I ran my first clinic of 2023 this week. During this clinic I had thirty-two individual patient interactions. These are a few of the people I saw:
A forty-two-year-old woman with metastatic ovarian cancer who I was treating on an early phase clinical trial investigating a new drug in advanced cancers. She had been on the trial for two months. We discussed the results of CT she just had. It showed progression of her cancer in most of the places it had spread to. She has already exhausted all the standard treatments that are used for her cancer. We are resorting to treating her with investigational drugs to try to see if we might find something that can slow her cancer growth and maybe give her more time with her family. We failed. Now she has to wait to see if we might find her a home on a different trial using a different experimental drug. I don’t know how long the wait will be. I don’t even know if we will be able to get her on another trial before her cancer grows and she gets too sick for treatment. She knows this. She is still optimistic.
A sixty-six-year-old woman with resected colorectal cancer who I am treating with curative intent. She just finished her first round of the recommended four cycles of chemotherapy. She tolerated the chemotherapy well for the most part, only having a couple of days of diarrhea. The diarrhea might have been from the poisons I prescribed her; it also might not have been. According to statistics, she should survive her treatment and her cancer. She has between a seventy to seventy-five percent chance of cure if she completes her treatment. She seemed scared to me. I think that is a normal feeling to have under the circumstances she finds herself in.
A seventy-nine-year-old man with metastatic colon cancer on a pill type of chemotherapy as first-line palliative treatment. His original diagnosis was over twelve years ago. He had a recurrence this year which is rather strange for colorectal cancer. It is rare for this type of cancer to come back after more than a decade. He is frail now. He came in a wheelchair. He was not strong enough walk from the parking lot to the clinic room. His cancer had a mixed response to the three months of treatment he just completed. This chemo is only expected to control his cancer for a little while but if it does, it will, in the process, extend his life by many months. He told me he is not scared. He said he’s had a good life. He wants me to throw everything I have at his cancer. “Why not,” he says. “What do I have to lose?”
A forty-year-old female with metastatic colon cancer on an end-of-the-line clinical trial. She has no other treatment options. She is hoping the trial medications will afford her more time with her young family. She has an acneiform rash on her face, chest, and back from the treatment. She is also more tired. I think she downplays her treatment related side effects because she doesn’t want to give me any reason to consider dropping the doses of the drugs. This is something I know I must be careful with – trusting she is reporting her side effects appropriately. Her will to live is still greater than her ability to accept defeat.
A sixty-three-year-old female who just had a metastatic colorectal cancer lesion cut out of her liver. She has had a rough year and a half. She went through chemotherapy and radiation for six weeks just over a year ago. Surgical resection of her rectal cancer followed. I gave her four more months of chemotherapy after that to try to increase her cure rate. Six months later she was diagnosed with a local recurrence and a spot of cancer in her liver presumed to be related to rectal cancer spread. She had repeat surgery to remove the recurrent rectal cancer. A liver surgeon then removed the cancer from liver. She told me she didn’t want more chemotherapy now. I told her that was fine because the only treatment I could recommend was a repeat of the stuff she has already received. Knowing her cancer grew back so fast after her chemotherapy didn’t give me much confidence that it would do much for her if we tried it again. Her cancer is still potentially curable with all the surgery she had. She might have a forty to fifty percent chance of cure. She said something that was interesting to me while we were talking. She told me she wasn’t sure what I was going to say about chemotherapy but that when she asked God if she should do more treatment now, her answer back from God was no. It found this fascinating as I don’t have many patients telling me about their specific questions and discussions with God. I wish I would have asked her how she received the answer she got. Maybe I will next time I see her.
A sixty-six-year-old lady with metastatic pancreas cancer who told me she was feeling too unwell to try second-line chemotherapy. We just discovered the first chemotherapy we tried didn’t work at all. Her body is weak. Her will to push through more side effects from a different treatment regimen is even weaker. She will now continue her path with pain and symptom management alone. We will not treat her cancer with any further anti-cancer drugs. I discharged her from my clinic to be followed by her family doctor and palliative home care. She seems perfectly at peace with this decision and calm after she got the answer to her question about how much time she might have left. The answer: no more than a few months probably. I don’t really know for sure.
