“Emperor of all Maladies” they call you.

Indeed, you cause and create so much melancholy

Only to be shaken when my friend is gone.

Grief, I have experienced all the stages,

Animosity toward this infirmity is robust,

But despite the sadness, hope is not gone.

One day, yes someday, we will ward off this sickness.

Yes, that day is dedicated to all who endured, directly or indirectly.

Indeed you cause and create so much melancholy,

Every medical specialty is a unique subject, and oncology is no exception. Despite the vastness and depth that it entails, it resorts to some of the most universal laws of “being human.”

Every organ has a different kind of cancer, and each cancer is an independent disease in terms of its course, treatment modalities, and outcomes. Two people with the same cancer type can react in completely different ways, depending on their age, race, gender, lifestyle differences, motivational capacity, and physical strength.

When an oncologist starts caring for a patient, besides applying the guidelines to the case scenario, one cannot disregard the variables that accompany an individual as a virtue of their being. The oncologist and his or her patient are about to undertake a journey that is exclusive to only that one case.

Most cancer treatments span from a few months to a lifetime, based on the stage of the disease. Beyond the physical stress and strain on the patient’s body, this long haul is besieged by overwhelming emotions. Anxiety, apprehension, fright, anger, and depression are just a few of the many feelings that come to haunt the patients and their families. And thus, while oncologists take care of the physicality of the disease, they become a friend and confidante of their patients and families— and sometimes even, in a sense, a family member as well.

An oncology clinic is a place where no one would ever wish to be. However, when life does put an individual through that fight against cancer, patients end up forming a most powerful bond with their oncologist.

While we oncologists consciously take care of our patients, putting the best data into clinical perspective, trying to discuss the difficult options for treatment, to ensure the best line of action, we are also establishing relationships of compassion, empathy, affection, and friendship with patients and their families. The physician is a human being first, and a trained oncologist second. And while it is a generally accepted rule to remain professional and keep emotional attachments to a minimum, it is rather difficult to practice this directive in oncology. Most of the time, logic and science have some sentiment and intuition at play in the background.

When I state this fact, I must clarify, I am not referring to emotional bias influencing rational judgment; instead, I am talking about an oncologist’s dilemma and dismay when the current treatments are failing unexpectedly, there are no more treatment options left to pursue, or the patient has rapidly progressing disease. There are times when all the available treatment options have been exhausted, but the oncologist is not yet ready to accept the loss.

Death is an inevitable part of life; it is the single most all-inclusive phenomenon. Although everybody knows this, nobody wants to see loved ones dying, and an oncologist is no exception. When a patient approaches the end of life despite treatment, the oncologist also confronts feelings of desolation and disappointment. Despite being well aware that they made their best attempt at treating a particular case, the oncologist can’t help but speculate about other possibilities. Was there any other option? Was there any clinical trial anywhere in the country that could have benefited the patient? Could there have been some out-ofthe-box treatment? Sometimes we just ask ourselves, when will we be able to find an answer to our questions and prayers? It’s hard not to have doubts about the fairness of the world.

Ultimately, I would say most oncologists are optimistic individuals, people of forbearance. We see the alchemy of life and death on a regular basis, but this does not dampen our spirit to start afresh when we begin a new patient’s care. I don’t mean to imply that all oncologists are upbeat all the time; there are days when we feel worn out. However, we recuperate quickly, to put our best efforts into each patient’s treatment. There are new medications getting approved for most, if not all, tumor types. There are countless clinical trials in multiple cancer institutions all over the world. Many cancer treatments have achieved landmark success in transforming a once-fatal disease into a chronic disease a patient can live with for a prolonged period. There is an endless anticipation and aspiration to be better, to do better, and to keep persevering, as we strive to make this ghastly disease nothing but a piece of history.

Articles

The Loss of My Friend

After attending a family event in California, I was landing in Chicago, the city I did my residency in, when my cell phone gained a signal and messages and e-mails started to pour in. It is amazing how technology captures our attention and plays a large role in day-to-day life. I had already been feeling anxious and restless during the flight, being disconnected from my phone. As I opened up my mailbox, there it was, an acceptance into one of the country’s best hematology/oncology programs at Baylor College of Medicine. Despite having just landed on the ground, I felt as if I had taken off into the air, much higher than the actual flight’s altitude. There was a sense of exhilaration as tears gathered in my eyes with deep satisfaction welling up my heart. My first thought was that “Dreams do come true.”

