Time Ran Out

Time Ran Out

Don S. Dizon, MD, FACP, FASCO

@drdonsdizon
Jul 31, 2018

Originally published in "Discussions with Don S. Dizon" on The Oncologist. Patient details changed to protect privacy.

She was a new patient to me, referred to discuss her recurrent gynecologic cancer. Her history dated back more than seven years prior, and at that time, she underwent surgical treatment and was ultimately diagnosed with stage II uterine cancer. Chemotherapy had not been recommended. She did get radiotherapy and underwent close follow-up. Five years later she had moved to annual visits with her oncology team, and all had been optimistic she was cured.

Several months ago, however, she presented with pain. At first, she felt it was sciatica, but the pain intensified to the point where she could no longer walk. She was referred to the emergency room and was shocked to be told she had “disease everywhere”—her bones were under siege, with her spine about to collapse around her spinal cord. Both femurs had disease as well, and were at risk of breakage. There was disease in her lungs and in her liver too. She was urgently admitted and underwent spine stabilization surgery. Pathology from her spine showed uterine cancer. A subsequent lung biopsy confirmed the same thing. Special stains were performed and showed this tumor had loss of mismatch repair proteins (MMR-deficient).

She came to clinic on a stretcher, unable to sit up, unable to walk. Her family accompanied her and I was glad to see she was not alone. We discussed her diagnosis and the extent of her tumor. Although she had a significant disease burden, I was hopeful: the finding of MMR deficiency meant she was a candidate for the immunotherapy pembrolizumab. With that she lit up, as did her family. “Well, that’s the first bit of good news we’ve had in a while!”

Having breathed that collective sigh of relief, she and her sisters told me more about their family. Although she had never married, she shared a bond with siblings, nieces, and nephews. It was clear to me—there was no shortage of love, for sure. We made a plan to start immunotherapy once she was better recovered.

She had resided in a rehabilitation center at the time and was undergoing daily radiation to her spine. Physical therapy was helping, though, and with time, she was able to sit up. Then one day, she got out of a chair, experienced intense pain in her leg, and almost fell. It turned out she had fractured her leg—a pathologic fracture due to cancer. She was admitted then and stabilized with a plan for more radiation. Because the radiation fields being treated were quite extensive (spine, both femurs), we opted not to start immunotherapy just then. I had hoped to start her as soon as radiation was finished, but within a matter of days, she had to be readmitted to the hospital, this time due to hypercalcemia. Although stabilized in a relatively short amount of time, the coming weeks saw her re-admitted multiple times, all due to complications of her cancer. A CT scan performed during one of her last hospitalizations had demonstrated diffuse disease progression.

I was on vacation when she last required admission, but when I got back, she was still in the hospital. Her family had left a message with my office, asking me to see her.  After reviewing what had happened since we last met, I made my way up to her room. She was asleep, but woke easily. After some small talk with her and her family, she asked, “What do you think, Doc? Do you think I can get that treatment soon?”

I hesitated. On the one hand, I desperately wanted her to get pembrolizumab. Her tumor was telling me it would work. I had personally seen it work, almost miraculously, in a similar patient with endometrial cancer, also facing a high tumor burden. She deserved this chance to live, and return to some semblance of a normal life. Who knows? If she had a great response, perhaps she could walk again!

Even as these thoughts ran through my head, though, I could no longer ignore her deterioration. Her bones and spines were literally buckling under the volume of her cancer, and her most recent scans showed it was taking over her vital organs. What if pembrolizumab actually made things worse, or perhaps even killed her from side effects and unintended consequences? How would we all feel then?

Ultimately, I had to come face to face with what was obvious. In front of me was someone who was dying and my window to safely administer pembrolizumab had closed. “Honestly,” I started. “I would love nothing more than to treat you, to give you a chance to rediscover life. But I don’t think that’s going to happen and frankly, treatment would not be safe. I think you are dying and I think you only have days to weeks left.”

She buckled and began to cry. “I know,” she said. “I’ve known for a while.” We talked a bit more about where she wanted to live out the rest of her life. She was scared of pain and of discomfort, and she wanted more than anything else to go peacefully. We talked about a hospice facility, but her medical needs were so great. Ultimately we decided that inpatient hospice on our floor was the best solution. Our team could take care of her, and we could take care of her family. She died in peace, surrounded by her family who loved her so much.  

In the end, while precision therapy was available, the window for treatment had closed and my patient did not have the opportunity to try it. I tried to hide my frustration and anguish from everyone in that room, but I saw it mirrored back to me in the faces of all of the people who loved her. It wasn’t fair, and even in an era where we celebrate breakthroughs in cancer treatment, there will still be patients like this, and we will mourn our inability to do more.

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