Copyright
This book is not intended as a substitute for medical advice of physicians. The reader should regularly consult a physician in all matters relating to his or her health, and particularly in respect of any symptoms that may require diagnosis or medical attention.
Copyright © 2018 by Steven A. Curley, MD
Cover design by Edward A. Crawford
Cover photograph by Getty Images
Cover copyright © 2018 by Hachette Book Group, Inc.
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First Edition: May 2018
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Library of Congress Control Number: 2017963558
ISBN: 978-1-5460-8270-5 (hardcover), 978-1-5460-8269-9 (ebook)
E3-20180516-JV-PC
CONTENTS
Cover
Title Page
Copyright
Dedication
Introduction
1. A Fishing Story
2. Heroes Walking among Us
3. Good News, Bad News
4. You Can’t Make This Stuff Up
5. Opportunity Calling, Version 1.0
6. Does Your Dogma Bite?
7. A Roll of the Genes
8. Told You So
9. The Five-Year Cancer-Survival Mark
10. Opportunity Calling, Version 2.0
11. Breathless
12. Mister Lobster Guy
13. What’s the Alternative?
14. Go for It
15. Good Morning!
16. The Wrestler
17. The Deacon’s Wife, aka “The Real Muhthuh”
18. The Photographer
19. The Rancher
20. It’s Not Fair
21. New York State of Mind
22. Feeling Lucky?
23. The Swimmer
24. Things Get Complicated
25. The Golfer
26. Million-Dollar Man
27. Great Case
28. Surf’s Up
29. This Is Too Real
30. Be the Dog
Acknowledgments
About the Author
Newsletters
To my wife, Natalie.
Thank-you will never be enough.
INTRODUCTION
My parents are native New Mexicans. My mother was born in Taos and my father in Albuquerque. They were both born during the Great Depression, a few years before the onset of World War II. That was when the population of humans in New Mexico was only slightly greater than the population of coyotes.
I am the only member of my extended family not born in either New Mexico or Colorado. I was born in the panhandle of Texas, where my father was playing professional, minor-league baseball at the time. At age six weeks, I moved to New Mexico with my parents, so I have no recollection of my time as a Texan. My grandfather, my mother’s father, always called me Tex. It was not a term of endearment.
Growing up in New Mexico in the 1960s and ’70s was a simple and pleasant experience. My impressions of the world came from movies or television, on the rare times when my brother and I were allowed to watch it, but mostly they came from books. I loved to read, and books were my source of adventure, education, and imagination. I voraciously devoured history and fiction with equal gusto. Reading was the only way I thought I would ever visit places beyond my immediate borders. My teachers were wise enough to recognize that I needed activities to keep me busy—and to prevent me from chatting with my neighbors when I finished my work. So they plied me with books and writing assignments to describe the adventures and historical events I learned about in my readings.
Along with our friends, my brother and I wandered the mesas and arroyos at the base of the Sandia Mountains in Albuquerque. We played baseball, football, basketball, and every make-believe game we could imagine. In retrospect, ours was a rather idyllic existence.
I didn’t realize New Mexico was a climatically, culturally, and geographically diverse state until I was in college. I was the first member of my entire family to attend college, much less obtain a university degree. As an undergrad, I decided to apply to medical school. Using my parents’ home address, I sent a form letter to more than forty medical schools throughout the United States requesting information about their programs and application processes. Every school except one replied by providing a description of their courses and requirements for admission. The one exception was the University of Oklahoma Health Sciences Center in Oklahoma City. Parenthetically, the panhandle of Oklahoma borders the far northeast corner of New Mexico. Rather than a booklet describing the medical school experience at the University of Oklahoma, I received a personal letter from the dean of the school. He thanked me for my interest in the program but went on to tell me that, regrettably, the University of Oklahoma did not accept applications from foreign students.
Clearly, the dean was geographically challenged. Technically New Mexico and Oklahoma are neighboring states. I shared the letter with several of my friends, including one who was a political science major. We all thought it was very funny, and my friend showed the letter to one of his professors in the Department of Political Science. The professor was a retired United States senator from the state of Oklahoma. We mistakenly thought he would laugh when he read the letter. He did not. He was outraged. He had the dean of the medical school on the phone within minutes and gave him a brief but direct lesson on the geography of the United States. Subsequently, the dean told the professor I should definitely apply to medical school at the University of Oklahoma.
No thanks.
I like stories, whether told by a masterful chronicler of tales or written in a book or magazine. I always enjoy learning new things and exploring new places I can visualize in my imagination. It amazes me that my career as an academic surgical oncologist has allowed me to visit hundreds of places I could only wistfully dream of actually seeing as a boy: the pyramids of Giza, the Colosseum in Rome, the Great Wall of China, dozens of other man-made marvels, and natural wonders and vistas on every continent except Antarctica (it’s on the bucket list).
