When Being Wrong Feels So Right: The Joy of Seeing a Patient Defy the Odds

When Being Wrong Feels So Right: The Joy of Seeing a Patient Defy the Odds

Don S. Dizon, MD, FACP

@drdonsdizon
Dec 14, 2016

Originally published in "Discussions with Don S. Dizon" on The Oncologist

I believe in miracles. That might sound odd coming from an oncologist—especially since our field is driven by the data. Our path forward continues to be built through trials and the collaboration between clinicians and patients, working together to forge a better way to treat cancer. I certainly believe in evidence, but still… I believe in miracles.

Judy* is one of those miracles. I had met her 8 years ago, 7 months after she had been diagnosed with metastatic endometrial cancer. After a successful surgery, she underwent chemotherapy “to prevent recurrence.” Despite this, her post-treatment CT scan showed that the cancer had spread to her liver. It was so surprising to her team that they pursued a liver biopsy, which unfortunately confirmed metastatic disease.

Judy was devastated and scared—unclear what her future held. Reviewing her records, I was not optimistic either. Her tumor had proven itself to be quite virulent, and unfortunately, there weren’t great standard-of-care options. At the time, I worked outside of Boston, but suggested she seek out clinical trials in the city, since none were available where I was. She expressed that she hoped to stay local and initiate a treatment closer to her family; given the seriousness of her condition, I felt that would be appropriate.

“What am I looking at, doc?” she asked.

“Well, it’s not a curable situation and given that it grew despite chemotherapy, I think you have months, not years.”

“You mean, I could be dead in 6 months?” she asked.

“I don’t have a crystal ball and don’t pretend to read the future.” I said. “But this is a serious situation and most patients typically live less than a year.”

She sat there shocked for a while, as did her family. Her daughter started to cry and I felt powerless to do anything. So I sat with them, not saying anything.

“Well, what next?” she finally asked.

Since she felt well, I suggested we try endocrine therapy. Perhaps we could stabilize her disease in order to give her time, without exposing her to the toxicities of chemotherapy. I explained my rationale to her, assuring her I would follow her closely to ensure she did not experience rapid development of symptoms due to her cancer. She asked many questions and ultimately agreed to this approach.

I saw her every 3 weeks. After 6 weeks, she noticed her energy had improved. Her appetite, which had been diminished during chemotherapy, had returned and she was, in fact, putting on weight. I marveled at how well she tolerated treatment.

After 3 months, we repeated imaging. To my shock, her tumor had disappeared—her liver was normal, with no signs of the cancer that had previously been seen. She was in remission.

She was stunned with this news, and overjoyed. “Do you still think I’m going to die, though?” she asked.

“I think I was wrong,” I responded. “I don’t think you’re going anywhere right now.”

I’d like to think it was a brilliant recommendation on my part, based on the role of hormonal pathways in endometrial cancer. But that would be false. My recommendation was based on a single-arm, phase II trial that showed a good response rate, regardless of tumor grade or hormone receptor status. It was driven by my desire to treat her with agents that would maintain, not detract from, her quality of life. Yet her response far exceeded what even I hoped for, and I could not explain why she responded so well. To me, it was nothing short of a miracle.

As we move forward in oncology, my hope is that miracles like this happen more often, guided not by chance but by a better understanding of cancer biology. The promise of precision medicine remains a real one that I firmly believe in, and I think this will be the way forward for others who come after Judy.

*Name changed to protect privacy.

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