Multidisciplinary team management of many types of cancer has led to significant improvements in median and overall survival. Unfortunately, there are still other cancers which we have impacted little.  In patients with pancreatic adenocarcinoma and hepatocellular cancer, we have been able to improve median survival only by a matter of a few months, and at a cost of toxicity associated with the treatments.  From the point of view of a surgical oncologist, I believe there will be rapid advances over the next several decades.

Robotic Surgery

There is already one surgery robot system on the market and another will soon be available. The advances in robotics and imaging have allowed for improved 3-dimensional spacial recognition of anatomy, and the range of movement of instruments will continue to improve.  Real-time haptic feedback may become possible with enhanced neural network systems.  It is already possible to perform some operations with greater facility, such as very low sphincter-sparing operations for rectal adenocarcinoma in patients who previously would have required a permanent colostomy.  As surgeons’ ability and experience with new robotic equipment becomes greater, the number and types of operation performed will increase and patient recovery time, length of hospital stay, and return to full functional status will improve.  Competition may drive down the exorbitant cost of current equipment.

More Cost Effective Screening

The mapping of the human genome was a phenomenal project and achievement. However, we still do not understand the function of all of the genes identified or the complex interactions with other molecules in the nucleus.  We also forget that cancer is a perfect experiment in evolutionary biology.  Once cancer has developed, we begin treatments with cytotoxic chemotherapy drugs, targeted agents, immunotherapies, and ionizing radiation.  Many of the treatments are themselves mutagenic, and place selection pressure on cells with beneficial mutations allowing them to evade response or repair damage caused by the treatment, survive, multiply, and metastasize.  In some patients who are seeming success stories, new cancers develop years or decades later, induced by our therapies to treat their initial cancer.  Currently, we place far too little emphasis on screening and prevention of cancer.  Hopefully, in the not too distant future, screening of patients with simple, readily available, and inexpensive blood tests looking at circulating cells and free DNA may allow us to recognize patients at high risk to develop certain malignancies, or to detect cancer at far earlier stages when surgical and other therapies have a higher probability of success.

Changing the Mindset

A diagnosis of cancer incites fear and uncertainty in patients and their family members. Many feel they are receiving a certain death sentence.  While we have improved the probability of long-term success with some cancers, there are others where we have simply shifted the survival curve to produce a few more months of survival before the patient succumbs.  We need to adopt strategies that allow us to contain and control malignant disease without necessarily eradicating it.  If a tumor or tumors are in a dormant or senescent state and not causing symptoms or problems, minimally toxic treatments stopping tumor growth and progression allowing the patient to live a normal and productive life would be a success.  Patients with a diagnosis of diabetes are never “cured” of their diabetes, but with proper medical management their disease can be controlled and they can survive and function without any of the negative consequences and sequelae of the disease.  If we can understand genetic signaling and aberrations sufficiently, perhaps we can control cancer for long periods while maintaining a high quality of life for our patients.

Taking on Tough Political Issues

I am often asked by patients if I believe there will ever be a “cure” for cancer. I invariably reply it is unlikely if we continue to engage in activities and behaviors which increase the likelihood of developing cancer.  Cigarette smoking, smokeless tobacco use, excess alcohol or food intake, lack of exercise, and pollution of the environment around us produce carcinogens or conditions increasing the risk of cancer development.  Unless we find the courage and strength to limit access or ban substances that are known carcinogens, like cigarettes, and begin as thoughtful citizens of the planet behaving in a more responsible fashion to eliminate air, ground, and water pollution, we will not make a significant impact on the incidence of cancer.  We must also be willing to develop greater and more far reaching population education programs about things as simple as proper ultraviolet light protection during sun exposure, and to recognize tanning beds or excessive, unprotected natural sunlight exposure increases the risk of a particularly difficult and vicious malignancy, melanoma.  Whether we like to admit it or not, humans respond to societal pressures and images displayed or touted by media, marketing firms, or so-called beauty and glamor outlets that may actually be harmful to the health of the populace.  People do and should have a free will, but they should also be given understandable, honest, and rational information on the potential consequences of their choices.  There should also be a higher level of personal accountability and responsibility for negative outcomes based on an individual’s choices.

Global Cancer Care

It is estimated that between half and two thirds of the world’s population, particularly in poor or developing countries, have limited or no access to cancer prevention, screening, or care. The improved outcomes we report in medical and surgical journals from advanced countries assume the treatment can be paid for and access is available to all.  Nothing is further from the truth.  Meaningful efforts to rein in the rampant increases in cancer drug costs, reduce the prohibitively long and expensive process to develop and approve a novel treatment, and to provide training and education for practitioners in developing countries must be made.  The disparities even within the United States are great, and it is well known and documented that disadvantage populations are often diagnosed with later stage disease, and generally have reduced chances of long-term success with the treatments available.  We must become inclusive, not exclusive, in our worldview and through outreach and development programs begin to build infrastructure and access to affordable care worldwide.

