damage to be expected.
Death Later Better Than Death Now
After an hour together, he had decided that death later would always be better than death now. As we warmly shook hands, he turned the family photo toward me as final confirmation of the motivation behind his decision.
I spent a few minutes collecting my thoughts and trying to soften the hammer blows to my head with some deep breathing and ibuprofen before venturing to the work room to dictate my consultation note and find the attending cardiologist.
“Thanks for seeing Mr. L. What do you think?”
The chief cardiac surgery resident had found me first. It was not every day that an oncologist is needed in the CCU. I was not as incognito as I thought.
I explained the onco-scenario in detail and could sense the disappointment when I came to estimates of life expectancy. A median survival of 2 to 3 years after a bypass would be woefully inadequate from the perspective of a cardiac surgeon, whereas, for an oncologist, it represents a realistically optimal outcome with current therapeutic options. If otherwise healthy patients survived cardiac surgery—an increasingly expected outcome given current technology—they are fixed and unlikely ever to suffer a cardiac death. However, otherwise healthy patients with metastatic cancer are never healthy again. I could never fix Mr. L.
I spent some time trying to convince the resident that the value of whatever time is left for given patients is known only to them. And the risk-benefit equation that underlies any medical or surgical decision is always assessed from the vulnerable position of the unwell, with the ultimate decision usually made on the basis of parameters beyond medical or surgical outcome expectations. I noticed his eyes looking beyond me and knew that he was barely listening to my philosophical explanation as to why I recommended proceeding with the surgery.
The risk-benefit equation that underlies any medical or surgical decision is always assessed from the vulnerable position of the unwell…— Daniel Rayson, MD
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Family Milestones Along the Cancer Journey
In the end, Mr. L underwent a three-vessel coronary artery bypass graft, which he sailed through without complication.
I took care of him for the next 4 years, sequencing both chemotherapy and targeted therapy, as his disease waxed and waned in threat until finally there was no stopping it. I got to know his wife of 31 years who along with their three grown children celebrated the arrival of their first grandchild during one of his visits to the chemotherapy unit. I saw photos of family milestones along the path of his cancer journey and laughed with him when he was teased about his chemo good looks. I wrote letters that he took with him on family trips to give to border control if he was asked about his narcotic medications or to medical personnel if they needed background and guidance if he got sick. He always told me that the letter was more important than his passport, knowing that there would be someone at the end of the line to help him and his family if he got into trouble.
Epilogue
A few weeks after he died, I ran into one of my palliative care colleagues who I knew was involved in Mr. L’s last weeks. He confirmed that he passed away peacefully and in comfort. His wife and three children were with him, and his favorite music was playing as he became unresponsive. I gave him my thanks for helping with his care and for allowing him to die in peace and turned away to walk back to the clinic.
“Oh, one more thing,” he called out.
I turned back in mid-stride.
He told me to tell you that he was glad he did not die of a broken heart.
DISCLOSURE: Dr. Rayson has served as a consultant or advisor to Ipsen, Novartis Canada Pharmaceuticals, Roche Canada, Pfizer, AstraZeneca Canada, and Advanced Accelerator Applications; has received honoraria from Ipsen, Pfizer, and Advanced Accelerator Applications; and has received research funding from Pfizer, Novartis, Odonate Therapeutics, Immunomedics, Cascadian Therapeutics, Sermonix Pharmaceuticals, and Seattle Genetics.
At the time this article was published in the Journal of Clinical Oncology, Dr. Rayson was affiliated with Queen Elizabeth II Health Science Centre, Halifax, Nova Scotia, Canada.
