Archives of The Cheerful Oncologist, Volume 2

I recently had the opportunity to attend a weekend meeting in Las Vegas and because it had been years since I had seen the place I decided to go. After a sunny flight I soon found myself careening through the streets in a taxi, listening to a rather heated cell phone conversation in Polish between my driver and some mysterious voice from the ether. I say Polish but actually it could have been English, or even Klingon, I was so distracted by the large number of fellow motorists we tried to take out, not to mention several unfortunate pedestrians lost in daydreams. As we sped past the glistening hotels arrayed like jewels in Cleopatra’s walk-in closet, I relished the chance to learn a helpful fact or two about my chosen profession, but my goals for the trip were more frivolous than that. I wanted to immerse myself for a couple of days in Las Vegas in an attempt to try to understand what is it about this city that attracts visitors like an overturned garbage can to a passing family of raccoons.

48 hours later, in desperate need of a shave, I limped past the final row of slot machines warbling happily in the airport terminal and boarded my flight back to reality, waving off offers of coffee and oxygen from the attendants. It wasn’t until today that I was able to put any coherent thoughts together about the neon sandstorm, the screaming trampoline, the groaning mass of marching idiocy - the utter preposterousness that is Las Vegas. The conclusion I have reached is painful but must be reported in the interest of social science as one small step in our attempt to explain the zeitgeist of this country. In a nutshell it is this:

Las Vegas has become the paradigm for our popular culture.

It represents the America that fluffy media stars, advertising executives and retailers dream of. As proof of this theorem allow me to adduce the following evidence (of course all of these observations were recorded from a safe distance):

America is The Garden of Earthly Delights! What’s that you say? You want pirate ships, loud music, dancing girls, dancing bears, Hermes ties, karaoke or twelve dollar martinis? Want to forget about your job, or your kids, or your car payments? Come to the Garden that is Las Vegas! See the women come and go, talking of Barry Manilow. Whatever your silliest fraternity-party-gone-wild fantasy is, here you can run around dressed up like a Hell’s Angel, or Ricky Ricardo, or Julius Caesar for all we care. Feel free to scream at your friends loitering inside the Ermenigildo Zegna shop to come and look at the water fountains dance to tunes from Phantom of the Opera. Go on and enjoy yourself - you deserve it! How many times did you watch Casablanca and feel a pang of jealousy anyway?

America Has Attitude! Just watch it buster! I’m on my way to the best time of my life and if you aren’t happy for me, well sit thee on a spit thou impertinent foul-practicing maggot-pie! I’ve got a flagon of grog hanging from my neck, a pocket full of fascinating promotional cards with ladies’ telephone numbers on them and the bold, brave spring of the tiger that quickens my walk. Fun is my goddess tonight - in fact I might just get this tattooed on that inviting expanse of skin just north of my keister where billboards for attitude are displayed with pride. Deal me in!

America Reeks with Temptation! “Well, Mother, what do you want to do tonight? Should we go play “The Beverly Hillbillies” slots and try to win that silver Harley, or try to run up a migraine-sized bar tab, or take in one of the “adults only” floor shows, or hit the midnight buffet for all its worth, or just open a new carton of Marlboro Lights and order a movie from Spectravision?”

America is the Great Equalizer! Gee, how wonderful it is to see you, Mr. or Ms. Billionaire/Movie Star/Celebrity-For-Some-Unknown-Reason! What’s that you say? Your limo is hopelessly stuck in traffic on Las Vegas Boulevard? Sorry we can’t clear out a lane of traffic for you. And the band is playing too loud? Your pillow isn’t as wonderful as you thought it would be? You don’t want to walk through the casino to get to your private high-roller room? And a person of your stature shouldn’t have to pay any gambling debts anyway? Sorry, but out here everyone looks the same to us - like a wad of greenbacks just waiting to be stuffed into the drop box.