Thinking Outside the Box

Personalized or individualized patient cancer care is a popular buzz phrase these days. In reality, we currently have very few drugs or targeted agents to act upon the numerous genetic or epigenetic abnormalities present in the average cancer.  To search for drugs to new targets or abnormal pathways, we must create a system where there is rapid assessment, cost effectiveness, and streamlined regulatory approval for patients with lethal diseases.  Personalized cancer treatment is not affordable without major changes in policy and practice.  We should recognize malignant tumors have interesting physicochemical and electrical properties different from the normal tissues from which they arise.  Therapy with electromagnetic fields specifically tailored to a given patient’s tumor properties can enhance tumor blood flow and improve delivery of drugs or agents while reducing toxicity and side effects.  Developing approaches that do not produce acute and long-term side effects or an increased risk to develop second malignancies must be a priority.

Science and technology information is being produced at an incomprehensible rate. We need help from specialized colleagues with big data management and recognition of trends and developments which can be quickly disseminated throughout the medical community, and to appropriate patient populations.  All of these measures require commitment and dedication to changing the way we think, reversing priorities based far too much on profitability of treatments rather than availability and affordability of treatment, and we cannot ignore the importance of programs to improve cancer prevention, screening, and early diagnosis.

Every Friday night we ate dinner at my mother’s parents’ house. I poignantly remember an after dinner ritual.  My grandfather would retire to his recliner, toothpick in his mouth, and instruct one of his grandchildren to turn on the bulky multicomponent console color television with built in radio, turntable, and speakers.  It was time to watch Friday night boxing.  There was no remote control, we kids were the channel changers and volume knob manipulators.  My grandfather was usually not an emotional man, but he would become quite animated and occasionally agitated watching the fight, particularly if there was a boxer he favored in the match.  The grandchildren enjoyed watching him more than we did the pugilists on the flickering television screen.

My father’s father, on the other hand, was a wrestling fan. By wrestling, I mean the wrestling seen on Saturday afternoon television featuring men in tight shorts, outlandish costumes, some wearing hoods or masks over their heads, entering the ring wearing colorful capes to either wild applause or catcalls and hisses, bouncing off the ropes to clothesline their onrushing opponent, and jumping from the turnbuckles to land on their hapless opponent laid out on the mat below.  Even to a boy it was obvious bad theater and fraud, but I enjoyed watching my grandfather yelling at the television, berating the bad guys and the referees during these spectacles.  He knew the name of every hero and villain, and he would hurl epitaphs at the masked men in tight wrestling suites while openly cheering for those he admired.  He particularly loved the chaos of tag team matches, guaranteed to degenerate into a free-for-all with all the combatants in the ring, throwing chairs, and occasionally even body slamming the referee to the canvas.  I still remember some of the names and can mentally visualize the antics; Gene Kiniski, The Sheik, Ray Mendoza, Dory Funk Jr., Terry Funk, Mad Dog Vachon, Hard Boiled Haggarty, Raul Reyes, Killer Kowalski, and Johnny Valentine.  As I grew older I mistakenly pointed out these matches were all rehearsed and the outcomes were scripted; this wasn’t real sport.  He fixed me with a glare, informed me I was getting, “a little too big for my britches”, and asked me if I thought 250 lb. men climbing to the top of the ropes to hurl themselves on their foe below, or the prostrate , seemingly stunned wrestler on the mat absorbing the flying blow delivered from above should be considered as anything less than athletic.

Good point. I wouldn’t want to do it.

Cancer patients and caregivers grapple with malignant disease every day. Surgical oncology is an unusual, but not unique, sub-specialty area in surgical care.  Many surgeons will enter the lives of their patients for an acute illness or event, perform the indicated operation to improve their condition, care for them in the hospital, and then see them for one or two post-operative visits in the office before discharging them on to the rest of their lives.  Some surgical sub-specialties, including surgical oncology, follow their patients longitudinally.  All of the oncology-related specialties follow their patients for years, if not for the lifetime of our patients after a diagnosis of cancer.  We are watching for the success of our treatment, evidence of any recurrent or new metastatic disease, and treating any symptoms or problems related to the therapies we deliver.  We get a chance to know our patients and their families, and to watch how they respond to a diagnosis of cancer and to living with the ever-present specter of possible return of malignant disease.

I admire the pluck and defiance of patients who have a “never give up” attitude. One of those patients is on my mind today. When I walked into an examination room to meet him, he sprang to his feet, grasped my hand and shook it vigorously, smiled a dazzling white smile, and then gave me a bear hug.  Effusive.  His first words, “Doc, you’re going to help me beat this thing!”  At this point he was still shaking my hand, his grip getting tighter, so I politely asked him to release my hand lest I be unable to perform an operation on him because of damaged digits.  He laughed and immediately cut me loose, allowing circulation to return to my fingers.  We sat down to talk.  I was not surprised this gentleman had an impressive grip.  He was in his late 40s and built like a football running back or rugby player.  I actually asked him if he had been a football player.  He feigned disgust and exasperation and said, “No, I’m a real athlete.  I am a wrestler.” As I explored his history it turned out he had been a collegiate wrestler of significant accomplishment and repute.  After completing his collegiate career, he founded a successful business and spent his time raising his family, expanding his business acumen, and refereeing high school and college wrestling matches around his home state.

