Tagged Chemotherapy

When the Cancer Doctor Leaves

Doctors

When the Cancer Doctor Leaves

I knew how difficult it would be to tell my colleagues I was leaving for a new job. I didn’t anticipate how hard it would be to tell my patients.

Credit…Aaron Josefczyk/Reuters

  • Jan. 14, 2021, 5:00 a.m. ET

“I’ve known you since 2003,” my patient reminded me, after I had entered the examination room and took my usual seat a few feet away from her. She was sitting next to her husband, just as she had been at her first visit 17 years earlier, and both wore winter jackets to withstand the sleet that Cleveland had decided to dump on us in late October. “That was when I first learned I had leukemia,” she added. He nodded dutifully, remembering the day.

I was freshly out of my fellowship training in hematology-oncology back then, and still nervous every time I wrote a prescription for chemotherapy on my own, without an attending’s co-signature. In her case, it was for the drug imatinib, which had been on the market only a couple of years.

At the time, a study had just reported that 95 percent of patients who had her type of leukemia and who were treated with the drug imatinib achieved a remission. But on average, patients in that study had been followed for just a year and a half, so I couldn’t predict for her how long the drug might work in her case.

Seventeen years later, she was still in a remission. During that time, she had retired from her job as a nurse, undergone a couple of knee replacements, and had a cardiac procedure to treat her atrial fibrillation.

“You had a toddler at home,” she reminded me. That son was now in college. “And then your daughter was born the next year. And you had another boy, right?”

I nodded, and in turn reminded her of the grandchildren she had welcomed into the world during the same time. We had grown older together. Then we sat quietly, staring at each other and enjoying the shared memories.

“I can’t believe you’re leaving me,” she said softly.

When I decided to take a new job in Miami, I knew how difficult it would be to tell the other doctors, nurses, pharmacists and social workers I work with, the team from whom I had learned so much and relied upon so heavily for years.

I didn’t anticipate how hard it would be to tell my patients.

For some with longstanding, chronic cancers, it was like saying goodbye to a beloved friend or a comrade-in-arms, as if we were reflecting on having faced down an unforgiving foe together, and had lived to tell about it.

For others, still receiving therapy for a leukemia that had not yet receded, I felt as if I were betraying them in medias res. I spent a lot of time reviewing their treatment plans and reinforcing how I would transition their care to another doctor, probably more to reassure myself than my patients, that they would be OK.

A few were angry. Unbeknownst to me, my hospital, ever efficient, had sent out a letter informing patients of my departure and offering the option to choose any one of eight other doctors who could assume their care — even before I had a chance to tell some of them in person. How were they expected to choose, and why hadn’t I told them I was leaving, they demanded indignantly.

I felt the same way as my patients, and quickly sent out my own follow-up letter offering to select a specialist for their specific types of cancer, and telling my patients I would miss them.

I then spent weeks apologizing, in person, for the first letter.

And though I always tell my patients the best gift I could ever hope for is their good health, many brought presents or cards.

One man in his 60s had just received another round of chemotherapy for a leukemia that kept coming back. I think we both knew that the next time the leukemia returned, it would be here to stay. When I entered his examination room, he greeted me where my other patient had left off.

“I can’t believe you’re leaving me.”

Before I could even take a seat, he handed me a plain brown bag with some white tissue paper poking out of the top and urged me to remove its contents.

Inside was a drawing of the steel truss arches of Cleveland’s I-90 Innerbelt bridge, with the city skyline rising above it.

“It’s beautiful,” I told him. “I don’t know what to say.”

“You can hang this on your office wall in Miami,” he suggested, starting to cry. “So you’ll always remember Cleveland.” And then, Covid-19 precautions be damned, he walked over and gave me a huge bear hug. After a few seconds we separated.

“No,” I said, tearing up. “I’ll hang up the picture and always remember you.”

Mikkael Sekeres (@mikkaelsekeres), formerly the director of the leukemia program at the Cleveland Clinic, is the chief of the Division of Hematology, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine and author of When Blood Breaks Down: Life Lessons From Leukemia.”

