“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

The garage door starts to close, and I step out of the car. I can hear the squeals of joy from my 5 kids. The stresses of work vanish, even if for only a moment. I step through the door, and I am swarmed by small children clamoring for my attention. This kind of reception would make Mickey Mouse jealous. Then I come back to reality as my 8-year-old says, “Hey Dad,” without moving from the couch. Kids become too cool so fast. His action—or lack thereof&mdash;reminds me that time is swiftly passing.

Just 3 years ago, I delivered the crushing blow to my wife that I wanted to pursue an oncology fellowship. Medical school and residency is typically no walk through the park, and she was ready to move on to the next phase in our life. I questioned whether my career goals aligned with our family goals. Now, I pride myself on being a family guy, putting my family first, so I had to ask myself, “Is a fellowship the best thing for my family?” The answer to that question had to be an unequivocal “yes” before pursuing any oncology fellowship.

Oncology fellows have many aspects to their lives, and corresponding to each aspect, we have goals. In order to accomplish it all, these goals can’t be in conflict. Too often, without realizing it, doctors set goals that make sense on their own, but that compete with each other. We can’t let completing 1 goal render another impossible. When we set our goals, we must make sure that they’re cohesive enough to ensure that all can be obtained.

As fathers, we must prioritize families. Fathers are critically important to the success of a family; they are a vital component. If you don’t believe me, then visit the National Fatherhood Initiative’s website (fatherhood.org). There you can find countless statistics outlining the importance of fatherhood. We must ensure that our career goals don’t conflict with the goals we have for our families. A goal is the destination, and a plan is the route. Those who accomplish the most develop a plan, then spend the time to make sure the goal is reached. Benjamin Franklin is credited with saying, “If you want something done, ask a busy person.” Why is that? Well, it’s all about time management.

Time management begins with establishing priorities. I recently participated in a conference during which, as an icebreaking exercise, the audience was asked: If you could have 1 superpower, what it would be? The conference was attended by physicians of all specialties, and the majority selected a superpower that would create more time.

Time is our most limited and valuable commodity, and since it is limited, the best goals work synergistically. For example, choosing the right fellowship is important to creating synergistic goals. This decision requires you to be clear on what you want out of your fellowship: experience, mentorship, prestige, etc. The other aspects of life, particularly family life, can’t be paused, nor should we want to try. You can’t say, “I can do anything for a few years,” while neglecting your family. Our families keep us grounded, love and support us, and bring us fulfillment. These things sustain us, hone our abilities, and can make us more efficient. We can accomplish our goals without sacrificing our time with our families, but this requires a well thought out plan. Maybe it means selecting a city where you can afford a comfortable home, have a minimal commute to work, or live near extended family.

Successfully attaining our goals in fellowship is demanding, and understandably so. They are accomplished by establishing work/life balance. The blog HappyMD by Dike Drummond, MD, recommends these 3 steps:

Put you first. I recommend a change to step 1: “Put your family first.” The moment someone becomes a father, his perspectives change and the realization sets in that the needs of his child will always come before his own. For that moment, we are setting goals and developing plans for our children’s needs and to foster their success. We are not “Disneyland dads” making special guest appearances and buying our kids’ happiness. Fatherhood, more than any other defining characteristic, becomes who we are.

Put them on your calendar. As a fellow, you are not going to make it to every soccer game or spelling bee. But some events are a mustattend. We have to identify them and get them on the calendar. Attending these events tells the child or spouse that we love them and that we do prioritize them above our careers.

Say “no” with power and grace. This one can be difficult, as we didn’t get this far in our careers by saying “no” very often. Doing so, however, is better than saying “yes” and not accomplishing the task or, worse, sacrificing your family. One of my favorite quotes comes from David O’McKay, ninth president of the Church of Jesus Christ of Latter-day Saints, who said, “No other success can compensate for failure in the home.” Remember your priorities, and make sure that each new task aligns with your family.

For fellows, the easiest way to address the issue of having and accomplishing it all is to select your mentors carefully. Selecting mentors is an important component to creating synergy between your fellowship and your home life. I selected mentors who had a good work/life balance; individuals to whom success was extremely important, but who equally valued their their families. This allowed me to be more forthright about my responsibilities at home and honest about my ability to accept different projects and research endeavors. A mentor who knows the importance of this balance can create the opportunities suited to your success.

Fathers in fellowship must set career and family goals that aren’t in conflict. Family goals require our time and attention, so we must prioritize the family first, manage our time appropriately, and be willing to say “no” to things that conflict with our desired goals. Fathers are vital to the success of families. Our greatest title will always be Dad.

Successfully attaining our goals in fellowship is demanding. They are accomplished by establishing work/life balance.

