October 11, 2011


He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.


Anonymous said...

An incredible story with such a sad outcome. You are an amazing writer who can grasp the most difficult situation with true understanding of the case at hand. Keep up the great posts!

Anonymous said...

Wow, I'm volunteering at a hospital in WA. Just imagine how odd it would be if you met one of your readers at the hospital without knowing it!