Patients Are Your Biggest Teachers and We Must Learn to Befriend Them

Deciding on a subspecialty during my medicine residency was not easy. In fact, my brother was the first one to prompt me to opt for hematology/oncology, as he himself was practicing surgical oncology and felt this would be a great option for me. A few close friends, however, disliked the idea because of my jubilant and perky, yet very emotional, personality. Everyone who even faintly knew me felt that I would become depressed when I would see my patients dying because of this ghastly disease, often regarded as, “The Emperor of All Maladies.” Nonetheless, I weighed my options and after putting much thought into it, I did finally make a decision to pursue hematology/oncology.

As I started my fellowship in January of 2013, every passing day and every single patient that I met with, strengthened my determination to master this subject. Fortunately, I had the privilege of connecting with indomitable faculty at Baylor and ever inspiring seniors and friends who helped me learn the fine details of the topic material and the art of managing patients with cancer.

At the end of the day, however, I must say that the most important teachers in this field are your patients. Beginning with their first scan, when a mass “concerning for malignancy” shows up, patients experience profound anxiety and curiosity. Physicians disclose the scan findings to patients, who then undergo pathologic diagnosis and are referred to medical oncology for consideration of systemic therapy. The first visit with a medical oncologist is the most crucial. The appointment can last anywhere from 45 minutes to an hour and a half. The patient will have a million relevant questions to ask about the exact diagnosis, staging, and their treatment options.

And, of course, the patient will ask the worst and most difficult question, “Doc, how much time do I have?” As a physician in training, I found responding to patients’ questions very difficult in the beginning. Beyond questions on diagnosis and stage, I struggled with how to answer questions related to prognosis or questions on the category-1 treatment options recommended for their cancer type. Slowly, however, I found that you do get a grip on how to handle these situations. It took me around 6 months to become comfortable establishing myself as a confidante and a friend to my patients.

When patients with cancer are waiting inside a clinic room, they are normally filled with a swirling storm of thoughts and emotions related to their diagnosis and prognosis. If they are an established patient, they are more concerned about treatment response and the possibility of disease progression. Therefore, it is of tremendous importance that we are not only good physicians, but also good friends with our patients.

Cancer Treatment Is Not a Destination, It is a Journey!

One of my attendings taught the fellows not to introduce ourselves as “doctors.” “They already know you are a doctor, you don’t have to reiterate that fact,” he would say. Now, when I enter the room and introduce myself, I tell them, “Hi, I’m Dr Kamboj.” Almost 100% of the time they ask me how to pronounce my last name. I normally respond with, “You can call me Jasmine, and I absolutely don’t mind that.” There is a sense of relief and comfort as I say this. Most of the patients start calling me “Dr Jasmine.” I feel I have won a battle when my patients come comfortably into my zone or territory and offer me their trust. As patients with cancer, they are literally placing their lives into your hands. Gaining their trust is vital, as we are starting this voyage together.

Once the diagnosis has been revealed to the patient, and prognosis and treatment options have been discussed, I feel the most significant next step is to “give them some space.” Not pressing on patients during the same clinic visit for their final decision, allowing them time to discuss their situation with their loved ones, and offering them all of their available options are critical points in care. When I say “available options,” I not only discuss the treatment for cancer, but also insurance coverage, drug assistance programs, social work help for sorting out a tough family situation, and transportation issues. For those of us who are in private practice, insurance approvals form a dominant part of such issues while for those who are in county settings, social assistance can be very taxing.

Most of the time when you throw the ball in a patient’s court they ask YOU to make the final decision on their behalf. They often say, “You are the doctor, and you know what is the best for me, so you decide what I should opt for.” At this point, we need to jump in as their shepherd and escort them along their path. When a patient is about to begin this frightful expedition, the key is to lay out the plan in 2 ways. First, explain the overall plan (eg, for locally advanced rectal cancer, chemotherapy and radiation to start, followed by surgery, followed by more chemotherapy). Second, we must tell the patient what to expect over the next few days to weeks. This may include discussing side effect profiles of chemotherapy or common side effects from radiation (although radiation oncologists would go over these details in their clinic, as well).

Patients should be aware of what to expect, as surprises are not pleasant for patients who are already going through a lot of turmoil. Often, when we are not clear enough in outlining the overall plan, a patient may be taken aback when they visit us after surgery only to have us reveal the plan for 4 more months of chemotherapy (again, following the example of locally advanced rectal cancer).