What - did someone mention money? Now what could filthy lucre, Las Vegas and American popular culture have in common? If I may be so bold as to supply an answer, offered not just as an arrogant riposte but as the proof of the matter - Revelare Pecunia!. If there is one thing that fuels the engine of rampant consumerism, of happy days and good times, of being cool and trying valiantly to get something for nothing - it’s money. Money is what Las Vegas is all about, and just like the myriad delights offered for sale in this country, unless we are wise enough to know the real reason why we are tossing our hard-earned scratch into the pit we will find ourselves wandering the crowded alleys late at night, holding a fistful of the stuff high into the air as a beacon for all the carnival barkers searching for their next sucker.

[Editor’s note: the author apparently was too embarrassed to admit that while he lost only ten bucks playing “The Wheel of Fortune”, he blew the rest of his budget on a ticket to see Carrot Top.]

The consensus recommendations for treating breast cancer, known affectionately as the “standard of care” or “current guidelines”, are rapidly changing due to advances in the efficacy of chemotherapy and targeted therapy. The way it works is like this: patients who enroll in a randomized clinical trial are given either one treatment or another, then followed for years to determine which group had the better outcome. What outcomes are measured, you ask? Here are the biggies:

1. Whether or not the tumor decreased in size substantially with treatment, called the response rate.

2. The percentage of patients who are still alive as time goes by, called the overall survival rate.

3. The length of time it took for the cancer to reappear in the body, called the time to progression.

4. The percentage of patients who are not just alive but also still free from any signs of their cancer, called the relapse-free survival rate.

These are the main outcomes that breast cancer researchers study when trying to determine if a new treatment is superior to the current “standard of care.” If the new treatment is proved to produce better outcomes, and not just due to dumb luck (example: flipping a quarter five times, observing the results and then selling it on eBay as a coin that always lands on heads), or finagling good results by sneaking bias into the study (example: “Gee, do you think it’s possible that the reason your patients treated with apricot pits lived so long is because most of them didn’t have metastatic cancer to begin with?”), this treatment will be adopted as a new guideline.

With that introduction, here are five bits of information to remember the next time you run into a relative or friend who has just been diagnosed with breast cancer. The treatments mentioned have been proven in randomized clinical trials to be effective enough for consideration as a new standard of care in the treatment of breast cancer. Of course, as with all medical advances the results will be under continued scrutiny to see if their advantage holds up over the years. The five things are:

1. Breast tumors can be diagnosed with a simple core needle biopsy (rather than an excisional biopsy), leaving the tumor in place. Then gives the patient the option of shrinking the tumor first - called primary systemic therapy or induction therapy, and a smaller tumor increases the chance that a mastectomy will not be necessary at the time of definitive surgery.

2. Large primary tumors can be transformed into small ones, or even be made to disappear, by giving chemotherapy before surgery. Not every patient is a good candidate for aggressive chemotherapy though, especially the elderly. Fortunately there are several oral medications called aromatase inhibitors that are highly effective in reducing tumors - with minimal side effects. These medications are part of primary systemic hormone therapy of breast cancer.

3. Patients with negative axillary lymph nodes who are also estrogen-receptor, progesterone-receptor and HER-2 negative (called “triple negative”) have such an elevated risk of relapse that they should be considered for the more aggressive chemotherapy regimens typically given only to lymph node-positive patients. And with that in mind:

4. Patients with positive axillary lymph nodes should be offered a chemotherapy regimen that includes the class of drug known as a taxane (either paclitaxel or docetaxel), as the addition of this agent has produced superior outcomes compared with regimens that do not contain it.

5. Finally, all patients whose tumors overexpress the HER-2 receptor should be considered for adjuvant treatment with the monoclonal antibody trastuzumab (brand-name Herceptin), as the addition of this targeted therapy to chemotherapy improves both overall and relapse-free survival.

For more information (albeit somewhat technical) try this site from the NCI, and thank you for your time.