I was seeing this man for a diagnosis of colorectal cancer liver metastasis. Eight months prior to our initial meeting, he noticed some blood in his bowel movements and made an appointment with his primary care physician.  His doctor noted that he did have blood on a rectal exam and that he was slightly anemic on blood tests.  He had never before had a colonoscopy and there was no family history of colon cancer.  A gastroenterologist was consulted and a colonoscopy revealed a colon cancer.  The patient underwent an operation in his hometown to remove the malignant colon tumor. The gross and microscopic review of the surgical resection specimen by a pathologist discovered cancer in several lymph nodes near the primary tumor, and a biopsy of a liver tumor performed by the surgeon confirmed liver metastasis in the right lobe of his liver.  Stage IV disease, signifying blood-borne spread, successful implantation, and growth of malignant cells from the colon cancer to another organ, his liver.

The patient recovered from his colon operation at a meteoric pace (his hometown surgeon’s description when I spoke to him), and then received six months of systemic intravenous chemotherapy. He was referred to me to address the sole clinically evident site of malignant disease, a tumor in the right lobe of his liver.  I use the statement “clinically evident” purposefully, on our state-of-the-art computerized tomography (CT) scans the radiologists and I did not detect any suspicious tumors or “lesions” in his lungs, lymph nodes, or peritoneal cavity.  Just a solitary liver metastasis smack dab in the middle of the right lobe.  An almost Pavlovian circumstance for a hepatobiliary surgical oncologist who loves to attack and remove liver malignancies in this remarkably fit, healthy young man.

This gentleman was one of the most energetic, positive attitude, “let’s get this done” people I have met in any aspect of my life. We talked for about half an hour during our first visit, and I performed a physical examination.  I reviewed the CT scans we performed and the pathology information he brought with him.  He had a 5 cm liver tumor which originally was almost 8 cm in diameter.  The tumor volume reduction indicted a positive response to chemotherapy.  In oncology, numerous studies have indicated patients showing shrinkage of their tumors with chemotherapy tend to have a longer survival time after surgical and other anti-cancer therapies.  It’s all statistics and probabilities; the bottom line is we can never know what’s going to happen specifically to one given patient.  This patient told me he was ready for me to operate and “get this devil out of me” as quickly as possible.

The next week I performed an exploratory laparotomy. Surgeons are multi-sensory creatures. We like to visually inspect the area of the operation, but we also like to feel.  I palpated the lymph nodes near the blood vessels heading into his liver.  Several of them felt hard like small stones despite not being enlarged.  I removed all of these regional lymph nodes adjacent to the liver and then completed a routine right hepatectomy.  Upon checking the remainder of the belly cavity visually and tactilely, there was no evidence of tumor to be found at any other site.

My patient was up walking laps in the hallways of the surgical unit the night of his operation. Several nurses told me they were exhausted just watching him.  He was indefatigable.  He consistently had a huge smile on his face and greeted everyone with a bone-crushing handshake.  He left the hospital only four days after his operation.  As he stated, “All systems are working, I’m outta here.”

See ya!

I saw him in clinic the following week and we reviewed the results from surgery. I explained to him the pathologist found not only the single liver tumor we knew was present, but also three additional 2–3 mm tumors were detected near the large tumor.  None of these tumors was close to the liver transection line, we had achieved a tumor margin-negative operation.  Furthermore, three of the twelve lymph nodes removed from around the blood vessels supplying his liver contained metastatic colorectal cancer.  He was nonplussed, and asked if it was still possible to be cured.  The question I get every week.  I explained the finding of the small tumors in the liver combined with lymph node metastases meant there was a higher probability he could have microscopic cancer cells hiding elsewhere in his body.  In other words, his chance for long-term cancer free survival was significantly reduced, but was not zero.  I finished with the assurance I planned to follow him closely and watch for any recurrence.  That earned me a grand smile, more damage to my right hand, and an exhalation-inducing embrace.  He returned home and spoke to his medical oncologist.  They decided to proceed with another six months of a different chemotherapy regimen.  At the end of the second six months of cytotoxic drugs, he returned to see me in clinic.  All of our blood tests and CT scans on him showed no problem, no clinically evident cancer.

I wasn’t sure if my right hand or chest was going to remain intact thanks to this patient.

