Every Cancer Patient Needs Radiation Therapy!
Authors: Benjamin W. Corn
Journal: Journal of Clinical Oncology (2009)

DOI: 10.1200/JCO.2008.21.6762 The request for consultation is submitted. A 72-year-old retired engineer with renal cell carcinoma has back pain due to bone metastases in the thoracic vertebral bodies (T6-T10). The pain is refractory to opioid analgesics. The referring physician underscores that the patient received a course of spinal irradiation to this region 3 years ago and derived significant benefit. Our service is consulted to determine whether reirradiation to the same area is possible. The question has intriguing radiobiological consequences, and I send the resident physician to see the patient; she returns 3 hours later. She is beaming with pride. She has acquired a sense of scholarship about the patient and the disease. As she walks into my office, there is a newfound swagger about her, and she is clearly anxious to disclose her findings to me. After providing a summary of the disease history, including a learned dissertation about the targeted therapies, which he did not respond to during the interval since diagnosis, she concludes with a piece of information that the other physicians have overlooked. It turns out that the patient has already been reirradiated to the thoracic spine as part of an experimental protocol at a neighboring hospital. Although the chart did not initially contain a summary of that second course of radiotherapy, she has since obtained the treatment records and portal images from the hospital down the road. Retreating is not an option since he has received the maximum allowable dose. As much as I consider myself a “treater,” even I have my limits. I conclude that absent an institutional review board–approved protocol for re-reirradiation, I must decline to subject this older gentleman to the beam. In view of the dose-fractionation schedules employed and the volumes of tissue exposed, we resolve that we cannot introduce any more radiotherapy, even with an armamentarium at our disposal that includes the latest in therapies (eg, intensity-modulated radiation therapy, stereotactic body radiation therapy, and so on). The time has come for me to meet the patient. Together, the resident and I cross the bridge that leads to the ward where the patient waits. This wing of the medical center has not yet been renovated, and it feels that we have stepped back into the hospital that time has forgotten. Just before we enter the room, the resident unleashes a volley of existential questions directed at me, her senior (supposedly more knowledgeable) mentor. “How can we help him maintain hope? How can despair be averted? Have we nothing to offer?!” I am introduced as the attending physician. I, too, am anxious when I realize that there is no obvious oncologic intervention for me to recommend. Just as I am about to come up with some meaningless jargon, the resident again draws down on her instincts as healer. She sits on the edge of the bed and engages the patient in conversation. By now, she has learned enough about his social history to carry out sophisticated small talk. Neither he nor she appears to notice me. In some way she has deftly managed to convey that we can not treat him. He is unphased and much more interested in keeping the dialogue alive. The patient then endeavors to bring me into the conversation. In addition to a very high intelligence quotient, he is endowed with large quantities of emotional intelligence. “Do you see what she has done?” he queries me as if I am the junior trainee in need of didactic teaching. I am not given the opportunity to respond. Instead, he continues. “This budding cancer specialist, this exquisite young lady is gifted. She has managed to convey to me that there is nothing that can be actively pursued. But she has made it clear, and I believe her, that she will not abandon me. She has smothered me with her presence. She radiates love.” It is the latter statement that lingers within me. Suddenly, I realize that we can avail ourselves of another type of radiation therapy— one that has nothing to do with linear accelerators or heavy particles, but everything to do with being sincere. It is a radiation therapy that is not an outgrowth of an Ivy League education, but one that is borne of intense empathy. It is a form of JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 27 NUMBER 13 MAY 1 2009