Challenging Case Teaches Oncology Fellow the Power of Hope

My patient, “Mr D”, presented with esophageal cancer. He was a robust man who looked much younger than his 64 years and had remained active after retirement. He had served in the military for many years and was a classic Southern gentleman with a strong faith who attended church regularly. He had enjoyed good health until the preceding months, when he developed progressive dysphagia. Otherwise, Mr D had felt well enough to travel to the Grand Canyon during the summer and had delayed seeing his physician.

When Mr D returned home, his primary care physician initially reassured him that there was nothing to be overly concerned about. However, a routine endoscopy revealed a large esophageal mass that proved to be adenocarcinoma.

When I first sat down with Mr D and his wife, it was clear that they were both overwhelmed by their current situation. In a frenetic way, they had sought out several opinions regarding treatment prior to meeting with me and my colleagues. First, they sought out advice from a local oncologist. Then, they traveled and were evaluated at Memorial Sloan Kettering Cancer Center (MSK). Following their visit to MSK, they sought advice at Mayo Clinic. Although exhausted, Mr D and his wife travelled to Cleveland Clinic before making any final decisions.

I was faced with providing Mr D and his wife with news that they had heard before. I explained that his esophageal tumor appeared to be unresectable and that upfront systemic chemotherapy would be the best approach for treatment. Although he showed no evidence of metastatic disease on staging scans, it was clear that there was only a limited chance of cure. Advanced esophageal cancer is a highly lethal malignancy and often spreads despite aggressive therapy. I discussed that treatment would be palliative in an attempt to reduce the esophageal mass and prevent additional side effect from his cancer; treatment would not eradicate the disease. When confronted with this information, Mr. D appeared defeated and weary. He was emphatic as he looked straight into my eyes and said, “I know you can cure me. I am going to beat this.”

As a young oncology fellow, I struggled to respond to this statement. How could I be realistic about his diagnosis without taking away his hope? In the eld of oncology, trainees are taught to be honest when delivering a cancer prognosis, yet to always leave some room for hope. When predicting when a patient may succumb to a malignancy, we cite historic precedent. But there are the rare patients who survive many months, even years, longer than initially assumed. I often remind patients that there are outliers—cancer treatment super responders who defy any traditional trajectory that could be predicted based on disease staging. And so, I suggested to Mr D that although there was no guarantee that his tumor would respond, enrolling in a clinical trial with induction chemotherapy followed by surgical resection, if there was dramatic tumor shrinkage, would be his best course of action.

Mr D subsequently enrolled in a trial and received 4 cycles of leucovorin, uorouracil, and oxaliplatin (FOLFOX) combination therapy. At each follow-up visit, Mr D appeared to be tolerating treatment extremely well; his dysphagia resolved entirely. His excitement grew, as did mine, as he completed 4 rounds of chemotherapy. We therefore took the next step of scheduling his surgery for the following month. Then, during his final visit before restaging scans were to be obtained, Mr D appeared concerned. He mentioned that he had developed some vague abdominal pain in the preceding days.

Given his clinical course, I reassured him that it was likely nothing. I, too, held the same hope that he had responded to treatment. Unfortunately, the results of a computed tomography (CT) scan of his abdomen delivered on the following day revealed small, but undeniable, peritoneal nodules that raised suspicion of carcinomatosis. A subsequent CT-guided biopsy of 1 of these nodules demonstrated adenocarcinoma.

I called Mr D later that day to inform him of the bad news. He now had metastatic disease and would not be a candidate for surgery. Instead, we would have to proceed with second-line systemic chemotherapy. I told him I was concerned that his cancer had progressed in a short period of time.

To this news, he simply responded with, “I believe in the power of hope,” which astonished me. Mr D went on to receive several cycles of treatment, followed by a course of palliative radiotherapy after his esophageal tumor grew in size again. He then enrolled in hospice care, but passed away only a few months later.

Mr D’s case left a lasting impression on me and my approach to practicing medicine. While his story may not be unique, it does remind me what a tremendous privilege it is to be an oncologist and to dispense hope to my patients. Hope is a powerful tool. To hope is to be human—undoubtedly an evolutionary behavior that has allowed humanity to overcome incredible adversity throughout the centuries. As an oncologist, I witness humans facing extreme challenges every day. Mr. D’s story is reminder of why I maintain hope for all of my patients and their families.