At the end of a hectic day not long ago, I was asked to consult on an urgent case: an eighty-eight-year-old hospitalized patient who was in a coma. The referring doctor, a caring physician, stated bluntly, He’s very sick and close to death. The scans show widespread cancer, though we haven’t done a biopsy. Given his age, I think the best way to proceed is hospice, and I’ve recommended this to his sons. They’re very realistic but want to meet with an oncologist for closure.
The patient, Abe, was a retired dentist who had been living with his wife in another state. For some time he had been experiencing fevers, weight loss, and progressive weakness. But because his wife had Alzheimer’s disease and he looked after her, he neglected his own declining health. The couple’s sons had recently visited them and immediately insisted that their parents return home for medical care. By the time Abe was examined by a physician, he required hospitalization; he was too weak to walk, was becoming confused, and soon after lost consciousness. I encountered a long, gaunt, handsome man in a hospital bed; he had a shock of white hair and few wrinkles, appearing younger than his age.
His temperature was 103 degrees and he was clammy to the touch. He did not open his eyes when I called his name and only moaned when I shook him. CT scans to locate a source of fever had revealed a tumor the size of a volleyball in his abdomen, smaller tumors in his chest, and widespread involvement of the bones. The situation was grim. According to his sons, Abe had been alert and clear thinking until the current illness. They wanted to know whether there was any chance he could improve and whether it was worthwhile to pursue a biopsy to determine the type of cancer he had. I told them that it probably wasn’t, adding that I rarely said this. Given his age, debilitated condition, and widespread malignancy, even a very treatable cancer such as lymphoma would probably not turn around in time. The chances of success were low.
And how would we define success? If we could shrink the cancer but Abe remained in a coma, would we have helped him? What if treatments only prolonged his suffering? Certainly the case could be made for being humane and letting him pass, since he was so close. They acknowledged all of this and said they would confer and get back to me with their decision.
Not long after, they called. Dad was always a fighter and tough as nails. He would want to know what he had. And he would want to try to fight. We can’t let him go without at least knowing what he has. That would not be honoring the way he lived his life, the way he taught us to be. So let’s do the biopsy, let’s go for it. I replied, Fine, let’s do it. But we have to act quickly. I want the biopsy done this afternoon so we can have a result by tomorrow.
The diagnosis was large cell lymphoma. I can’t predict whether the cancer will respond to treatment or if he’ll wake up, I told them, but he probably won’t experience severe side effects from the recommended chemotherapy. If we’re going to try, let’s do it right and give him every chance. Again they conferred and said that they would get back to me. I got the call: Fire away. We administered CHOP-Rixutan therapy and hoped for the best.
I saw Abe the next morning on my rounds, and his fever was down, attributable to the steroid medication he received as part of the treatment. He looked more comfortable but was still unresponsive. His sons milled around the halls while his wife sat by his side, quiet and pensive. I returned the next day to find no change. I saw him on the third, fourth, fifth, and sixth days following treatment. He lay motionless in the bed, with no signs of improvement. All I could do was counsel his family. On the seventh morning, I made my rounds early. The hospital was quiet, and Abe was alone in his room. I stood at his bedside and performed my usual examination. Out of habit, I called his name, not expecting a response. There was none. But as I turned to leave, he sprang bolt upright, opened crystal-clear blue eyes, and blurted out emphatically as he tapped on his right temple, My name is Abe, and I have all my marbles! I was flabbergasted. He continued and became choked up, Thank you, doctor, thank you for all you’ve done.
I was floored, tongue-tied, and choked up, too. Well . . . I can see that you do . . . have all your marbles! You are so welcome! Abe received additional treatments and achieved a remission of his cancer. He enjoyed more time with his family and actually survived his wife; he died not long after she did of causes unrelated to cancer. I relate this story to illustrate the sometimes dramatic results that can be obtained with effective chemotherapy.
Cancer was recognized thousands of years ago, but only recently have we felt comfortable mentioning the C word and discussing this disease openly. The pink ribbon and the yellow LIVESTRONG wristband are symbols recognized the world over and represent our collective hope for the conquest of cancer. We are more comfortable talking about cancer because of the many improvements in treatment that have come about in the past forty years. Almost everybody knows somebody who is a survivor. Advances are announced frequently in the news. Surgery is becoming less invasive, radiation therapy more pinpointed and intense. Research is yielding an array of promising new drugs. Although we have far to go in reaching our goals for many cancers, we are indeed living in a new era of hope in which the chances of surviving even advanced cancer improve every year
The medicines that underlie the revolution in the management of cancer are the focus of this article. Oncologists currently have at their disposal approximately one hundred individual drugs and many drug combinations to treat cancer. Several hundred new medicines and immune treatments are being developed and tested in clinical trials. Thousands more are undoubtedly being hatched in the fertile brains of today’s cancer researchers. The treatment targets are not just the cancer cells but also the surrounding normal tissues that support them. Cancer-fighting drugs can be classified into three broad categories:
1. Chemotherapy
2. Targeted therapies
3. Hormone therapies
Immune therapies such as vaccines and cell-based therapies are not yet standard treatment, although there is great hope for their success. Interferon and interleukin are approved but are not discussed in detail here. Some targeted therapies also activate the immune system to fight cancer.
In this article, I explain how cancer-fighting drugs work, as well as how radiation therapy works. The accompanying images enable you to visualize cancer being eradicated by these treatments. If you are a cancer patient, ask your oncologist which types of medicines you are receiving (many patients receive more than one type), and go to those sections to fix an image in your mind’s eye of what those treatments are doing to your cancer. Visualizing cancer being rubbed out and the body healing will be empowering and give you a greater sense of control over the disease.
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