Collection of essays by leading oncologists puts a human face on the practice of medicine

More than 35 ASCO members contributed personal essays to a recently published collection of stories about humanism in medicine, including ASCO Past Presidents Paul A. Bunn, Jr., MD, FASCO, and Emil J. Freireich, MD, FASCO, and current President-Elect Julie M. Vose, MD, MBA, FASCO, among other prominent physicians. The Big Casino: America’s Best Cancer Doctors Share Their Most Powerful Stories is a collaboration between Stanley H. Winokur, MD, Medical Director of Axess Oncology and ASCO member, and Vincent Coppola,a journalist and author who was diagnosed with cancer in 2012.

In the interview that follows, Dr. Winokur discusses the book’s contributors, themes, and his own essays. “Young doctors, especially, are going to be inspired by the stories in the book,” he said. “The authors are their mentors, their heroes, being completely real.”

In the book’s foreword, why did you describe cancer as “the most private of diseases”?
SW: For years, cancer has been attached to the word “death.” The reason the book is called The Big Casino is because for many years we tried to avoid using the word “cancer.” We knew how scary it was: It was another way of saying “death.” That fear is what made cancer the most private of diseases. That’s why the experience between an oncologist and a patient is so intimate—I don’t know of any other specialty in medicine with that kind of intimacy.

The author list is impressive. Were you surprised by the response when you asked for contributors?
SW: The doctors who answered the call are some of the busiest doctors in the world. And without fail, they all responded that they were grateful for the opportunity. I believe there are hundreds more doctors who would have contributed. It’s therapeutic to share these stories. I’m looking at creating a website where people can continue to submit their stories, as a vehicle to share the gifts we’ve been given.

What guidance did you give to the authors for their contributions?
SW: I personally talked with every author that I invited, and I said, “You’re a rock star in the world of medicine. Everyone knows who you are as a scientist and a clinician. I’d like you to write about who you are as a human being.”

Patients talk about how grateful they are to their doctors. This book is about our gratitude for our patients, and the precious gifts they’ve given us. Gifts of courage, strength, hope, humor, determination, joy. So the question I asked the authors was, “What have you gotten from your patients?”

	Stanley H. Winokur, MD Institution: Medical Director, Axess Oncology Member since: 1970 Volunteer activities: Cancer Education Committee (Continuing Medical Education Subcommittee)

You contributed two stories to the book. The first, “How to Tell Patients They Have Cancer,” demonstrates a sense of gallows humor. Is that an essential trait when working in oncology?
SW: Yes, absolutely. That story happened when I was in medical school, about 40 years ago, and it shows the intense fear that doctors had of being real. We talked about “neoplasms” and “lesions” because we didn’t know how to tell a patient that they had cancer. We didn’t want to use that word. It was our armor, to avoid telling patients they might die. And there is a kind of dark humor in the way we discussed it.

That dark humor exists today in other ways. As doctors, we very rarely share those kinds of stories with the public because we don’t want to be seen as minimizing someone’s suffering, or to be perceived as insincere. But the humor is really about our own fear.

Many of the stories are an homage to particularly special patients, including your second essay, “Gratitude,” about a patient named Joan.
SW: Even today, after so many years, when I tell that story I start to cry. Joan gave me a gift—the gift of understanding—that I want to pass on. She told me to stop being a perfectionist. She reminded me of the wonderful years we were able to give her. She relieved me of my feelings of failure. She gave me the courage to move forward in the face of my fear. She was an angel for me.

Many authors discuss being a first-generation American, or the first person in their family to get an advanced education. Was this something you set out intentionally to explore?
SW: It was a happy accident of the contributions.There are many, many people who are oncologists because they feel a need to care, to help, to fix, to comfort—and those people come from all kinds of backgrounds. I was the first person in my family to go to college. I didn’t pick oncology to impress them. My hero was an oncologist, and I wanted to be like him. I wanted to care for people the way he did. He was a father figure to me.

Oncology is a higher calling. People are attracted to the intellectual aspects, of course—the biology, the problem-solving—but at the core is a desire in your heart to help someone through an extremely serious situation.

The field is changing. In many cases today, the physician is getting further away from the patient. We’re starting to become triage doctors who direct therapy, while nurses and advanced practice providers have more face-to-face interaction with the patients. It will be interesting to see whether the reasons that people go into oncology also change, and whether they are more interested in the science.

The promise of science and the hope that it brings to both doctors and patients is a major theme in thebook.
SW: The last essay, by Dr. Kenneth Foon, is very moving to me. He talks about remembering a time when “the big casino” was a place where you rolled the dice and you lost. The house always won. His story, about encountering a patient many years later, is about the power of science in beating those odds. What I love about the book is that the stories about scientific advances are also about humanity and connection.

Our culture often creates a dichotomy between science and faith, yet many of the authors—some of the best scientists in the world—discuss their religious or spiritual beliefs. What did you make of the discussion?
SW: To me, the foundation of any spirituality is connecting with something or someone else. You cannot take spirituality out of the picture when you’re dealing with such an intimate subject: that terrifying moment when someone finds out they have a disease that could kill them.

The doctors in our field whom I regard most highly are the ones who blend science and spirit. They have the capacity to connect the heart and the mind. It’s very rare that we get to talk about those issues at scientific meetings, which is another reason that I think people were excited to contribute to the book.

If readers take away only one message from the book, what do you hope they understand?
SW: Hope is a precious gift. We should never say to our patients, “There’s nothing else I can do for you.” There might not be any more drugs or therapies we can give them. But we can give them our compassion and our gratitude. We can stand next to them and hold their hand. There is always something we can do.

Dr. Winokur’s hope is that every oncologist and patient will have the opportunity to read The Big Casino.The book is being sold at cost, and no editor or contributor is profiting from its sales. Print and ebook editions are available on Amazon.com; visit thebigcasino.org for informationabout discounted bulk orders for your training program, cancer center, or practice.

The Big Casino Contributing Authors
Kenneth R. Adler, MD, FACP • Kenneth C. Anderson, MD • James O. Armitage, MD, FASCO • Sushil Bhardwaj, MD, FACP • Donald P. Braun, PhD • Paul A. Bunn Jr., MD, FASCO • Howard A. (Skip) Burris III, MD, FASCO • Bruce A. Chabner, MD, FASCO • Bruce D. Cheson, MD, FASCO • Morton Coleman, MD, FACP • Vincent J. Coppola • Shaker R. Dakhil, MD, FACP • Kishore K. Dass, MD • Michael Feinstein, MD • Kenneth A. Foon, MD • Emil J. Freireich, MD, FASCO • Eric Genden, MD, MHA • Edward R. George, MD • Robert J. Green, MD • Daniel G. Haller, MD, FACP, FRCP, FASCO • Jimmie H. Harvey, MD • William N. Harwin, MD • Jeremy K. Hon, MD • Elias Jabbour, MD • Mohammad Jahanzeb, MD • Fadlo R. Khuri, MD, FACP • Karen J. Krag, MD • Richard M. Levine, MD • Sagar Lonial, MD • John S. Macdonald, MD • Maurie Markman, MD, FASCO • Stanley M. Marks, MD • Jeffrey F. Patton, MD • Kanti R. Rai, MD • S. Vincent Rajkumar, MD • Hope S. Rugo, MD • Carolyn D. Runowicz, MD, FASCO • A. Collier Smyth, MD • Julie M. Vose, MD, MBA, FASCO • Grace Wang, MD • Stanley H. Winokur, MD •