A sixty-nine-year-old man who is trucking along, doing well with his diagnosis of metastatic cholangiocarcinoma. He has been receiving chemotherapy off and on for over a year. His cancer is very stable. He continues to be a jolly man with a lot of zest for life and living. He has a very positive attitude about his situation. I’m not sure where his positive attitude comes from. He says he was born with it. This makes me wonder if we are born with certain attitudes toward life, if we are nurtured into our personalities when we are young by the way we are loved or neglected, or if we grow into them from experiences we encounter. Whatever the cause of his positivity, it’s a pleasure to see when he visits in clinic.
As I reviewed my clinic at the end of the day, making sure my orders were written and my notes dictated, thoughts raced around my head about the people I interacted with that day. Maybe my thoughts kicked up their dust storm because of the life and death nature of my work. It is also likely they swirled because a new year had just been ushered in. I tried to focus on cleaning up the day, but thoughts whistled around my brain, wandering like tumbleweed on an open prairie highway. I had so many questions.
I wondered how many of the people I saw that day would make it another year. Would some still be standing to hug and kiss their most favorite person when the clock struck midnight on December 31, 2023? Would their significant other be able to give them a loving, bitter-sweet squeeze of their hand knowing that they got another year, but much of the next will not be shared? Would they be breathing in the next new year, or will they have already taken their last exhale? Of those I saw this week, how many will challenge their death date? Will there be life and death surprises? Of course, there will be surprises – good and bad surprises. We just don’t know when, who, what, where, and how those surprise will manifest.
I think there is something to be said for statistics, for average survivals, and median lengths of life for the cancers I treat. There is science behind those numbers. They are based on clinical trial data for the most part. I share these data with my patients if they want to know them. But the power of the mind never ceases to amaze me. There are some people who mystically exceed statistics: a woman who must get to the birth of her great grandchild; a man who can’t go until he kisses his partner on their fiftieth wedding anniversary; a promise to last through a lifelong dream vacation with loved ones. I see miracles of life and love all the time. I don’t know how to explain them, but they happen.
I sat in my office after my long clinic day staring off into nothingness for many long minutes, holding space for my thoughts before I left for home that night. I try to not make predictions for, or about, my patients. I bet I’d be wrong more than half the time if I did. I do not have a crystal ball. I don’t want one. I sometimes wonder if my patients would want to know exactly when they will die. Would knowing change the choices they make for themselves? I am grateful I don’t have the power of that information.
Let’s roll the dice 2023. What gifts are you going to bring each of us? What will you take?
Author Notes:
I spent much of the last two weeks with the people I love. I was gifted my favorite gift from them – time. Time to play games. Time to laugh. Time to eat yummy food and desserts together. Time to cuddle on the couch. Time to hug. Time for sleep overs. Time for walks with the dog. Time for discussions about doing our best and perhaps trying to do even better. Time to reflect on 2022 and set some intentions for 2023.
Time: such a precious gift many of my patients don’t receive enough of.
Life is so vulnerable. None of us know if we will be around for another year. I could be hit by a bus crossing the street next month. Such an occurrence would be unlikely, but it is not impossible. I might get injured and not be able to fully function for a while. I might get a medical diagnosis that changes the trajectory of the remainder of my life. Or, I could have yet another year of abundance, filled with playful treasures and soul quenching experiences. I know what my intentions are. I don’t know what the universe will deliver. I can’t wait to find out.
Knowing many of my patients have so little time impacts me in many ways. I often wish everyone in the world could spend time with my patients. Such an experience might provide a different perspective on love and life. My patients make me a better human. I think seeing people die too soon helps me see the joy in little moments. I know my patients have taught me to adore life – to try to hold it safely in my arms for as long as I can and to try to do better, to love deeper. For me, at the end of each day, that’s what it is all about.
I am curious to know, reader, if this is the last year you have, what do you want to do more of? What is something new you might try for the first time? In what way will you try to do better in 2023?