After a long career an aged doctor decided that among other things the Chicago Cubs were never going to make it back to the World Series, so he gave up the ghost. He soon found himself in a long line winding its way toward the magnificent gates of heaven. When he got to the front he announced himself to St. Peter, who upon hearing his name made a sound like a dachshund jumping out of a hayloft, startling several roly-poly putti who were floating half-asleep above the saint. The following is an unexpurgated transcript of their conversation:

Saint Peter: You! Well it’s about time! We’ve been waiting for you!

Doctor: Oh? Why is that?

S.P.: ‘Oh? Oh?’ Don’t be coy with me, buddy. Aren’t you the doctor who kept constantly asking for miraculous healing for your patients? How many requests for divine intervention do you think we get up here? Do you know how much you distracted the Lord with your almost daily pleadings for mercy? What, do you think all we do around here is send the Holy Spirit by Fed Ex to your office every day?

Doctor: But Your Honor, I was a medical oncologist. Our treatments improved over time but never really cured even a majority of people with metastatic cancer. Was it wrong to ask for a little help from the Man upstairs?

S.P.: Don’t call me ‘Your Honor’! Who do you think I am, Judge Wapner? I’m the holder of the keys to get in this place - Your Holiness, to you, bub! Where in heaven’s name did you come up with the audacity to bombard us with all those incessant prayers? You not only monopolized the Lord’s time, you forced us to bring in so many temps Meyer Lansky and Bugsy Siegel ended up taking bets on how many could dance on the head of a pin.

Doctor: I know I was somewhat exuberant, but I don’t think I truly abused the privilege that much. It all started when I put in a quick request for some celestial intervention for one of my patients who was newly married. After all, could you just stand by and watch a healthy young man waste away, not to mention the Boss? Think about all the times He acted with mercy but from the touch of His robe or the sound of a nearby voice crying.

S.P.: Ahem! For your information, sir, we do not call the Messiah “The Boss.” Really! Now, as to the particulars of your entry…according to my records you successfully received so many instances of grace (yes, I know you weren’t actually praying for your own personal salvation) that your account is overdrawn. For your penance you’ll have to wait out here for say, two or three millennia.

Doctor: Oh, for Christ’s - nevermind. Look - I liked to know that everything was being done to help my patients - that was part of the reason why I asked the Heavenly Father to intercede. It wasn’t like I was asking for eternal life; even those who are cured of cancer will eventually find themselves cooling their heels in front of this desk - and what a beautiful piece of furniture is it, I might say - adds loads to your regalness, Your Worship.

S.P.: Don’t try to butter me up - you are officially bankrupt and will have to either earn your way in here or enjoy playing a few billion games of solitaire.

Doctor: Did you say earn your way in here?

S.P.: Yes, there is a little know codicil in the Bible that allows goody-two-shoes like yourself to obtain a speed pass to the Elysian Fields if you agree to continue your good works out here in the holding area.

Doctor: Say no more, O bearded wonder! Just give me a stethoscope and show me the way to the nearest ward!

Thus did the old sawbones hobble on down the road where, except for one or two cases of terminal egomania, he thoroughly enjoyed his second chance at caring for those who suffer. In fact, he loved his work so much that when his name was finally called it took four members of the 1932 Chicago Bears to drag him away from the sick bay and through the golden archway to Paradise.

[Editor’s note: the following observations, while hopefully germane to his readers, are not meant by The C.O. to represent nor replace an erudite theological analysis of the topic. So there.]

“Heaven wheels above you, displaying to you her eternal glories, and still your eyes are on the ground.” -Dante Alighieri

Is it conceivable that during our lifetime we are given an occasional glimpse of what awaits us after death? Rephrasing the question, does God ever reveal what heaven is like to us before we die, perhaps as a way to inspire and prepare us for eternal life?

