Not Everyone Follows the Literature... and on Rare Occasions that Works

Not Everyone Follows the Literature... and on Rare Occasions that Works

Don S. Dizon, MD, FACP, FASCO

Apr 23, 2015

She had come to my office looking to transfer her care—she and her family were relocating from the South to New England. She had a history of stage IV high-grade serous ovarian cancer (due to a positive pleural effusion). Her primary treatment with her original physicians was an aggressive surgical cytoreduction with complete resection of disease. Adjuvant intravenous plus intraperitoneal therapy followed, after which she received “maintenance” chemotherapy (“to make sure it stays away,” she told me). After a year of monthly chemotherapy, a CT scan was performed, and unfortunately, it showed new disease—in her lungs. Although the final report concluded that these findings strongly suggested metastatic disease, there was no further workup. Her doctors discontinued chemotherapy and recommended surveillance. She had no symptoms of her cancer, so that’s what she did.

She faithfully attended each appointment with her original physicians and continued to get scans. She told me she never felt sick and, that were it not for the possibility of having metastatic disease, she felt almost “normal”; she worked full-time and she and her family travelled quite a bit.

Approximately four months before we met, things started to change. She developed shortness of breath, which became worse when she tried to lie down. A workup commenced and there was now fluid in her lung. A chest tube was placed and the pleural fluid was positive for cancer. It could not have happened at a worse time, as she and her family were in the process of moving. Despite this turn of events, she kept the move on schedule. Once the situation had stabilized, they headed to Providence and that’s where I became involved.

I remember reviewing her records with her. I wondered why her doctors had given her IV/IP chemotherapy—the evidence suggests the benefit of treatment is not in women with stage IV disease, but those optimally cytoreduced for stage III ovarian cancer. I wondered why she had received maintenance chemotherapy—the data suggest that doing so has not been shown to improve survival. And, I wondered why she did not undergo a biopsy of her lung lesions, at the very least to prove she had progressed during treatment. I told her as much and discussed what I “knew” regarding ovarian cancer. “Frankly,” I said, “I am amazed by you and your doctors. . . . I don’t know of many who would have recommended observation when the scan showed lung lesions.” I admitted that my gut instinct always said to “treat,” especially when one of my patients shows recurrence or relapse. I rarely will offer observation because I am afraid of what might happen.

But, that visit represented her ninth year living with ovarian cancer—and the eighth year since chemotherapy was discontinued. She paused for a second and then looked at me. “Well, I guess I should be glad you weren’t my doctor way back then, huh?”

After a few moments, we both started laughing. “I can’t argue with you there,” I said.

She reminded me of an important point: that cancer is not predictable, no matter what you read in the literature or what the data tells you. She reminded me that observation is an option after disease has recurred, and it is a reasonable one because observation is not synonymous with “let’s do nothing.” Observation represents action—regular visits, exams, and imaging are all a part of it.

For this patient, observation proved to be the right decision. Despite having high-grade disease, she had stable lung findings, across years. And, certainly, her quality of life was far better off chemotherapy than it could ever be on it.

But now, she was symptomatic and we needed a plan. “Are you ready to be on chemo again?” I asked.

“Yup, let’s do this,” she said. And with that, we set to work tailoring a treatment plan for her to target this cancer, which had “woken up” after a long period of quiescence.

*Details changed to protect anonymity.


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Sana A. Al Sukhun, MD, MSc, FASCO

May, 01 2015 11:21 AM

Dear Dr Dizon,

Thank you for sharing this piece, remarkable live proof of cancer heterogeneity. Yes, as long as we donnot have a test to tell us what kind of "cancer" a patient has, the clinical test "close observation to get to know the disease" is the best test. We need to listen to our patients more in this era of "high tech" medicine.

Sana Al Sukhun

President of Jordanian Oncology Society

Don S. Dizon, MD, FACP

May, 01 2015 1:10 PM

Dear Dr Al Sukhun:

I very much appreciate your comment, especially the final thought of how important the patient voice continues to be, even in the era of "high tech" and precision therapies! My best, D

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