Mar 02, 2022
By Taylor L. Barnett, MD
I had an organic chemistry professor who would say that, in the end, when faced with any disease—be it HIV, ALS, or cancer—the doctor will always lose. Disheartened does not come close to describing what the lecture hall packed full of aspiring physicians felt upon hearing this, and a few classmates even dropped the class that very day. I realized the academic road ahead of me was going to be a challenge, not because I desired to prove my professor wrong, but because I wanted to discover for myself what becoming and being a doctor would mean to me—and, perhaps, if I would be a loser too. Little did I know such exposure would begin before I ever donned a white coat.
I was 22 years old and a few days away from my university graduation when I found myself at the local emergency room for an evaluation of a daylong history of tinnitus and a frontal headache. The resident examining me must have picked up on something, or for some reason decided to be extra thorough with her review of systems, as she asked me, “Taylor, have you been having any groin discomfort?”
We have all had those moments when a patient gets that deer-in-headlights reaction after being asked what seems, to us, like a completely routine question. I too had that moment of disconnect, but thankfully something inside of me told me to be honest and lead with a “Now-that-you-mention-it” response that made the young doctor’s forehead wrinkle. I had been feeling some occasional gnawing pain in my right testicle for months, along with a small lump. At the time (again, 22) I did not think much of it and had ignored it up until that point. The doctor shook her head and did an exam, which indeed found a bean-sized fixed hard mass just on the lateral portion of my right testicle. “Well, it’s about time you came in,” she said.
Before I knew it, I found myself getting vials of blood taken and being put through the truth machine. Tumor markers including beta-HCG, AFP, and LDH were elevated. The CT scan showed some scattered enlarged retroperitoneal lymph nodes up to 2 cm in diameter. I was evaluated promptly by a urologist who recommended a unilateral orchiectomy, given the concern for malignancy. Apparently, there was nothing wrong with my hearing or head after all.
Just 5 hours after checking into the ER, I was on an operating room table with a large group of gowned figures surrounding me and a face mask coming toward me. The last thing I remember was the nurse anesthetist speaking to me in Farsi and telling me about her life in Iran. Someone must have told her I studied the language in college; apparently, I was reciting Hafez while going under anesthesia. I left the hospital the following day; a day later, I walked across the graduation stage to accept my diploma.
Spending the coming summer undergoing chemotherapy was not how I intended to celebrate my scholastic achievements from the previous 4 years. Maybe I was in some denial, but I honestly feared moving back in with my parents more than the cancer itself. That is probably why I made the decision, much to the great dissatisfaction of my parents and doctors, to take a month-long trip to Europe with my college friends, in an attempt to put the real world on hold for a bit.
By the time I had a follow-up visit with an oncologist, almost 7 weeks had passed since my orchiectomy, which my older-and-wiser self would consider far too long. Repeat CT scans unfortunately showed new metastases above the diaphragm in some thoracic nodal areas. There was also a 1.5-cm lung nodule concerning for malignancy. Final pathology from the right orchiectomy revealed a mixed germ cell tumor limited to the testis, replacing the upper two-thirds of the right testicle. Also identified were a large embryonal component (approximately 95%) and presence of lymphovascular invasion, both features which are considered by some to be higher risk for relapse according to National Comprehensive Cancer Network guidelines. Post-orchiectomy tumor markers improved although remained elevated.
Taken together, these findings put me at good-risk stage IIIA disease. The classification of good risk did little to soothe me when I learned that in testicular cancer, there is no such thing as stage IV disease. I promptly signed consent for chemotherapy and, on my birthday, started three 3-week cycles of adjuvant bleomycin/etoposide/cisplatin. Chemotherapy did not always seem to agree with me; unsurprising, given that the side effects of cisplatin are fairly notorious (although the renal and neurotoxicities have become more manageable over the years). I had neutropenic fever during my second cycle but recovered. I was fortunate not to have much nausea or vomiting thanks to an aggressive antiemetic prophylaxis regimen.
Today, I am over 13 years out from treatment with no evidence of recurrence. I do not see an oncologist anymore (although I encounter enough of them on a daily basis). I do as I advise my patients, which is to perform regular testicular exams and improve overall health even after formal surveillance ends. I see my primary care doctor regularly, am proactive about my cardiovascular health given a family and personal history of disease, maintain a balanced diet, and exercise regularly.
I still have many residual effects of chemotherapy: a chronic hacking cough with some mild radiographic pulmonary scarring, Raynaud’s phenomenon, noticeable (but not bothersome) peripheral neuropathy in my toes. I have occasional episodes of tinnitus—ironic, considering that it was my original complaint in the ER 13 years ago—and unfortunately have had a decline in my hearing, mostly with high-pitched sounds. These side effects are varying degrees of common among testicular cancer survivors and those treated with cisplatin, and they have made me diligent in educating my patients about long-term and late effects.
Fast forward to my first year of oncology fellowship, and I am sitting in an exam room with my first patient with testicular cancer, 8 years after my diagnosis. I sat across from this man, the same age as I when I was diagnosed, to lead him on his own journey into battle, and felt everything come full circle. The residual peripheral neuropathy and hearing loss, the times of doubt and uncertainty at each surveillance scan, the innumerable late nights passed in solitude in my medical school library while studying for the next of a multitude of exams, the staggering tuition I paid to invest in my education and achieve my medical degree, the joy of the highs and the heartbreak of the lows—all of that was worth it to be here in this moment with him.
The burden of treatment may linger, but I’m proud to say I have come out on the other side of the journey a better man, husband, and doctor. I have developed a deep understanding and empathy for my patients who go through their own struggles with cancer and chemotherapy. I am inspired to learn more about their disease processes, stay current with the latest developments, and teach my fellows what I have learned and experienced as they become my colleagues in what I consider to be the most challenging yet rewarding field of medicine.
I still think occasionally of my organic chemistry professor and his grim message that when it comes to disease versus doctor, the doctor will lose every time. I understand his point, but my experience has taught me differently. The one piece of advice I would impart upon other young oncologists is to never stop learning. If you take time to learn from your patients and to offer them a real human connection in return, you will never be the loser.
Dr. Barnett is an adolescent and young adult (AYA) oncology specialist, an officer in the United States Air Force, and an assistant professor in the hematology/oncology fellowship program at Brooke Army Medical Center in San Antonio, TX. He is a member of the ASCO Trainee and Early Career Advisory Group. Disclosure.