On the rare occasion I’m in a social situation with people who aren’t in medicine (yes, I’m sure you know I don’t get out much, so this is largely from remote memory), the most common question that follows my answer to what I do for a living is, “How can you do what you do?”. People imagine the obvious low points of telling people about a new cancer, about delivering bad news and discussing people’s difficult cancer-related symptoms and potential to decline despite our best efforts. It’s fair to wonder what keeps us going. So I thought I’d provide a brief sketch of a day in my clinic, which offers several ups along with the downs everyone might envision as dominating life in the oncology clinic.
Work starts at about 7AM. At least the drive in avoids the big traffic. I review my schedule, briefly reviewing the recent records of the people coming in that day, including a more detailed review of the records of new patients, including reviewing their scans that are usually delivered in anticipation of their arrival in my clinic. Check e-mail, sign head shots in response to fan mail*, etc. (*in truth, it is perhaps technically more accurate to say that I sign dozens of orders for prescription refills and lab orders).
Before clinic starts, I head to the hospital to round on inpatients of mine in the hospital. One is a young man with testicular cancer who is doing fine on his chemo, though he’s grown weary of the hospital food after three admissions lasting 5 days each for inpatient chemo. Fortunately, this is his last planned round of chemo, so the end is in sight. And he knows I’m not responsible for the food. At least his nausea is so well controlled that he’s interested in eating.
Another patient is one I’ve known for a couple of years who, over a course of just a few weeks, developed dysphagia (inability to swallow larger bits of food). She unfortunately was found to have clearly progressing disease around her esophagus after receiving chemo and radiation for locally advanced NSCLC, followed by radiation to the area when that was the only area of progression about 9 months after the initial chemo/radiation (not standard, but a hope of pushing the envelope to cure her cancer). When the thoracic surgeon with great experience managing esophageal disease examined her to put in a stent to better open the esophagus, he saw that she actually has a small tracheo-esophageal fistula, an opening between the trachea and the esophagus. Fortunately, that is being blocked by the well-placed stent, but this was an unwelcome complication, and I speak with her and her two children about plans to move forward with a trial of Tarceva (erlotinib) in a few weeks. However, we’re all aware of the challenges we’re likely to face.
Clinic starts with a very nice, elderly patient who was recently found to have pleural metastases when she underwent surgery that followed initial chemo and radiation planned as induction therapy for stage IIIA N2 NSCLC. Of course, we were all disappointed (bordering on crushed) that she had advanced, incurable cancer and that the scans she had after her induction therapy and before surgery hadn’t detected the disease before she underwent surgery (the surgeon looked, took biopsies, and then ended the surgery when he confirmed that the pleural nodules were cancer). Immediately after surgery, I talked with her and her family about the potential value of a different, less challenging chemo, and I started her on carboplatin and Alimta (pemetrexed). It may have been that she was still recovering from surgery, but she had a harder time than I’d have hoped or expected, so after some extra recovery time, we agreed to have her switch to single agent Alimta, which she received two weeks ago. Having her come in at a time when I wanted to check her labs, she relates that she did just fine this time around, so we plan to try another cycle of single agent Alimta next week and then do a scan. We consider perhaps returning to the doublet in the future. We’re hopeful.
Next is a return visit by a patient with metastatic lung cancer who is on maintenance therapy after responding on first line therapy, now positively giddy that she is feeling so well on a clinical trial with a novel agent (called imitelstat, which is a telomerase inhibitor). Her last scan on the trial showed stable disease. Every time she visits, she’s effusive in her gratitude and tells me I’m a miracle worker. I half-heartedly (at best) deflect the compliment and am happy to continue the love fest.