When Cancer Treatment Offers Hope More Than Cure

We joked that she had nine lives.

And like a cat, over the years, no matter the adversity — the extreme toxicities that resulted from her many rounds of chemotherapy, the bowel perforation that left her with an ostomy, the trips to the intensive care unit — she always landed on her feet, the wattage of her personality undimmed.

With the most recent return of her leukemia in the fall, I asked her, not for the first time, if she had been through enough, and would like to forgo any more treatment.

Photo

Mikkael Sekeres, M.D.

Mikkael Sekeres, M.D.Credit

“I’m not ready to give up yet,” she told me. “I still got a whole lot of living yet to do.”

Her partner of 45 years was sitting next to her, his arms crossed over his Cleveland Browns shirt, his hoary beard making his reaction to her comment somewhat inscrutable, other than his nodding. He came to every appointment, and always deferred to her, offering his opinions on the woeful state of Cleveland sports teams, but on nothing having to do with her medical condition. He just quietly supported her decisions. Though I had learned his name when I first met them years ago, I had since forgotten it in favor of what she called him – Boo. I referred to him as “Mr. Boo.”

Whenever her leukemia returned, she never asked about the likelihood that chemotherapy would work. Even if she had, my response would have been, by necessity, vague. No studies of patients who have had multiple relapses of leukemia have compared one treatment approach to another, and those that report outcomes in such patients suffer from what is called “confounding by indication.” In other words, people who are healthier are more likely to be offered chemotherapy, and thus more likely to live longer regardless of what they received. My patient was just such a person.

She entered the hospital to receive more chemotherapy, and as before became profoundly ill, narrowly skirting death yet again. Five weeks later, her blood counts had returned to normal, indicating that the leukemia had receded one more time, and she was back in clinic. I walked into her room to give her the good news.

She was a shadow of her former self.

Slumped in a wheelchair, she sat listing to one side, clutching a tissue in one hand. Mr. Boo sat close by, his arms crossed over a Cleveland Cavaliers shirt. I nodded to him and then asked her how she was doing.

“I’m tired, Lord have mercy I am tired,” she answered. Mr. Boo said nothing. I moved a chair next to hers and held her hand as she cried quietly, the three of us absorbed in her emotions, enveloped by the silence in the room.

“This one was tough,” I said eventually, stating the obvious. She nodded. I turned to her partner. “How’s she doing at home, Mr. Boo?”

“Oh, she’s doing,” he said, rearranging himself to sit up in his chair a little straighter. “It’s hard, though. She spends most of her time on the couch, and gets from there to the bathroom and back. But that’s about it.”

I turned back to my patient, still holding her hand. “How about we take a little break from the treatment?”

She nodded, and we sat in silence again. After a while, she asked “When we gonna get started on chemo again?”

I looked uncertainly at her and then at Mr. Boo. He looked back at me, awaiting my reply. This time, I rearranged myself to sit up a little straighter in my chair.

“Well, I have to wonder if giving you more chemotherapy is the right thing to do, with all that you’ve been through. I’m wondering if we should be talking about bringing more care into your home, to assist both you and Mr. Boo. Maybe even hospice.”

I had said the word.

Though I explained to her the many benefits of hospice, how their providers could help her at home in a way I couldn’t in relieving her symptoms, and in making her more comfortable, she didn’t meet me in the eyes for the rest of the appointment, almost as if I had betrayed her.

She hadn’t been eating or drinking much at home, so I admitted her to the hospital for a few days for hydration and she perked up, rising like Lazarus yet again, and returned to my clinic the following week.

She was smiling, laughing, had been doing well with physical therapy, and even was able to get out of her wheelchair to the exam table.

And she wanted to discuss the next round of chemotherapy.

For my patient, I came to see, treatment was inextricably linked to hope, and I suspected that it was her hope, much more than the chemotherapy, that had kept her going years beyond what I would have predicted.

But I was the one who had to keep writing orders for the chemotherapy, albeit in low doses, that was keeping her hope, and thus her, alive.

Was that so wrong?

Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic.

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