The good results and good news were short lived. Six months later, a blood test we measure in patients with colorectal cancer called CEA, an abbreviation for carcinoembryonic antigen, was elevated in him.  When I saw his lab results, I immediately scrolled through his CT scans, and then quietly cursed at the computer screen.  He had four new tumors in the hypertrophied left lobe of his liver along with a dozen or more small lung metastases scattered throughout both lungs.  I walked into an examination room to tell him the news.  He knew from my face I was about to drop a bomb on him.  Before I could say anything, he stood up, hugged me, and to my amazement said, ”We’ll beat this thing!”  I reassured him we were in the fight together and I then went over all of his results.  He sat quietly nodding, occasionally asking for clarification, and finally asked, “Okay, what’s our next move?” I spoke with my colleagues in medical oncology and we determined a new sequence of drugs to treat him for this rapid recurrence.

At a visit with me three months later, he launched the question patients often ask, he wanted to know how long he would live. He was a motivated, insightful, intelligent individual and as we sat together in a clinic room, he rifled through copies of scientific papers describing chemotherapy and novel treatments for stage IV colorectal cancer.  He noted from his reading the median survival with the chemotherapy drugs he was receiving ranged from 18–24 months.  I replied those perceptions and statistics were correct, but there was no way to predict if he would live less or more time than the average.  He laughed, tossed the research papers on the floor, and said, “These don’t describe me!”

After six months of additional chemotherapy, this gentleman’s lung metastases had completely disappeared on CT scans of the chest, and the liver metastases appeared to be calcified scar tissue. His CEA blood test had returned to a normal value.  After considering his situation and excellent anti-tumor response in a tumor board meeting, my colleagues and I determined we would stop chemotherapy and follow him.  This we did with blood tests, CT scans, and physical examinations every three months for another year.  At the one year off chemotherapy mark, his CEA value was again elevated and CT scans revealed recurrence in the liver, lungs, and peritoneal cavity.  Grimly, I walked into the examination room to have a heartrending discussion.  I reviewed the test results as his wife quietly wept, and before addressing me, he turned to her, gave her a hug, and told her he would be all right.  He pivoted to me and flashed a dazzling smile saying, “Remember, we are in this together.”

Yes we are. Based on probabilities, patterns, and the rapid recurrence of his cancer in multiple sites, this man would not have been predicted to survive more than 2 or 3 years after his initial cancer diagnosis.  I mentioned previously he was on my mind because I received a note from his brother recently informing me he had finally lost his battle and had passed away.  It was almost 8 years from the time of his original cancer diagnosis.  Throughout all of those years I saw him every 3 months and arranged for him to see numerous specialists and medical oncologists administering a variety of new clinical trials for colorectal cancer.  His medical oncologist at home is very active in treating patients with established and new regimens for gastrointestinal malignancies.  When we spoke on the phone about our mutual patient, it was always with a note of admiration for his courage and formidible spirit.

I grew up watching boxers and faux wrestlers (performance athletes?) with my grandfathers. Several of the wrestlers we watched on Saturday afternoon television had been college wrestlers, some even competing in the Olympics.  They were indeed athletes.  Not great actors, but athletes, nonetheless.  Perhaps the ability to work hard, to strive, to endure pain and discomfort and defeat is what led my patient, the wrestler, to survive as long as he did. I have seen similar powerful and courageous efforts from patients of all ages and backgrounds.  I am reminded of a verse of the lyrics from one of my favorite songs from childhood, “The Boxer”, performed by Paul Simon and Art Garfunkel.

                                In the clearing stands a boxer,

                                and a fighter by his trade

                                And he carries the reminders

                                of every glove that laid him down or cut him

                                till he cried out, in his anger and his shame,

                                “ I am leaving, I am leaving”,

                                but the fighter still remains.

Warrior terminology abounds in the cancer lexicon.  “The War on Cancer.”  “She lost her battle with cancer.”  “I am fighting cancer.”  ‘We are going to attack your cancer with every weapon in our arsenal.”  “He refuses to surrender and will keep battling.”  “She is soldiering on through this fight with cancer.”    “I am going to beat and defeat this cancer.”  “It was a courageous fight.”  “We have your cancer on the ropes.”

Patients diagnosed with cancer and treated with our multidisciplinary approaches are knocked down physically and emotionally, but they pick themselves up off the canvas and struggle on. They carry the reminders of the acute and chronic side effects from cytotoxic chemotherapy, the radiation-induced skin and functional organ changes, and the surgical scars, complications, and impairments imposed by the blades of surgical oncologists like me. Though sometimes they want to, they don’t leave.  They remain.  They maintain.  I respect the effort, the invincible spirit, and the patients who don’t give a damn about the odds or probabilities; they are going out swinging.  We are tag team partners in Oncology, entering the ring to attack a patient’s cancer with every move and method we know.  Hell, I’ll even throw a few chairs if it will help.

Indomitable. The wrestler.  I honor you.