If not then (or if let’s say there is no heaven), why do some people experience moments of bliss more wonderful than anything ever felt - more than falling in love, more than holding one’s baby for the first time, more than the greatest day of one’s life? What is this feeling that sweeps over us as if we are leaning over the edge of a canyon, held aloft by a breeze made from the singing of a thousand children? Is it just the brain playing tricks on us, or an incidence of jamais vu?

Or is it possible to feel heaven on earth?

I remember hearing the story of a pastor who while conducting the funeral of a young girl who had died from cancer said that even if God gave her the chance to return to her mother and father she would never leave, so powerful is the joy of heaven. That comment was not only comforting - it stunned me. If these words are the truth, why would anyone feel sadness for such a perfect resolution to the agony of suffering or growing old?

I suppose it can be argued that in order to prevent us from wasting our lives away pining for heaven or even ending our lives in order to speed up the transfer, God does not reveal the afterlife to those who still hold breath. This seems like a logical way to keep us focused on our mission here.

Nevertheless I believe that the aura of heaven can be sensed in this world - and obviously I am just one in a long line of believers who have commented on this phenomenom. Not surprisingly, I have encountered this aura of bliss only when outdoors - especially when happening upon a sunlit landscape late in the day. Contrary to my view of such an epiphany one famous interpreter didn’t exactly turn cartwheels of hallelujah when she squinted against the December light. Listen to this poem by Emily Dickinson:

There’s a certain Slant of light,
Winter Afternoons–
That oppresses, like the Heft
Of Cathedral Tunes–

When it comes, the Landscape listens–
Shadows–hold their breath–
When it goes, ’tis like the Distance
On the look of Death–

Yes, I know these lines can be read as Dickinson expressing awe for the concept of death (and the promise of heaven) as well as melancholy, but her interpretation of a sunny winter afternoon is definitely not what I’m talking about. Rather, (if I may borrow her opening line), what I mean is this:

There’s a certain slant of light
That bathes the weary day,
Whispers to our sorrow,
Before it fades away.

All that gusts before us,
Beckons with a hand,
Pulls us ever faster,
Till we reach our dawn.

If the world can be divided into two groups - those who believe that heaven exists and can be sensed in our world and those who don’t, I can’t find any better way to express my gratitude in being a believer than to arise each morning, tell my family I love them and then go to work.

“Why wasn’t someone looking for this?”

My new patient stared up at me after delivering this salvo, expecting me to conjure up an answer that would either alleviate her distress at being diagnosed with inoperable cancer or at least acknowledge that someone was to blame for not finding this tumor earlier. I stood over her bed, poised with what I hoped was viewed as respectful concern, a dignified smile of compassion wallpapered to my face while the team of dingalings in charge of my professional behavior searched the files for a helpful response to her question.

“Uh…Uh…Uh….” This series of belches seemed to provide as much comfort to her as if I had stood on a chair and belted out the Slovenian National Anthem. The dilemma was obvious, at least to me: my patient had just been discovered to have pancreatic cancer, which is difficult to find while still small enough to afford a successful operation, not to mention the fact that even after surgical resection the survival rate is low. It is not a tumor that has been thwarted by early detection. How could I tell her that in her case it wouldn’t have made any difference if her tumor had been found earlier? I buttered her bed with a few platitudes while I pondered the particulars of this situation.

There are certain types of cancer that are associated with a higher chance of survival if found early - lung, breast, prostate and colon cancer lead this list - but this patient’s pancreatic mass had already spread to her liver before she or anyone else knew it. In other words, by the time the doctors had discovered what was the cause of her recent complaints of abdominal pain, she had become jaundiced from a bile duct obstruction and even worse, had liver metastases. This put her beyond any hope for cure. Was she right in questioning the timeliness of her work-up? Had her doctors failed to follow the standard of care by not obtaining a CT scan at the time of the initial visit?