One of the storytellers I admire is Ernie Pyle, a famous World War II news correspondent who, like me, lived in Albuquerque. A Pulitzer Prize–winning journalist, Pyle was known for his accounts of everyday, otherwise-anonymous people and, in wartime, for his extraordinary features on ordinary soldiers. He wrote clean, clear, crisp stories and painted word pictures capable of evoking great emotion. Sadly, Ernie Pyle was killed while embedded with a division of army troops attempting to take Ie Island in April 1945, before the invasion of Okinawa.
I am no Ernie Pyle, but this is a book of stories about some of my real patients and real situations in modern
cancer care. I like to tell stories that have inspired me. It’s how I encourage patients dealing with the fear and uncertainty that come with a diagnosis of cancer. Not all of the stories have happy endings. But I recognize that patients relate to the harsh realities faced by other people dealing with the same potentially grim outcome. And they can find empathy and comfort in knowing they are not alone. For privacy reasons, I cannot identify patients by name or specific characteristics that would allow them to be recognized, but all the patients and families described in this book are actual people, individuals who have demonstrated remarkable characteristics and virtues that have been a lesson and blessing to me and others involved in their care. For the few chapters in which information is divulged that might identify a specific patient, express written consent to publish the story was obtained from the patient and/or family.
In 1971 President Richard Nixon declared a “war on cancer,” which led to Congress’s passing the National Cancer Act the same year. If we are at war with cancer, it is by far the longest and most costly conflict in the history of the United States. The list of Americans killed or injured by cancer and our treatments is prodigious. The socioeconomic burden for cancer care in the United States and worldwide is mind-boggling. The impact of a cancer diagnosis on patients, their families, friends, and co-workers is profound and life-altering. The loss of productivity, skills, financial security, and normal lifestyle is staggering. And the emotional burden for patients and their caregivers—whether soon after diagnosis or when death from a progressive and incurable disease becomes inevitable—is incalculable and imponderable.
But ponder we must. The war on cancer continues. Here and there we win minor victories and even occasional major battles. The enemy is still active, however, and the cost in human lives and well-being is unacceptable. These accounts from the front lines represent a small fraction of the patients I have been privileged to care for during my career as a surgical oncologist. I am mindful of the virtues displayed by these common but remarkable people because they are a daily gift granted unconditionally to me. Some of the narratives describe important experiences about preparedness and what I learned from the occasional serendipitous opportunity.
My goal is to share these gifts from my patients and to honor all patients, family members, friends, acquaintances, and caregivers who have been or still are involved in the fight against cancer. I respect you all.
Fight on!
1
A Fishing Story
“Hope is being able to see that there is light despite all of the darkness.”
Desmond Tutu
Hope: A feeling of expectation and desire for a certain thing to happen
I learn useful life lessons from each patient I meet. Some are positive messages, reminding me of the importance of maintaining balance between family, work, and leisure activities. But more frequently I witness examples of the remarkable resilience of the human spirit when faced with a diagnosis of cancer and the reality and risks of a major surgical procedure. Occasionally patients and their family members utter sad remarks when they are faced with a grim prognosis and the emotions associated with onrushing mortality. Their comments invariably involve an inventory of regrets, including, “I should have spent more time with my kids,” “I wish I had told my father (or mother, brother, sister, child, or some other person) that I loved them before they died,” and “I have spent my entire life working, I never took time for anything else.” I wince when I hear openly expressed regret; I recognize I am hearing painful and heartfelt truths. Every week I am reminded that I do not want to look back at my life with a long list of regrets, things I’ll wish I had done, and what-ifs.
Early in my academic career I was blessed to meet a great teacher in the guise of a patient. He came to my clinic during my first year as an assistant professor of surgery, shortly after I completed a fellowship in surgical oncology. My patient was a sixty-nine-year-old Baptist minister from a small town in Mississippi. His medical oncologist referred him to me. The physician called me and said, “I don’t think there is anything you can do for him, but he needs to hear that from you because he doesn’t believe me.” This tall, imposing patient had colon cancer that had metastasized to his liver. The malignant tumor in his colon had been removed the year before I met him, and he had received chemotherapy to treat several large tumors found in his liver. However, the chemotherapy had not worked and the tumors had grown. The medical oncologist told him he would live no more than six months, and because he was an avid fisherman when he was not preaching or helping others in his community, the doctor suggested that he go out and enjoy his remaining time by getting in as much fishing as possible.
