I’d known her for almost three years. She had advanced
ovarian cancer—clear cell—and was diagnosed with disease already in her chest,
stage IV. She had a terrific response to neoadjuvant chemotherapy, which had
resolved her extra-abdominal disease sites after three cycles. She had an
aggressive interval surgery that achieved complete resection of residual cancer
(an R0 resection). She had completed adjuvant chemotherapy and I declared her
to be in remission at that time—but it was short-lived; within four months, her
disease had returned. Platinum resistance, we call it. We started a new regimen
then—not for cure, I told her and her husband. The goal was control.
“How long can we control this?” she asked at the time.
“One can never be sure, but we can hope for a long period of
stability that will extend for many months. Even if you do not go into
remission, which is very unlikely, you can certainly live with this if we can
get it to stop growing.”
“Months?” she asked, almost incredulous.
“Many months,” I responded. “It might be as short as three,
but could go to 12 and beyond. I just cannot tell you with any degree of
certainty.”
That was 14 months ago. She had responded well to
second-line treatment, and most of her disease had resolved on subsequent
scans. She had returned to work and to the joys of motherhood, aiming to take
control of a life that had been upended due to cancer.
“You’re doing great,” I told her at one of her pre-treatment
visits.
“I actually feel great—better than I did even before I got
sick! Is that weird?” she said with a smile.
“Not at all,” I responded.
Sadly, four months after that conversation, her cancer
progressed and she went from healthy to sick rapidly, requiring hospitalization
for a bowel obstruction and suffered from unremitting ascites. Pain became an
issue as well and within weeks she required narcotics.
At her next outpatient visit she looked despondent. She
still could not believe how quickly things changed in a matter of months.
“I felt like I could live forever, and now, I know I won’t.”
She started to cry then. So did her husband.
We talked about treatment options. She certainly was not out
of options, but each was associated with
side effects and the expectations of benefit were low. She inquired
about hospice and wanted to know what I thought.
“Well, I think walking this road is one I cannot do for you.
I can give you the options, but at the end of the day, it will be you living
with this cancer and its symptoms, and you who has to endure the treatments and
its side effects. If you told me today you did not want more treatment, that
your goals were to be comfortable and with your family for as long as you have,
then I would support that. This is your life—I want you to live all of it on
your terms.”
She looked at me, and then at her husband. At the time I
thought she was searching for our permission without asking for it, but in
retrospect, I think she was looking for the courage to say what she wanted. A
few moments passed, and then she spoke.
“I choose to live, then, but I choose not to suffer through
more treatments. I am ready.”
I thought of her incredible response to treatment, her
prolonged remission which defied even my expectations. I wanted her to realize
how well she had done, that at least
she was able to enjoy so much time despite her quick recurrence. I wanted her
to know that she had beat the odds, if only for a while, and that many other
women would not be sitting in this room with me. Yes, at least she was still alive. But, at the end of the day, I knew
that would not be comforting.
For most people, “at least” is never enough, because when it
comes to life, most of us—cancer or no cancer—always want more.
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