Following a busy morning, I grabbed a quick lunch and, as usual, ate quickly at my desk while completing transcriptions and catching up on e-mail before diving into the afternoon. My first patient of the afternoon was a 75 year-old gentleman with prostate cancer who has done very well on combined androgen blockade for many years. Though his PSA has been rising very slowly, he continues to feel well, and his PSA remains low enough to defer on making any changes. I explain to him that even though we may need to switch to a different treatment approach in a few years, the slow rate of rise after so many years on his current therapy makes it very likely that he’ll do very well on subsequent therapies, whenever we pursue them. There’s an excellent chance that his cancer won’t limit his survival. It’s important to remind ourselves that we have a risk of over-treating as well as under-treating cancer, and this concern permeates management of prostate cancer, which can often follow a very indolent course even as a systemic disease.
In the next room is a very vital 83 year-old woman who underwent surgery for a stage I adeno/bronchioloalveolar carcinoma in October of 2009. Another physician had done testing for serum tumor markers in her just after surgery, showing an elevated CA-125 level, which is of unclear significance, but the other physician told her at that time that she probably had residual viable cancer. I explained that I didn’t think this was necessarily the case; moreover, I felt that her risk of recurrence was low enough that I recommended against adjuvant chemotherapy. Sure enough, her CA-125 (which I don’t typically check in the post-operative setting) drifted back down to the normal range with nothing but time, and on today’s visit she returns for a surveillance CT that shows no changes and nothing that suggests recurrence. This scan is a cause for celebration, though she remains anxious about recurrence. Her CA-125 level remains reassuringly low, though I send this test only because of the precedent that was established: her case only illustrates the perils of sending studies that we can’t interpret.
The patient I see next transferred her care to me from another oncologist several weeks ago. She has advanced squamous cell NSCLC and had a very good response to chemotherapy last summer, but she also developed increasing neuropathy and fatigue with ongoing treatment. As I read her treating oncologist’s reports of her ongoing treatment despite her acknowledged complaints of cumulative side effects from week after week of chemo, which are not surprising after more than six cycles of first line chemo, I wonder whether the financial incentive to recommend more treatment is a significant motivating factor in his failure to propose a break from therapy that it seems she could easily tolerate and really needs. She was thrilled and relieved when I suggested that it would be completely feasible for her to take a break from treatment. I am now seeing her a month later, when she’s feeling remarkably better in terms of her neuropathy, energy level, and overall outlook. We agree to obtain a CT scan at her next visit, when we might discuss subsequent treatment options if her cancer shows clear progression. On the other hand, if her scan is stable, I think it will be feasible for her to continue to enjoy a respite from treatment and be followed closely.
I then meet a new patient referred from a pulmonologist I work with, who unfortunately has a new diagnosis of metastatic lung adenocarcinoma, though physicians before me suggested that he could potentially be treated with curative intent. I have the unenviable job of explaining that the PET/CT ordered since his prior visits confirmed spread beyond the point of curability. After a broad discussion of how we approach advanced lung cancer and what treatment can offer, he and his wife are tearful and clearly somewhat shell-shocked. We discuss treatment options, but I’d like to send his tumor tissue for molecular marker studies such as the presence of an EGFR or KRAS mutations or an ALK translocation. We’ll defer on discussion of specific recommendations until the studies are back in a week, and this also provides the opportunity for him and his wife to process what we’ve discussed.
I next see a patient on clinical protocol. He underwent surgery for stage I NSCLC a few months ago, but his cancer was low enough risk that he wasn’t inclined to receive adjuvant chemotherapy. Instead, he was happy to have the opportunity to enroll on the MAGRIT trial that randomizes patients to either the MAGE-A3 vaccine or placebo as adjuvant therapy. As we’ve seen with nearly every patient participating on this or other vaccine trials, he’s had essentially no symptoms from the vaccine: just a day of a slightly sore arm and some redness at the injection site. He continues on the protocol, and we agree that it would be a great advance if the trial shows a significant benefit and that an easily tolerated vaccine would be either a valuable addition to or alternative for more challenging chemotherapy in the post-operative setting.
My last patient of the afternoon is a 59 year old never-smoking woman coming to the end of whole brain radiation and soon to start systemic therapy for her metastatic lung adenocarcinoma. She had unsuspected, asymptomatic brain metastases, and while she was receiving her brain radiation, I had her tumor tissue sent for molecular markers. She was found to have an activating exon 19 deletion in the EGFR gene, but she also has a T790M mutation associated with resistance to EGFR inhibitor therapy. The latter is a common mechanism for acquired resistance to oral EGFR inhibitor therapy in patients who have a good initial response, but it can also be seen in previously untreated patients, in whom it is presumably a reason why the response rate to EGFR tyrosine kinase inhibitors like Tarceva (erlotinib) or Iressa (gefitinib) is in the 70% range rather than the 100% response rate we might expect. Though there isn’t any established approach for this combination of mutations, I explain that I expect she wouldn’t have a high probability of a profound response to first line EGFR inhibitor therapy. Instead, I recommend chemotherapy, and we discuss the details of my recommended plan for her to start cisplatin and Alimta (pemetrexed) next week. She receives an injection of vitamin B12 and a prescription for folate and decadron premedication. She’s anxious to get started with her chemo.
The afternoon clinic ends a little early because I’m meeting with some administrators and tech-oriented people at my institution to discuss the potential opportunities for developing tele-oncology. I’m extremely interested in this effort and would love to pioneer this in my region, with a hope and expectation that this will become a widespread practice as the technology improves and bandwidth becomes less of a limitation. I am thrilled to have leadership of my institution see the value of this, and I eagerly accept the opportunity to move forward with making early efforts a practical reality.
After the meeting, I head back to my office to complete paperwork (such fun!), take another stab at e-mail, and check into GRACE to see what’s happening. Then I get a call from home: my wife asking me when I’m coming home…it’s time for me to get going. I know I’ll be checking back in later.
That’s a pretty typical day, with some highlights and a few lowlights. I was able to share some good news, get some hugs, and express some genuine optimism, along with sharing some unfortunate news with some people and inducing some tears. Every day is a similar balance. Over time, I’ve been amazed by the resilience of patients and caregivers in adapting to serious challenges and limitations, but I also see that oncologists adapt as well, sustaining ourselves with the positive, whether it’s the joy of telling someone that their CT years after treatment suggests that they’re cured, or helping a patient receiving supportive care with better pain control. Though our impact is limited by the situation, if at the end of the day we’ve helped people, one way or another, I think we can take some comfort in that.