I was blessed to meet a great teacher in the guise of a patient early in my academic career. He came to my clinic in my first year after completing a Fellowship in Surgical Oncology, my first year as an Assistant Professor of Surgery.  My patient was a 69 year-old Baptist Minister from a small town in Mississippi.  He was referred to me by his medical oncologist who 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 man had colon cancer that had metastasized (spread) to his liver.  The malignant tumor in his colon was removed the year before I met him, and he had received chemotherapy to treat several large tumors found in his liver.  The chemotherapy had not worked and the tumors grew.  At the point I met him, the medical oncologist told him he would live no more than 6 months, and because he was an avid fisherman when 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 hope from a patient or their family, 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 examining room, this man was slouched on the examining table in the perfunctory blue and white, open-backed, always unflattering hospital gown. He made eye contact with me briefly, then looked down to the floor.  In that momentary meeting of our eyes, I saw no sparkle, no life, 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.  Mid-way 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 laying in bed, and that the active, gregarious man with the quick wit and booming voice she had married was gone.

After I interviewed and examined the Minister I left the room so he could dress and sit in a chair next to his wife. I reviewed the results of the lab tests and CT scans we had performed on him, and then returned to the examining room.  I explained to them that I believed it was possible to perform a difficult operation that would remove approximately 80% of his liver.  The operation would be risky, it was possible 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, assuming he survived a major operation and the recovery period, that I could not predict his long-term outcome or survival.  I emphasized that even if the operation was successful, it was 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 word play 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 several times in surprise at how different his eyes 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 occurred in his demeanor and as his wife smiled at me and 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 comes 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 plain spoken or pedantic.  He was a well-read and educated man and he loved to display his extensive etymologic 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 a 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.

I walked out of the examination room enthralled 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.  As with all who provide care for patients with debilitating and serious medical conditions, I have seen patients lapse into a state of abject, deep despair and complete hopelessness.  Like an autumn leaf falling from a tree branch, 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 months, in fact I have seen several patients die much more rapidly 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 operation was technically difficult.  He was a robust, barrel-chested man and had four large tumors in his liver.  Two of these were right lobe of the liver only, but the other two extended from the right lobe of his liver into portions of the left lobe of the liver. One of these latter two tumors also extended down to involve two of the three large veins that drain blood from the liver into the large vein, called the inferior vena cava, that carries blood back to the heart.  To assure that I had completely removed all of the tumor around these two veins, I removed 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 at the conclusion of the operation the surgical fellow who performed the operation with me and I quietly congratulated one another on a job well done.  Nonetheless, I admit to my own negative sentiments and relative paucity of optimism at the end of the operation.  I remarked to the surgical fellow working with me that while the operation had been technically challenging and a great lesson in surgical anatomy, I doubted that we had cured this patient because I was concerned his aggressive cancer would return.

“Never deny someone hope doctor.”  If I ever had a crystal ball to predict the future, I obviously dropped it in the mud a long time ago.  I was wrong about the Minister.  His cancer never returned.  He spent only one week in the hospital after his operation and his sliver of liver performed and regenerated beautifully.  For the first five years after the operation I saw him every three to six months with lab tests and CT scans to check for return of malignant tumors.  For the next six years I saw him only for an annual visit.  This man survived and enjoyed life for eleven years after being told that he only had only six months to live.  He died as many of us would wish to die, in his sleep from a stroke.  He gave his last sermon from the pulpit of his church three days before he died.  His cancer never returned to prey upon his mind and hunt down his hope.

After thinking about it, I realize I learned one additional lesson from this patient. He taught me that it was acceptable to express a little clean, righteous anger and then laugh and move on.  The Minister and I developed a ritual that was repeated with each of his visits after passage of the initial six months he was told he would live by his medical oncologist.  After I reviewed the results of his tests and CT scans and confirmed that all was well and that cancer had not returned, he would smile and say, “Let’s do it!”  From the examining room, I would dial the phone number of the medical oncologist in Mississippi who had referred him to me.  The Minister admitted to me he was angry that this doctor had needlessly denied him hope.  When the medical oncologist came to the phone, I would hand it to the Minister, who would identify himself to the doctor, and then he would say the same exact words, “Hey doc, you want to go fishing?”  As a surgeon, I confess I enjoyed witnessing the surgical precision with which the preacher inserted this verbal blade, deftly turning it to maximize the impact of his statement.  When I passed the phone to the Minister, he always had an impish, perhaps even devilish grin on his face.  Each time after he asked the doctor in Mississippi if he would care to join him for a fishing expedition, he would hand the phone back to me and a look of beatific serenity would come to his face.  The ritual was completed when I would take the phone and speak to the doctor in Mississippi.  In my first few conversations with this physician, I apologized for my obvious and indecorous breach in professional behavior, but to the credit of this man being regularly taunted by a Baptist Minister who wasn’t entirely forgiving, he would tell me that no apology was necessary and that he believed he deserved and benefited from these brief but poignant verbal reminders. As the years passed, he would be laughing when I put the phone to my ear and tell me that he really enjoyed those calls and that his whole office staff looked forward to this annual event.

