When the unexplainable happens

Richard C. Frank

About six months ago, I received a call at my house from a family friend who was in distress. As a community oncologist, it is not uncommon for me to receive cancer crisis calls from family, friends or someone I may not even know. This call concerned the grandfather, whom I will call John, of a friend of one of my boys; the caller was the boy's mother, whom I will call Donna, daughter of the patient.

I had actually known about the situation for some time. Donna and I had briefly talked about it at little league games or at places where parents run into each other. John had been battling liver cancer for over four years. He was being treated at a large, well-known cancer hospital and the doctors there had done an excellent job of keeping the cancer at bay. Over the years, parts of his liver had been surgically removed, others boiled with hot probes and many blood vessels had been choked off to deprive the cancer of oxygen. When these local measures no longer worked, he took chemotherapy and like a good soldier, even enrolled in clinical trials testing experimental ways to treat the cancer.

But John felt that the oncologist taking care of him now was mainly interested in enrolling him in study after study and that none of the chemotherapy or research treatments had done any good. The doctor did not answer his questions, talk to him about prognosis, or treat his ever-increasing pain. By the time his daughter reached out to me, the cancer was growing widespread in his liver and lungs, and John was told to enroll in a hospice program close to home. The center could not do anything more for him. They made him an appointment to return in three months, if he was still alive. Needless to say, the patient and his family were distraught.

Although I did not relish caring for a friend's dying parent, I agreed to see John in my office. I was thinking that I could at least make him feel cared for and supervise his end-of-life care. As John walked into my office and forced a smile, he appeared to be a man in the middle of the ocean holding onto a sinking boat. His wife and children filed in somberly. We started out by getting acquainted, talking about his life a bit and what he wanted most for the remainder of it; we even laughed some. John said he accepted that he was dying, that he could barely get out of bed and had no appetite, but that he just wanted to feel better if possible. He wanted to be hungry again, eat his favorite pasta meal, and be able to move without severe pain.

I first addressed his pain by prescribing a steady, more potent pain regimen. I had to assure him that taking narcotics would not make him an addict, something he feared and which greatly frustrated his family. Next, I was concerned about his shortness of breath, so I ordered a lung scan which revealed blood clots in his lungs (pulmonary emboli) in addition to the tumor deposits; I prescribed an injectable blood thinner, called enoxaparin (Lovenox). He seemed to immediately improved with these changes but he soon developed severe pain in his hip and I diagnosed new bone metastases. I convinced him to undergo a course of radiation therapy (he did not think it was worth the trouble), which fortunately did greatly diminished his pain.

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