Screening for cancer implies that a patient is subjected to a test designed to detect a malignancy that lives within the host without causing any symptoms of concern. It is hard to defend the doctor who doesn’t believe in mammograms, stool guaiacs and PSA checks (plus rectal exam) since these tests all have been shown to save lives. Pancreatic cancer, however, is a disease that is difficult to manage even in its earliest stages. I couldn’t find fault with my patient’s doctors for following what I consider to be a typical evaluation of abdominal pain, which eventually included the CT scan that uncovered the deadly problem. I can imagine what the consequences would be for doctors who ordered an abdominal CT on all their patients with pain, “just to be sure.”

Here are my personal guidelines for when to start hitting the “expensive imaging study” button on patients with noticeable symptoms that are disrupting their daily routine:

1. When the patient fails to improve after being treated for the particular diagnosis established by the doctor.

2. When new symptoms of concern appear, especially weight loss, or in my patient’s case jaundice.

3. When the disruption of the daily routine turns into disability (think of the patient who not only can’t work but now needs a wheelchair to get from the parking lot into the office).

Common sense is a wonderful tool for physicians to use when considering the possible causes of a patient’s symptoms. Combine that with concern for well-being, and voila! Rare will be the patient who fails to receive timely evaluations, appropriate testing, prompt follow-up calls and visits, and counseling delivered with clarity.

Now if we could only expand our list of cancers that can be defeated with simple screening tests, or expand our treatments that are effective in killing cancer, or develop methods to avoid getting cancer, or …

[At this point the author made a face usually seen on the juvenile members of the audience during Act II of Tristan und Isolde, and left for home…]

Oh it’s a long, long while, from May to December,
But the days grow short when you reach September…

The seemingly endless weeks of heat, canopied trees, buzzing bugs and wet bathing suits are finally coming to a close. Now as the earth has done for more cycles than can be fathomed, it will begin to lean away from Mother Sun like a 6th-grader avoiding a kiss, and bring on one of the two seasons of change - and a chance for us dreamers to reflect on the annual shedding of life that occurs.

My feeling is that autumn is the more emotional of the biannual transformations. When spring arrives to green up the neighborhood and unfurrow the brow of those who have languished under months of dim light, the cliche’ is that all is new - all is reborn. I’m sure that cheers up the frosted crowd hovering at the local public house. The problem with this bit of happiness is that we mortals typically have no recollection of our birth, not to mention the inchoate stages preceding the blessed event. Birth just hits us by surprise, and by the time we are grown we have only vague memories of what it was like to be as young as a warm day in March. We can’t relate to a season that cannot be relived by us.

But now as we mourn the demise of shady naps, shorts and flip-flops, ice cream runs and summer crushes we experience a more personal emotion - the season of loss. Our mood is confirmed by the drifting piles of leaves against the doorstep, by the sudden chill across the back when we forget to bring a jacket, by the abrupt darkness that blankets the landscape before we have a chance to walk the dog.

The span of life measured by one summer has passed, never to return.

Those who sit too long outside in the last gasp of a September night may sense the connection between the coming cold and their own remaining days. The two events announce themselves with clarity and precision, like a campanile knelling the final hour of the day: gone…gone…gone…. Before long, before the dew dampens our feet, we wander back inside. From the street a quiet square of yellow can be seen glowing into the solitary darkness - then it disappears.

Summer slams into us as hard as a back-slapping cousin up for a visit. It is a powerful season that demands attention, muscles and planning; it flings us upside down and fills us with sand; it roars with colors from a thousand delights and never asks once if we’re ready to stop. For twelve glorious weeks it owns us.

Then it dies. Autumn sweeps the last remnants of it into forgotten corners and we stand at the window, quivering with mortality.

For just one moment this month, as supple green arms all around us turn brittle and begin to fall, let us turn and see ourselves once again in summer - under the arms of our tanned parents, running across a toasted field toward a meadowlark, soaked from the river or from rain, surrounded by friends. The sound of our laughter is strong. It will carry us far into the months ahead, providing a lasting warmth against the fading light.