Two years before the Minister finally died at the age of 80, the doctor in Mississippi told me that because of this patient, he never answered the question asked to him by patients about their expected longevity with a diagnosis of advanced cancer. Instead, he would inform the patients and their families that he really couldn’t make such a prediction because of marked individual differences in responses to treatment, along with the immeasurable will to live even in individuals no longer receiving treatment for their cancer.  Together, he and I learned the importance of leaving no treatment stone unturned; to engage in multidisciplinary management and to consider all options for our patients. Great lessons from a great spiritual teacher, taught to a couple of hard-headed doctors.

“Hey doc, you want to go fishing?”

I would never make it as a professional poker player because I can’t bluff when I’m holding a bad hand or keep from grinning when I have a good one. My patients can tell from my face when I walk into the clinic room what the news is going to be. When all of the blood tests and scans reveal no evidence of cancer recurrence, I walk in smiling and immediately tell all gathered in the room that everything looks great and I see no evidence of any cancer. The remainder of the visit becomes a combination of medical checkup and social enterprise. I inquire about the well-being of their children, grandchildren, parents, other friends and relatives I have met, their pets, their gardening, their recent travels, and sundry snippets of their ongoing lives. Patients frequently bring pictures of children and grandchildren, or travel photos of places they have been since their last visit with me. Often I’m asked for medical advice on conditions totally unrelated to their cancers as they get farther and farther away from that diagnosis. My patients also know about tidbits from my life. They ask about the status of soccer teams that I coached, how my son or daughter were doing in college (both graduated and onto successful careers, thank you), and whether I have progressed from owning a Ferrari lanyard to hold and display my medical badge (I’m a fan of Ferrari F1 racing) to actually owning a Ferrari automobile (I do not).

I am told by patients, family members, and members of my patient care team that I am quite solemn when I walk in a clinic room to deliver bad news. No “light-hearted” chatter or discussion of recent family events or outings occurs. The nervous, hopeful smiles on the faces of the patient and the family members in the room quickly fade as I describe what I am seeing on their blood tests and the scans I have reviewed. Friedrich Nietzsche, the pejorative poster boy of pessimism, is credited with the aphorism, “Hope is the worst of evils, for it prolongs the torments of man.” Thankfully, he was not involved in the care of patients with cancer or other chronic illnesses. A particular patient comes to mind when I remember the importance of dealing with both the highs and the lows of talking with cancer patients.

The patient in question was the wife of an Emeritus Professor of Engineering at a prestigious American university. The Professor knew a thing or two about scientific investigation, statistics, and assessments of probability. Mrs. Professor had a large, grapefruit-sized malignant vascular tumor in the center of her liver called an epithelioid hemangioendothelioma. Quite a mouthful of a name for a rare malignant tumor of the liver. Her tumor was in an unfortunate location in the center of the liver and was wrapped around two of the three veins that drain all of the blood out of the liver into a large blood vessel called the inferior vena cava. The tumor was abutting a portion of the third vein. As a hepatobiliary surgical oncologist, I know I must preserve at least one of these veins to allow blood that flows into the liver to flow back out properly. She had seen surgeons at several other hospitals in the United States and was told that the tumor was inoperable and untreatable. If she was lucky, she might live a year, these doctors told my patient and her husband. The Professor contacted me, and I examined Mrs. Professor and evaluated her prior scans, and then obtained some additional high resolution scans to better understand the appearance of her tumor. I realized that her particular tumor had a very thick fibrous capsule surrounding it. I explained to the patient and her husband that it may be possible to remove the tumor, but that it would be challenging. This lady who had been sullen, withdrawn, and tearful every time I had met with them previously suddenly looked up and said, “If there’s any chance, I’m willing to take it!” I preceded the next week to perform an operation that removed the entire left lobe and a portion of the right lobe of her liver and I was able to gently dissect the tumor capsule free from the third hepatic vein. The operation was successful and the patient recovered well over the next several weeks.

The Professor, having lots of time on his hands, sent an acerbic letter to the physicians at the other hospitals, explaining in detail to them his mathematical analysis of the fallacy of their prognosis when considering an individual patient in terms of a statistical mean. He pointedly informed them that it was impossible to predict if any given individual would fall near the mean or several standard errors away from the mean. In plain language, the Professor was indicating that predicting the length of survival of cancer patients is usually based from data on the life-span of a large number of people diagnosed with the same disease. Some people live for a shorter, possibly even much shorter time than the average, while some live for significantly longer periods than the average survival time. Unfortunately, for the next year when I would encounter these various surgeons at national or international surgery or cancer meetings, I would get some frosty glares and very little conversation.

