A War Story

Christopher Dittus, DO, MPH

Those were the words spoken by my favorite patient when I asked if he had enjoyed his time in the US Navy. Technically, doctors are not supposed to have favorite patients, but, since we are human, we all do.

I met Charles about a year ago during my first year of training as a hematology and oncology fellow. I remember him standing up slowly in the waiting room, cane in hand. Getting started took some time, but once he gained momentum, he could practically run.

I could tell immediately that he was a kind man, but this gentle demeanor was enveloped by sadness. I would soon find out that his wife had passed away several months prior to our first meeting, and he was in a state of bereavement.

Fortunately, he was not alone; he and his wife had raised 3 wonderful children. His daughter, Mary, often accompanied him to appointments along with her husband.

Charles was referred to our hematology clinic at the Jamaica Plain Campus of the Boston VA for pancytopenia, and for a man in his 70s, this laboratory finding was concerning.

Charles described to us how he lacked an appetite, was feeling increasingly tired, and had been losing weight over the past few months. He attributed these symptoms to his bereavement, but certain, more ominous, details emerged. He had developed substantial back pain about 6 months prior and was diagnosed with compression fractures. Additionally, he noted worsening dyspnea on exertion. Taken together, his symptoms were suggestive of a primary bone marrow disorder. He underwent a bone marrow biopsy, and the results confirmed our suspicion of multiple myeloma.

Between 1975 and 2006, the 5-year survival rate for multiple myeloma increased from 23% to 45%, with the greatest gains occurring after the year 2000.1

This trend reflects the myriad new treatments now available, including medications from entirely new pharmaceutical classes. Despite these advances, myeloma is rarely curable, and most patients will ultimately succumb to their disease. With this in mind, we started Charles on a very effective, and generally well-tolerated, regimen of lenalidomide and dexamethasone. Because of his age and comorbid conditions, he was not a candidate for bone marrow transplantation, so our goal was to put him into remission and keep him there as long as possible.

Unfortunately, Charles did not have the favorable initial response we had hoped for, and after 3 cycles we added a proteasome inhibitor, bortezomib, to his regimen. His myeloma responded, but again, not adequately.

After 3 cycles, his back pain worsened and it was decided that he should be treated with radiation therapy to his involved thoracolumbar vertebrae. Once his radiation therapy was completed, we initiated a new regimen, consisting of a traditional chemotherapeutic agent, cyclophosphamide, as well as bortezomib and dexamethasone (VCD).

Over time, I developed a professional friendship with Charles, and he told me more about his family, military experiences, and life after the military. In the US Navy, he served on 2 different vessels starting in 1959. He described, proudly, how the first ship he served on was an ice-breaker that ultimately went on to be the first ship of its kind to overtake an enemy ship. He recalled only good memories of being at sea, except, of course, for when there were severe storms.

After the military, his love for the sea continued, and he enjoyed fishing and lobstering from his 30-foot fishing vessel.

Recently, Charles completed his third cycle of VCD, and he now has stable disease. If and when he stops responding to this regimen, we have many more options available. For now, he is able to enjoy spending time watching his grandchildren grow up and excel at sports.

Charles’s war is not as dramatic as those we see in the movies, or even those recalled in the waiting room by his fellow combat veterans. His is one of attrition, with an enemy that cannot be seen with the naked eye. Although he may ultimately lose this war, right now, he is surely winning.

1. National Cancer Institute. Fast stats: an interactive tool for access to SEER cancer statistics. Surveillance, Epidemiology, and End Results Program website. http://seer.cancer. gov/faststats. Accessed February 6, 2015.

Although this anecdote is based on a true event, names have been changed to preserve anonymity.