Musings of a Cancer Doctor (2012)

GEORGE W. SLEDGE JR., MD, Immediate Past President of the American Society of Clinical Oncology, is Ballve-Lantero Professor of Oncology and Professor of Medicine and Pathology at Indiana University Simon Cancer Center.On Friday, March 2nd, I was in clinic seeing my breast cancer patients. It was a short day: I was flying off to Dallas late in the afternoon for a meeting, so my last patient was scheduled for around 2:30. On my list that day was a study patient receiving a targeted therapy for recurrent HER2-positive disease. She had suffered fairly significant toxicity from one of her study drugs, and we spent a good portion of our time together trying to decide whether to continue it at a lower dose or not. I wish I could trust my aging brain better than I can, but I think my last memory of her was of her wishing me a safe trip to Texas. I travel far more than is good for me, and my patients know it, and some worry about it. I always assure them that I will tell the pilot to be extra-special careful because their doctor is on board, and—I jest—I am certain that because of my words he will go out of his way not to crash the plane. I think I had this conversation with her, but I can't be certain, to my shame. Our final conversations become fraught with meaning only in retrospect, and I had no sense that this was our final conversation, or that it would be worth remembering. My final meetings with patients are usually something quite different: conversations regarding hospice care, advanced care planning, pain control, my apologizing for my inadequacies as a physician and modern medicine's inability to prevent the inevitable, followed by tearful hugs and sad goodbyes. I fear and treasure the memory of those conversations. But this wasn't one of them. She was responding to therapy, and it was one of those wonderful new HER2-targeting combinations filling oncologists and their patients with so much hope. HER2-positive disease is on its way to being testis cancer, or something similar. This was a trip devoted to tinkering around the edges. It had no stench of death about it. I went to the airport, where the television monitors showed a pretty ugly front moving through to the south of us. We had seen two storm fronts move through Indianapolis earlier in the day, which I had missed other than seeing gray skies at a distance once when I went out to the waiting room. I thought nothing of it, other than its potential to delay my flight. My plane took off on time, and landed on time, and when I got to my hotel room and turned on CNN I learned that a tornado had tore through the southern part of Indiana. My patient, after leaving me, received her study drug. She then had driven home, driven south into the fearsome maw of Mother Nature. There she had run some errands, and was out on the road when the tornado picked up her van and casually, thoughtlessly, tossed it against a tree. Amidst the widespread devastation of that part of the state she was not immediately discovered, and when she was the following day, she was dead. I found out about this earlier today, the Monday after the Friday clinic where I told her “see you soon.” One of my research nurses came by to tell me the news. I was flabbergasted then, and now. I don't quite know how to process it. Death on a clinical trial has its own system. You can't just die; you have to do it by the book. Death on a clinical trial is a Serious Adverse Event, to be reported immediately, and with attribution. We filed a form outlining what had occurred, and answering seemingly sane questions such as “AE suspected to be caused by [study drug]?” and “AE Non-Serious or Serious?” and questions regarding whether the adverse event “resulted in a congenital anomaly/birth defect in offspring of study subject?” There are times when life's enormous absurdity smacks you hard in the face, and certainly listing “tornado” as the cause of death for a patient with metastatic breast cancer comes close to the top of the list. Each part of this country has its own natural disasters. In California they have earthquakes, and in the Gulf they have hurricanes. Here in the Midwest we have tornadoes, more tornadoes than any place on the planet. They usually are part of some vast, violent, rapidly moving front. They come and go with frightening speed. The pictures out of southern Indiana the last few days are typical: homes, schools, businesses turned into matchsticks in seconds. A line of destruction, and on either side of that line, a block away, buildings totally untouched: terror, fringed by normality. Where that line is placed is totally arbitrary, which makes one wonder: chance, fate, destiny, the hand of God, or just plain bad luck? Had I spent a few more minutes talking with her in clinic, would she still be alive, her schedule pushed back just enough to avoid the worst of that storm? I don't know. But I know this: great storms teach us nothing new. We are tiny, puny, inconsequential creatures, and a great wind can pick us up and snuff out our lives and we are gone forever, except in the memory of those who care about us. This is as true today as it was ten thousand years ago. Great storms teach nothing new. But the trial she was on has the potential to help save lives, hundreds, perhaps thousands, of lives. It will teach us something new. Her willingness to put her body on the line, her cheerful toleration of adverse events, her hopes that her life might help others; they defined her, not that bizarre “serious adverse event” which ended her life. I only wish, wish with some desperate deep sadness tonight, that I had known her better, and remembered more about her. I'm sure she was, like all of us, something exceptional, something special, unique and irreplaceable. More from George Sledge on his OT Blog! Read and comment at http://bit.ly/OT-Sledge