For the next three years, I saw Mrs. Professor every four months and with each visit I would enter the room smiling and pleased to report that all looked well on the blood tests and the scans. Unfortunately, three and a half years after her operation, the nature of the clinic visit changed. The moment I walked in the door of the room the professor said, “Uh oh!” Mrs. Professor immediately looked crest fallen and asked, “What is wrong?”. I sat down and explained to them that there were new small tumors in her liver and in her lungs. She asked how this could be possible since she felt so well, and I countered that small tumors frequently do not cause symptoms or problems that make the patient aware of their presence. I spent almost an hour answering an array of questions from my patient and the Professor, many of which were different ways of asking me to predict the future and her probable longevity. I repeatedly explained that this was a bad prognostic finding, and that her particular tumor was generally quite resistant to chemotherapy. She stated openly that she had no interest in taking chemotherapy or other treatments that would adversely impact the quality of her life. She then looked at me with tears in her eyes and asked, “Does this mean I won’t see you again?” I immediately replied that I would continue to see her on a regular basis throughout her life and that in my opinion part of the job for all of us in oncology is to support and care for our patients through all phases of the disease, even when our treatments have failed to eradicate the malignancy. I also confirmed that I respected her decision to decline chemotherapy treatment, and that I would assist her at any time. The patient smiled wanly, and reported that she was relieved that my colleagues and I would be available to treat any symptoms and help her should she develop any discomfort or other problems.

I continued to see my patient and the Professor every three months for another year. I arranged for consultation visits with physicians from our Palliative Care Service. Approximately fourteen months after I delivered the bad news that her cancer had recurred, the Professor called me and said that she was fading rapidly and they would likely not return. A month later I received a poignant and personal letter. In it, the professor included the obituary from the local newspaper regarding his wife’s death. It chronicled an impressive array of accomplishments and interests enjoyed over the course of a life lived fully. There was also a small hand painted watercolor card from the patient with a note to me. In it, she thanked me for giving her hope at that initial visit when I told her that it may be possible to remove her liver tumor with an operation. She then wrote something that I will never forget, “When I saw the other doctors, I felt rejected, trashed, and discarded. I felt they were dismissing me because they could not remove my cancer. All my hope was killed.” The note went on to thank me for giving her several additional years of life to enjoy traveling with her husband and spending time with friends and activities that were important to her. I make no apology to Friedrich Nietzsche or his acolytes, for I know that the death of hope is a much greater torment for patients than the presence of hope.

They didn’t teach a course on delivering bad news when I was in medical school, surgical residency, or during my surgical oncology fellowship. I often think of this cartoon by New Yorker cartoonist Matthew Diffee:

Delivering and receiving bad news is difficult for everyone involved in cancer care (and any other area of Medicine or life, for that matter): the patient, their family members, their friends, the physicians, and the members of the medical and nursing teams. We can’t have Mr. Bickles deliver the bad news for us and then walk away unscathed. There is an emotional toll taken on all of us. We can deliver bad news with compassion and care, and that should be the goal. Patients have the right to know that they are facing a battle with cancer that they will ultimately lose, but that physicians and other medical professionals will fight alongside them and support them and their family members. Supporting the family members of a cancer patient is too often a forgotten or unspoken component in cancer care, but one which requires mindfulness because all members of the family suffer and need support as they watch the disease progress and change their mother, father, son, daughter…whomever. One thing I learned early in my career is that patients may feel they will be abandoned by the medical profession when we can no longer treat or alter the progression of their cancer. Recall the words written by my patient, “I felt rejected, trashed, and discarded. I felt they were dismissing me because they could not remove my cancer.” Regardless of the outcome, I believe we must fight the battle hand in hand with our patients to the end, providing hope tempered with realistic expectations, discussion of possible symptoms and problems, compassion, and reassurance that we are there to help throughout the process.

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 facing the reality and risks of a major surgical procedure and a diagnosis of cancer. Rarely, patients and their family members utter remorseful or simply sad remarks when they are faced with a grim prognosis and the emotions associated with an onrushing date with mortality. These comments invariably involve an inventory of regrets in life, 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 these openly expressed remonstrations, I recognize that I am hearing painful and heartfelt truths. Not a week goes by that I am not reminded that I do not one day want to look back at my life with a long list of regrets, should have dones, and what ifs.

I was blessed to meet a great teacher in the guise of a patient early in my academic career. He came to my clinic in my first year after completing a Fellowship in Surgical Oncology, my first year as an Assistant Professor of Surgery. My patient was a 69 year-old Baptist Minister from a small town in Mississippi. He was referred to me by his medical oncologist who 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 man had colon cancer that had metastasized (spread) to his liver. The malignant tumor in his colon was removed the year before I met him, and he had received chemotherapy to treat several large tumors found in his liver. The chemotherapy had not worked and the tumors grew. At the point I met him, the medical oncologist told him he would live no more than 6 months, and because he was an avid fisherman when 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 hope from a patient or their family, 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 examining room, this man was slouched on the examining table in the perfunctory blue and white, open-backed, always unflattering hospital gown. He made eye contact with me briefly, then looked down to the floor. In that momentary meeting of our eyes, I saw no sparkle, no life, 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. Mid-way 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 laying in bed, and that the active, gregarious man with the quick wit and booming voice she had married was gone.