I learned two invaluable lessons from this patient and his family. First, never deny or dismiss a patient’s hope, even when from a medical perspective the situation seems hopeless and the patient is incurable. Second, quoting the minister directly, “Some doctors think of themselves as gods with a small g, but not one of you is God.”
When I first walked into the exam room, this man was slouched on the examining table in the standard blue-and-white, open-backed, unflattering hospital gown. He briefly made eye contact with me and then looked down to the floor. In that momentary glance, I saw no sparkle, no life, and no hope in his eyes. He responded to my initial questions with a monotonic and quiet voice. Several times I had to ask him to repeat an answer because his response was so muted. Midway through our first visit, the patient’s wife told me he had been very depressed by his diagnosis of untreatable, metastatic colon cancer. She reported—despite his occasional side-long warning glances requesting her silence—that while he was eating well, he was spending most of his time sitting in a chair or lying in bed. And that the active, gregarious man with the quick wit and booming voice that she had married was gone.
After I interviewed and examined the minister, I left the room and reviewed the results of the lab tests and computed tomography (CT) scans we had performed on him. When I returned to the room he was dressed and sitting in a chair next to his wife. I explained to them that I believed it was possible to perform a difficult operation that would remove approximately 80 percent of his liver. The operation would be risky, there was a potential that he would require blood transfusions, and, as a worst-case scenario, the small amount of remaining liver might not be sufficient to perform necessary functions. If I pushed the surgical envelope too far and removed too much normal liver, following the operation he could develop liver failure leading rapidly to his death. I also stated that, assuming he survived the major operation and the recovery period, I could not predict his long-term outcome or survival. I emphasized that even if the operation were successful, it would be possible that the cancer would recur in the remaining liver or in some other organ. I even attempted to raise his spirits a bit by injecting some puerile surgical wordplay when I said, “This operation will leave you with little more than a sliver of liver, but God willing it will be enough!”
At the conclusion of my very direct monologue, he looked up from the floor and once again his eyes met mine. I remember blinking in surprise several times at how different he now appeared. With his eyes bright and twinkling he asked, “Are you saying there is hope?”
I replied that I believed there was hope, albeit small and impossible to measure, but hope nonetheless.
An unforgettable and immediate transformation in his demeanor occurred, and his wife smiled at me as she mouthed the words, “He’s back.” He reverted instantaneously to what I would come to learn was his former, garrulous self.
The spiritually resuscitated minister sat upright, grasped my right hand with both of his hands, and launched into a memorable diatribe. “Never deny someone hope, Doctor, no matter how hopeless you know the situation to be. Humans need hope, without it there is depression, despair, and death. Why do you think the Jewish defenders at Masada held out against an overwhelming Roman force for so long? Because they had hope and they had faith. Why do people let you cut them
open? Hope. Never deny a human being hope, Doctor. Without it we have no humanity; we are only another animal.”
He was a forceful and eloquent speaker. With his Mississippi drawl, he could alternatively be plainspoken or pedantic. I discovered he was a well-read and educated man and he loved to display his extensive lexical armamentarium. Not infrequently after our conversations I would seek out a dictionary to learn the meaning of a word or two. I had no difficulty visualizing him preaching from the pulpit in his Baptist church, like a yo-yo dropping his parishioners to the floor with the fear of eternal damnation, and then pulling them back up into his hands with a message of redemption and salvation.
Enthralled, I walked out of the examination room and scheduled the operation for the next week. I was amazed by the sudden change I had witnessed in this man’s posture and overall demeanor. Like many who provide care for people with debilitating medical conditions, I have seen patients lapse into a state of abject despair. Their spiritual demise leads to a rapid downward spiral of their physical condition. These patients fulfill the expectations of medical practitioners who have told them their survival will be a matter of only weeks or a few months. In fact I have seen several patients die much sooner than I would have predicted when darkness and despair overwhelmed them.
I had the minister’s “sermon” on my mind throughout his operation. As I expected, the procedure was technically difficult. He was a robust, barrel-chested man and had four large tumors in his liver. All four were in the right lobe of liver, but two of them extended into portions of the left lobe. One also extended down to involve two of the three large veins that drain blood from the liver into the inferior vena cava, the large vein that carries blood back to the heart. To assure that I had completely removed the tumor around these two veins, I took out a portion of the wall of the inferior vena cava and replaced it with a patch from another vein. It was a liver surgery tour de force, and when it was over, the surgical fellow who performed the operation with me and I quietly congratulated each other on a job well done. Nonetheless, I admit to having had my own negative sentiments and a paucity of optimism. I remarked to the surgical fellow that while the operation had been technically challenging and a great lesson in surgical anatomy, I doubted that we had cured this patient. I was concerned that the aggressive cancer would return.