Remember That Both the Patient and the Doctor (YOU) Are Human Beings

We usually follow up with our patients every 3 weeks, or sometimes more frequently, to monitor their adverse effects and tolerance of chemotherapy. We should never shy away from adjusting the dose of chemotherapy based on their tolerance. Again, supportive care is critical. In this day and age, many chemotherapy treatments are not as harsh as they used to be. The key is to use the right supportive and prophylactic medications at the right time. Pain, nausea, diarrhea, malnutrition, anxiety, and depression are commonly experienced by patients with cancer, and there are excellent guidelines for the management of all of these conditions. Studies have shown that practicing good palliative care from the start of cancer treatment improves survival. Any oncologist can recommend chemotherapy, but what makes you distinct from the rest is how comfortably your patients sail through their treatments.

I feel that one very common mistake is maintaining a very serious environment in the clinic 24/7. Despite the fact that the patients who enter an oncology clinic are overwhelmed with apprehension, I feel it is essential that we don’t forget the basic etiquette of “being human.” Laughing with them, initiating a conversation with their accompanying family members, narrating your own experiences, letting them know the simplest things like, “It is not your fault that you have cancer,” asking them toward the end of encounter, “Is there anything else I can help you with?”, will go a long way in calming down the trepidation.

Of course, you have to make a judgement call regarding what to say and when. We cannot laugh during end-of-life discussions; rather, these conversations require a great deal of compassion and empathy.

As cancers doctors, we are in the habit of overexpecting and overestimating in certain circumstances. Most of us have type A personalities and always seek to achieve better in our personal or professional lives.

That principle also holds true for us when it comes to our patients. It is important, however, to us and to them to be able to identify where to put a full stop or a comma in the cancer treatment. Advising your patients to take a chemotherapy holiday to be able to make a trip to meet family and friends is most often well appreciated and does not adversely affect outcomes. To make a call to stop treatment after progression on multiple lines of chemotherapy or if a patient’s performance status rapidly deteriorates, is crucial. We must recognize that our job is to make things easier and better for them. Buying a few weeks extra at the cost of poor quality of life may not serve that purpose.

Like many others, I believe that medicine is an art. This is an area where having knowledge is only one part of the whole game. You must have attributes such as compassion, empathy, and humanness to be able to be a successful doctor. In oncology, these attributes are especially important as we often perform the task of giving bad news.

After our most powerful chemotherapeutic agents or targeted therapies fail, and surgery or radiation are not options due to widespread metastases, we need to inform patients about the futility of any further interventions. Not only must we acknowledge our limitations as a physician and the frailty of Western medicine, we must also suggest comfort care or hospice. By definition, this means that the patient has a life expectancy of 6 months or less. In actuality, in cancer medicine, it is often much less than that.

We must ensure that we explain to patients and their families the philosophy of supporting their emotional, social, and spiritual needs while addressing their symptoms. This helps care for them as a whole, as you are respecting their needs as a human being and their family members’ beliefs and wishes. Letting them know they are “not being abandoned” is of paramount importance to this extremely challenging discussion. Making yourself available, even when patients are in hospice, will do wonders. As I mentioned previously, cancer treatment is a journey, and we form a bond with our patients and their families. We should not abruptly break that bond.

I have led a bachelorette lifestyle throughout my fellowship. My 5-year-old son has been in India with my wonderful parents, who have always tried to make my life easier and more comfortable. For those of us who have families, I think it is essential to take time off and spend time with our families on a regular basis. Hematology/oncology is a rapidly changing subspecialty and demands persistence in updating ourselves with the latest developments. Needless to say, the emotional aspect of the field can sometimes impact us significantly. Once we are seeing a patient every few weeks, over a long period of time, we develop a relationship not just at a professional level, but also at a spiritual level.

The losses are inevitable. To be able to accept those losses with dignity and not get affected negatively by the fragility of human life is a must, in order to cater properly to our other patients. A doctor’s family and friends, therefore, are as important on this journey as the doctor, patient and patient’s family.

In the end, I would like to express my gratitude to God, who has offered me this opportunity to be able to take care of patients affected by cancer; my family (my mother, father, brother, and my little son who means the world to me), who have always stood by me and been a constant source of strength during some really testing times; my teachers, seniors, friends, and staff at Baylor, who have taught me some very important lessons in the subject and in life; and last, but not least, all of my patients, who have made me the person and physician that I am today.

It is amazing how technology captures our attention and plays a large role in day-to-day life.

Jasmine Kamboj, MD

Articles

The Loss of My Friend

Living Life and Discovering Its Deeper Meaning