A Bag of Chips
Authors: Daniel Rayson
Journal: Journal of Clinical Oncology (2015)

DOI: 10.1200/JCO.2014.60.3795 I had heard about her from one of my colleagues in radiation oncology. A young woman diagnosed with metastatic breast cancer after suffering 3 to 4 months of progressive back and hip pain. I was told she was a photographer struggling to make ends meet taking photos of the pounding surf along the Atlantic Coast. She had sought medical care a number of times, but she was young, the pain seemed mechanical, and there were no other symptoms. Rest, ibuprofen, and time were prescribed. She was now on day 8 of a 10-day course of palliative radiation therapy for spinal cord compression. Her motor strength was recovering, and the pain was improving under cover of steroids and narcotics. The large breast mass discovered by the physician whom she was able to convince of her pain clarified everything, and she was now waiting for me. She was slumped forward in a wheelchair, disheveled hair scattered crazily across her face. She spoke little during our first encounter, clearly scared and partially stoned from the narcotics. Her mother stood guard, daring me with her eyes to say there was nothing to be done, that there was no hope. She was ready to pounce. Over the next 2.5 years, we traveled a ragged path, oscillating between treatment and observation, surgery and irradiation, endocrine therapy and chemotherapy, tears and laughter, anger and peace. Her mother made sure that we stayed on the same page and would interrupt if Dori was minimizing symptoms or if I was being unclear as to treatment goals or toxicities. Dori’s boyfriend, Mitch, was a quiet brooding presence, always there when it mattered most. Only toward the end did I learn that they had met just a few months before the diagnosis. We enjoyed the reprieves. I learned about her work and some of her loves. I learned that she swore at the chemotherapy nurses when the needles hurt and said she loved them in the next breath. At some point I found out that she had spoken at a number of breast cancer–related events. She gave me a copy of one of her speeches. The words were passionate and never self pitying. Her anger at the surgeon who told her she was going to die in a few months, making breast surgery pointless, fueled her drive to prove him wrong for as long as she could. She was experiencing a hiatus of relative disease stability until developing new headaches, slurred speech, and a strange inability to focus her vision. A computed tomography scan showed brain metastases, and her left eyelid became increasingly droopy because of an enlarging retro-orbital mass. During radiation therapy for these lesions, she connected with a friend of one of her favorite musicians on Facebook and was invited to his New Year’s Eve concert with a backstage pass. The only time I saw her cry was when I innocently asked about the concert. Nausea, fatigue, vision, and pain had denied her the experience. Six months after Dori developed brain metastases, I flew to Chicago for the American Society of Clinical Oncology (ASCO) 2014 meeting, joining 34,749 others. Before leaving I visited her in the palliative care unit where she lay with Mitch by her side. A sunken cot was next to her bed. We had a quiet laugh as I noted that her bedside table was full of small bags of barbecue chicken–flavored potato chips. These were her favorite kind, she told me. The taste made her smile. She made me promise to try them when I got back from Chicago, insisting that I would love them. She asked me to find something that would help her while I was there. At the ASCO meeting, I followed my usual routine, picking sessions that I thought would be relevant to my practice, running to poster discussions, and sitting through at least one set of presentations in a field completely out of my area of expertise. My favorite time is always the quiet before the show. I try to arrive 10 minutes early and sit in the huge room with my iPod tuned to my favorite music while watching the crowd quietly populate the vastness. Those moments bring me a strange peace amid the general chaos of the meeting. This time was different. I could not get comfortable. The smug feeling of being brought up to date by the brightest in the field armed with the most compelling data did little to counter the gnawing ache that nothing I would learn here could help Dori. As I wandered through the convention center, I wondered how many others had similar patients on their minds as we raced pass one another to the next sessions. How many felt as helpless? JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 10 APRIL 1 2015