Holidays in Cancer Land

December is a tough time for me. I find myself wishing the inpatient wards would be emptying and we would have successive nights without a patient needing to be urgently admitted. I fantasize that my patients, and those being treated for cancer by my colleagues, will have a respite, to go home, be with family, open presents, and a good holiday meal. Sadly, this is never the case. Patients will be diagnosed during the holiday season, some will require surgery, others will continue on chemotherapy. Some will receive good news that their cancer has responded, or that they are in remission. Others will be told that their cancer has progressed or that treatment has not worked or that they are dying. The wheels of medicine will continue to turn and we, as oncologists, will continue to care for our patients.

That is the reality of medicine, but in the era of precision therapies, we can look forward to miracles. Such was the case of Judy. She had seen me a few years ago—referred by a former colleague who had encouraged her to seek out a clinical trial. Judy was living with metastatic uterine cancer. She had undergone surgery and chemotherapy and had hoped to be cured, but a year later she developed a cough that would not go away, leading to the diagnosis of metastatic cancer involving her lungs. Since then she had been through three separate chemotherapy regimens, none of which had worked.

Despite these circumstances, Judy looked well. She engaged with me easily and we talked about her—her work, her husband and children, her hobbies. She smiled as she showed my pictures of her grandchildren. After just 30 minutes I felt I knew her.

“Well, doc,” she said. “Is there anything you can think of? I mean, I know I’ll die of this cancer eventually, but I have a lot of living left to do.”

We discussed options on and off of a clinical trial and we settled on one trial of immunotherapy.

“It’s a phase I trial, but this drug is promising, particularly in your tumor because it is associated with something called microsatellite instability. These drugs have shown activity in other hard-to-treat cancers, including melanoma and renal cell carcinoma.” I gave her the informed consent and suggested she take it home, but she insisted on reviewing it right there.

“I want to leave here with a plan—trial or no trial.”

After some time, and many questions, she agreed to participate in the trial, and a few weeks after this visit, she started treatment. Although she experienced toxicities when we first started treatment, it seemed to be easier to tolerate with time. Indeed, at our first response evaluation, she had achieved disease stability. “It stopped growing,” I told her. She was so relieved that she started to cry.

“After everything I’ve been through, I’ve learned to assume the worst news. I mean, nothing seemed to stop this cancer from growing. Until now.”

“Well, let’s see what we can do—who knows, it might shrink yet,” I said at the time.

Further treatment followed, but during this time, I had decided to leave my institution. Informing my patients I would be leaving proved to be a difficult task in general, but with Judy, I felt particularly heartsick. I had gotten to know her and her husband well, learning about her as a person, and how they had met. Over time, our conversations would often veer towards the social rather than strictly medical.  She would ask about me and my family and I would do the same. Knowing this was coming to an end left me particularly sad.

“Whatever happens, Judy, thank you for letting me in to your life, for letting me be your oncologist. It’s been such a huge honor, and you’ve made me a better oncologist. I know I will leave you in very good hands, so do not worry about that. But please also know, you will not be forgotten.”

“Thank you, Dr. Dizon. I can’t believe you are leaving, but do what you must. Life is too short. I will miss you very much.”

My first Christmas at my new institution was quiet—I had not yet built a busy practice so had time to work on academic pursuits. One day, I got a letter in the mail. I read the return address—it was from Judy. In it, she wished me Happy Holidays and hoped that I was happy. She told me of her family and I was happy to read everyone was well.

“I wanted to share the news of my cancer,” Judy continued. “It has now shrunk over 60%, and for the first time, I know what it feels like to hear that your tumor is responding. I owe it all to you, Dr. Dizon. You found this trial for me, and you didn’t give up on me. Thank you for giving me more time.”

As I read the letter, I smiled as I read how much she had benefited as part of a phase I trial. It made me realize that miracles do indeed come true, and as the New Year comes upon us, my wish: That more miracles are on the horizon, and that more patients benefit from the era of Precision Medicine.