After I interviewed and examined the Minister I left the room so he could dress and sit in a chair next to his wife. I reviewed the results of the lab tests and CT scans we had performed on him, and then returned to the examining room. I explained to them that I believed it was possible to perform a difficult operation that would remove approximately 80% of his liver. The operation would be risky, it was possible 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, assuming he survived a major operation and the recovery period, that I could not predict his long-term outcome or survival. I emphasized that even if the operation was successful, it was 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 word play 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 several times in surprise at how different his eyes 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 occurred in his demeanor and as his wife smiled at me and 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 comes 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 plain spoken or pedantic. He was a well-read and educated man and he loved to display his extensive etymologic 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 a 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.

I walked out of the examination room enthralled 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. As with all who provide care for patients with debilitating and serious medical conditions, I have seen patients lapse into a state of abject, deep despair and complete hopelessness. Like an autumn leaf falling from a tree branch, 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 months, in fact I have seen several patients die much more rapidly 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 operation was technically difficult. He was a robust, barrel-chested man and had four large tumors in his liver. Two of these were right lobe of the liver only, but the other two extended from the right lobe of his liver into portions of the left lobe of the liver. One of these latter two tumors also extended down to involve two of the three large veins that drain blood from the liver into the large vein, called the inferior vena cava, that carries blood back to the heart. To assure that I had completely removed all of the tumor around these two veins, I removed 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 at the conclusion of the operation the surgical fellow who performed the operation with me and I quietly congratulated one another on a job well done. Nonetheless, I admit to my own negative sentiments and relative paucity of optimism at the end of the operation. I remarked to the surgical fellow working with me that while the operation had been technically challenging and a great lesson in surgical anatomy, I doubted that we had cured this patient because I was concerned his aggressive cancer would return.

“Never deny someone hope doctor.” If I ever had a crystal ball to predict the future, I obviously dropped it in the mud a long time ago. I was wrong about the Minister. His cancer never returned. He spent only one week in the hospital after his operation and his sliver of liver performed and regenerated beautifully. For the first five years after the operation I saw him every three to six months with lab tests and CT scans to check for return of malignant tumors. For the next six years I saw him only for an annual visit. This man survived and enjoyed life for eleven years after being told that he only had only six months to live. He died as many of us would wish to die, in his sleep from a stroke. He gave his last sermon from the pulpit of his church three days before he died. His cancer never returned to prey upon his mind and hunt down his hope.

After thinking about it, I realize I learned one additional lesson from this patient. He taught me that it was acceptable to express a little clean, righteous anger and then laugh and move on. The Minister and I developed a ritual that was repeated with each of his visits after passage of the initial six months he was told he would live by his medical oncologist. After I reviewed the results of his tests and CT scans and confirmed that all was well and that cancer had not returned, he would smile and say, “Let’s do it!” From the examining room, I would dial the phone number of the medical oncologist in Mississippi who had referred him to me. The Minister admitted to me he was angry that this doctor had needlessly denied him hope. When the medical oncologist came to the phone, I would hand it to the Minister, who would identify himself to the doctor, and then he would say the same exact words, “Hey doc, you want to go fishing?” As a surgeon, I confess I enjoyed witnessing the surgical precision with which the preacher inserted this verbal blade, deftly turning it to maximize the impact of his statement. When I passed the phone to the Minister, he always had an impish, perhaps even devilish grin on his face. Each time after he asked the doctor in Mississippi if he would care to join him for a fishing expedition, he would hand the phone back to me and a look of beatific serenity would come to his face. The ritual was completed when I would take the phone and speak to the doctor in Mississippi. In my first few conversations with this physician, I apologized for my obvious and indecorous breach in professional behavior, but to the credit of this man being regularly taunted by a Baptist Minister who wasn’t entirely forgiving, he would tell me that no apology was necessary and that he believed he deserved and benefited from these brief but poignant verbal reminders. As the years passed, he would be laughing when I put the phone to my ear and tell me that he really enjoyed those calls and that his whole office staff looked forward to this annual event.

Two years before the Minister finally died at the age of 80, the doctor in Mississippi told me that because of this patient, he never answered the question asked to him by patients about their expected longevity with a diagnosis of advanced cancer. Instead, he would inform the patients and their families that he really couldn’t make such a prediction because of marked individual differences in responses to treatment, along with the immeasurable will to live even in individuals no longer receiving treatment for their cancer. Together, he and I learned the importance of leaving no treatment stone unturned; to engage in multidisciplinary management and to consider all options for our patients. Great lessons from a great spiritual teacher, taught to a couple of hard-headed doctors.

“Hey doc, you want to go fishing?”