Balancing Family With Career Goals During an Oncology Fellowship

 My patient, “Mr D”, presented with esophageal cancer. He was a robust man who looked much younger than his 64 years and had remained active after retirement. He had served in the military for many years and was a classic Southern gentleman with a strong faith who attended church regularly. He had enjoyed good health until the preceding months, when he developed progressive dysphagia. Otherwise, Mr D had felt well enough to travel to the Grand Canyon during the summer and had delayed seeing his physician.

When Mr D returned home, his primary care physician initially reassured him that there was nothing to be overly concerned about. However, a routine endoscopy revealed a large esophageal mass that proved to be adenocarcinoma.

When I first sat down with Mr D and his wife, it was clear that they were both overwhelmed by their current situation. In a frenetic way, they had sought out several opinions regarding treatment prior to meeting with me and my colleagues. First, they sought out advice from a local oncologist. Then, they traveled and were evaluated at Memorial Sloan Kettering Cancer Center (MSK). Following their visit to MSK, they sought advice at Mayo Clinic. Although exhausted, Mr D and his wife travelled to Cleveland Clinic before making any final decisions.

I was faced with providing Mr D and his wife with news that they had heard before. I explained that his esophageal tumor appeared to be unresectable and that upfront systemic chemotherapy would be the best approach for treatment. Although he showed no evidence of metastatic disease on staging scans, it was clear that there was only a limited chance of cure. Advanced esophageal cancer is a highly lethal malignancy and often spreads despite aggressive therapy. I discussed that treatment would be palliative in an attempt to reduce the esophageal mass and prevent additional side effect from his cancer; treatment would not eradicate the disease. When confronted with this information, Mr. D appeared defeated and weary. He was emphatic as he looked straight into my eyes and said, “I know you can cure me. I am going to beat this.”

As a young oncology fellow, I struggled to respond to this statement. How could I be realistic about his diagnosis without taking away his hope? In the eld of oncology, trainees are taught to be honest when delivering a cancer prognosis, yet to always leave some room for hope. When predicting when a patient may succumb to a malignancy, we cite historic precedent. But there are the rare patients who survive many months, even years, longer than initially assumed. I often remind patients that there are outliers—cancer treatment super responders who defy any traditional trajectory that could be predicted based on disease staging. And so, I suggested to Mr D that although there was no guarantee that his tumor would respond, enrolling in a clinical trial with induction chemotherapy followed by surgical resection, if there was dramatic tumor shrinkage, would be his best course of action.

Mr D subsequently enrolled in a trial and received 4 cycles of leucovorin, uorouracil, and oxaliplatin (FOLFOX) combination therapy. At each follow-up visit, Mr D appeared to be tolerating treatment extremely well; his dysphagia resolved entirely. His excitement grew, as did mine, as he completed 4 rounds of chemotherapy. We therefore took the next step of scheduling his surgery for the following month. Then, during his final visit before restaging scans were to be obtained, Mr D appeared concerned. He mentioned that he had developed some vague abdominal pain in the preceding days.

Given his clinical course, I reassured him that it was likely nothing. I, too, held the same hope that he had responded to treatment. Unfortunately, the results of a computed tomography (CT) scan of his abdomen delivered on the following day revealed small, but undeniable, peritoneal nodules that raised suspicion of carcinomatosis. A subsequent CT-guided biopsy of 1 of these nodules demonstrated adenocarcinoma.

I called Mr D later that day to inform him of the bad news. He now had metastatic disease and would not be a candidate for surgery. Instead, we would have to proceed with second-line systemic chemotherapy. I told him I was concerned that his cancer had progressed in a short period of time.

To this news, he simply responded with, “I believe in the power of hope,” which astonished me. Mr D went on to receive several cycles of treatment, followed by a course of palliative radiotherapy after his esophageal tumor grew in size again. He then enrolled in hospice care, but passed away only a few months later.

Mr D’s case left a lasting impression on me and my approach to practicing medicine. While his story may not be unique, it does remind me what a tremendous privilege it is to be an oncologist and to dispense hope to my patients. Hope is a powerful tool. To hope is to be human—undoubtedly an evolutionary behavior that has allowed humanity to overcome incredible adversity throughout the centuries. As an oncologist, I witness humans facing extreme challenges every day. Mr. D’s story is reminder of why I maintain hope for all of my patients and their families.

Advanced esophageal cancer is a highly lethal malignancy and often spreads despite aggressive therapy.

June 2017 | Oncology Fellows

The Loss of My Friend

Balancing Family With Career Goals During an Oncology Fellowship

Challenging Case Teaches Oncology Fellow the Power of Hope