By Meera Mohan, M.D., M.S.
On a beautiful Friday morning in the spring of 2020, Mr. B awaited his first dose of pembrolizumab in the chemotherapy infusion room. By this time he wrestled with cancer for about three years and underwent several lines of treatment, yet he was so resilient that that he continued weight training at home. He said, “It was still worth a try, if this could buy me some more time with my family.” After all, all bridges are built to be crossed. Like many cancer patients, his treatment was delayed as we tried to juggle our way through the current pandemic. It never ceases to amaze me how Mr. B always wore that big smile every single time I saw him. He says, “Smile makes me and people around me feel good; it is like an emotional contagion.” He was a true hero, navigating uncharted terrains, fighting this rare cancer for the past three years. He exemplified how an optimistic stance could negate even the most formidable conditions in life.
I met Mr. B for the first time three years ago as a very inquisitive first-year fellow. “We need help with a new patient in the walk-in clinic” announced the chief fellow, Dr. R. I volunteered myself.
Mr. B had “aggressive anaplastic thyroid cancer,” a rare cancer that sounded even rarer to a first-year fellow. He was recovering from recent pneumonectomy two weeks ago but what was so “striking” was the glowing smile on his face. I scribbled down his age – 60s — as I assessed the “performance status.” He was in his best physical shape ever and ran six miles per day. He had papillary thyroid cancer diagnosed at age 40 and now had recurrence in the lung with aggressive anaplastic thyroid cancer. He had smoked five cigarettes in his life, a noteworthy and precise remembrance.
During the first visit, we went through the customary discussion of cancer diagnosis and work-up and set out a possible treatment plan. Just before he departed, he asked, “Doc, how does this cancer behave? How much time do I have?” These very questions were ones I tried to avoid with all the speculations overcrowding my mind. After a moment of silence, I looked into his eyes and said, “This is an unusual cancer which can outsmart us, but I can reassure you … I’ll do everything possible to help you.” He echoed how he appreciated the truth upfront and how the truth would help him prepare for rational expectations of his life ahead.
He started chemotherapy around Thanksgiving Day 2017, but by the end of the second cycle he suffered from cardiac toxicity and treatment was halted. He was taken off all treatment by January 2018 and we pursued active surveillance. I told him, “Perhaps we will need to see you often as there is no real consensus on optimal follow-up of anaplastic thyroid cancer”. Living in rural America, he navigated 190 miles to make it to those frequent appointments and scans, but he never missed a single appointment in 3 years. He was often accompanied by his wife, Mrs. B.
One day I noticed a look of disquietude in her face. I took a leap. “Mrs. B, is everything all right?” She answered promptly that she was being worked up for cancer. This was an incredibly challenging time in their lives, yet he was ever so optimistic as he expressed, “There is always hope in the days ahead.” Perhaps, this ingrained hope of the best possible outcome is the strong force that leads our lives as oncologists. During these visits, I learned about his family with three daughters and how proud he was of their accomplishments; how he and his siblings had been a caregiver to his father and later to his mother during their last months of life. At one time we discussed the benevolence and affection that enriched his life as he said, “Everyone is born with love in their heart.” The support of his close-knit family and religious congregation always uplifted him during these tough times.
Eight months passed and on a Friday morning he came for a routine clinic visit. For the past two weeks he reported some heaviness in his tongue, his eating and articulation proving difficult. Being a young oncologist in training, I was still apprehensive in “breaking bad news” to my patients, but I gathered myself and told him that we might be dealing with a cancer relapse. Getting an MRI scan was tricky with Mr. B’s claustrophobia, but he insisted he would give it a fair try. As we feared, the tumor encroached upon his hypoglossal canals and caused compressive symptoms. By this time, he had lost twenty pounds and was unable to meet his nutritional needs. We discussed about percutaneous endoscopic gastrostomy (PEG) tube placement, but he disliked the idea. He received palliative local radiation and started on lenvatinib. Slowly, with the recovery of his neurological function, he started re-gaining weight. Life was again as normal as it could be except for the frequent Friday clinic visits.
On one Friday clinic visit in July 2019, Mr. B came in for routine follow-up. I noticed his limping as he walked in. He had been hurting for the past three weeks and had issues keeping up with his usual 3-mile run. My heart sank. By this time I was maturing as I was learning to maintain an optimistic body language while still having doubts in my mind. Unfortunately, the scans reported a new left femoral lesion with cortical destruction and concerns for impending fracture. Again, we were faced with the dilemma of choosing a treatment for his rare challenging cancer. He went on to have orthopedic surgery followed by local radiation therapy. He completed physical therapy and was able to ambulate without any support. Fortunately, we started him on targeted therapy with larotrectinib that was approved for NTRK fusion mutation agnostic of tumor type. During this time, he turned down the options of referral to centers with clinical trials for this rare cancer. He stated he was a “homebody” and the logistics of travelling back and forth were too complicated.
The ensuing eight months were mostly “uneventful” in our day-to-day lives and during this time he spent Christmas holidays with his family. Several weeks later in February 2020, we were confronted yet again with another glitch — disease progression in his lone lung threatening to cut off the bronchi. The ongoing battle had almost depleted our arsenal, but we searched deep for the slimmest ray of hope. Physical and psychological challenges during this journey got tougher — even brisk walking balancing out the risk of another fracture. By this time, he walked less than a mile a day.
Mr. B was the last patient on the last day of my fellow’s continuity clinic in May 2020, at the throes of COVID-19. During the past 12 weeks, most clinical appointments were cancelled or rescheduled in keeping with best-practice guidance during this pandemic. With forbidden hugging and handshakes this time, he said, “I know your work is done here. Each of us have an intended role to play in a given time of our lives and then we have to get ready for the next chapter. All we can do is play our part well.” Indeed, our patients are part of our lives as much as we are theirs. Mr. B walked out with the same high-spirited smile that he wore the first time I had seen him. I realized the secret behind the smile is not to accept cancer as an ill fate and drown in sorrow, but to uplift each other and he did this with his “smile.”
How a “seemingly simple smile” could leave behind an enduring impression in our lives.
Meera Mohan, M.D., M.S., was a fellow in the Division of Hematology/Oncology at UAMS.