I then see a new patient, a lifelong never-smoking Asian woman with a new adenocarcinoma. She looks and feels very well, but she unfortunately has metastatic disease documented on her imaging. Though we need to frame the discussion of what treatment can do with the limitation that it isn’t curative, we talk about the very significant chance that she has an EGFR mutation or ALK translocation that could be associated with a high probability of having a long and very good response to one of these generally well tolerated oral agents. I’m going to send her tumor tissue off for molecular testing and plan to see her back next week to review the results. If she has an EGFR mutation, I’ll start her on Tarceva (erlotinib). if she has an ALK translocation, I’ll start her on chemo but plan to enroll her on a trial with the ALK inhibitor crizotinib as soon as she qualifies. And if she has neither, I’ll pursue chemo, but we’ll discuss the details of that at the next visit, if that’s what it’s looking like. There’s only so much we can cover in an initial visit. She’s disappointed about the cancer not being curable, but she has a realistic hope that her cancer may have a marker associated with a more favorable prognosis.
Following her, I see a very young man newly diagnosed with a metastatic squamous cell NSCLC. He’s starting a clinical trial of first line carboplatin/Gemzar (gemcitabine) with or without the investigational PARP inhibitor iniparnib. He’s happy to have been randomized to the arm getting the novel agent with standard chemo: he’s hopeful. We also work on his pain control, which hasn’t been as good as I’d like, since he has extensive bone metastases (we’re also going to start XGEVA (denosumab) for that). I start him on long-acting narcotics, discussing the yin/yang of bowel medications along with that. His pain control may be a work in progress for a while, but we’re both looking forward to it improving over time. I’ll be following him closely.
My next patient is a woman who underwent surgery for a cancer of her renal pelvis, the collecting system of the kidney, which was followed by adjuvant chemotherapy. She was diagnosed and treated over two years ago, and today her follow up scans look great, with no evidence of cancer. We both know that she’s still at some risk for recurrence, but each favorable scan as more time goes by increases her odds. I’m very optimistic. Her life is back to normal, and her biggest issue is her desire to retire sooner than she thinks she’ll really be able to. I’ll schedule one more scan in a six month interval, which I’ll go over with her, hoping to give her the same good news. I get a hug.
I then see a patient of mine with advanced NSCLC who started on hospice a month ago after deciding that she didn’t want any additional treatment, which I felt was a very reasonable thought, since she’s been on and off of treatment (which has also often been effective) for about 3 years. She relates that she’s been extremely happy with hospice and the care they lavish on her, noting that her team has great experience. We discuss the unfortunate fact that far too many patients don’t start on hospice until they’re extremely debilitated, missing the opportunity she has to develop a relationship with her team before her needs become more pressing. We discuss and adjust her pain regimen, and I add another medication for her cough, and then we agree to have her come back to see me in another 4-6 weeks, as long as it isn’t a burden for her to come in. I know that if it’s a hassle for her, I can work with the hospice team via phone and fax to optimize her care.
Last before a lunch break is an ex-biker, ex-hippie who I’m treating for mucinous bronchioloalveolar carcinoma (BAC) that recurred, as I’d feared, within just a few months after his pneumonic BAC was resected. We’d checked him for an EGFR or KRAS mutation, as well as an ALK translocation, and he was negative for all of these, so I started him on carbo/Alimta with Avastin (bevacizumab). He’s done pretty well with treatment, but it knocks him down for several days after each treatment, a little more than I’d prefer. Nevertheless, I’m happy to report that his CT that he just had completed, which followed two cycles of treatment, shows a very good partial response. He’s not interested in making any changes. He and his wife share a tearful hug. I get a big hug, from each of them.
When I say lunch break, it unfortunately doesn’t necessarily mean that there is time to leave the building and get lunch. Today that break (an hour on the schedule, but with inevitable delays in the back and forth of the day, it’s about 40 minutes) is primarily to catch up on records, return a phone call from a referring physician, catch up on dictations, etc. Lunch will wait until a lull, as I have complete confidence, as you should too, that I will not starve by delaying a meal for a few hours.
Though there’s more to the day, there’s already enough to cover just the morning, so I’ll continue with afternoon coverage later. But you can already see that there are many hopeful and even joyful moments in the oncology clinic.