The ASCO Post is pleased to reproduce installments of the “Art of Oncology” as published previously in the Journal of Clinical Oncology (JCO). For information on how you can submit your own essay for consideration in JCO’s Art of Oncology, visit http://jco.ascopubs.org/site/ifc/determine-my-article-type.xhtml#art-of-oncology
There were once two patients with leukemia. Other than their diagnoses and their ages, these two men had nothing in common.
Michael was an artist—a sculptor. He had large, sensitive, blue eyes and a quiet, pensive manner. His acute observational power led him to ponder deep questions about everything around him. His contemplative and soft-spoken aura belied the work he did, which involved creating large, fluid, metal sculptures—beautiful paradoxes of weight and grace. His work required not just his artist’s vision but also tremendous physical strength to manipulate heavy sheets of steel, to bend them to his will, and to cut them into intricate shapes. The results were stunning pieces, 10 feet high and as many wide, and highly sought after.
Michael’s was a life of the mind and spirit. He lived in the heart of the city and was married to Lisa, a painter and teacher. He had so many books that they gathered dust on their many shelves, a constant source of worry as a possible source of infection. For Michael, every new experience left in its wake a profound curiosity, questioning, and then silence, as he absorbed what was happening to him. He missed nothing and described everything: the bewilderment of the diagnosis of acute myeloid leukemia (AML), the unfamiliar universe of the hospital and the new language it forced him to learn, the barrage of procedures that awaited him—emergent leukapheresis; the placement of a PICC [peripherally inserted central catheter] line to administer the toxins we hoped would bring about remission; a biopsy of his bone marrow; a lumbar puncture; and on and on.
Tom was a mortgage banker and former football player. Everything about him was big: He was fun and loud. He had expressive brown eyes, a bushy mustache, and lots of thick brown hair, which he brushed back over his head. Tom drank innumerable 2-liter bottles of Diet Pepsi—without a glass—and spent his days buying, selling, competing, barking, jockeying for position. His life was abundant and chaotic. He and his wife, Karen, also a mortgage banker, had a tumultuous relationship, having divorced and then reunited.
In their living-large lives, they had both become dangerously overweight and a few years before, with a fanatical intensity, had lost nearly 300 pounds between them. Tom revered all of the chronically underachieving Philadelphia sports teams, but he loved the Eagles best. He wore that love on his sleeve, literally, with a satin Eagles jacket that accompanied him to every visit. The highlight of his family’s year was their annual vacation to Disney World, and his leukemia treatment was going to derail their trip.
Despite this, Tom took his diagnosis almost in stride: “Tell me what I’ve got to do to beat this thing, doc, and I’ll do it.” He received his treatments with calm, intensity, and grit, never trembling and never yielding. He asked few questions and marched forward with determination.
Different Types of Fear
Tom and Michael were diagnosed with AML within weeks of one another, and each received his initial induction during a 30-day hospital stay. Residing on different floors at different times, their paths never crossed in our large oncology unit. Only I, as their physician, was aware of their vaguely parallel paths.
Most patients find cancer terrifying, of course, but an acute leukemia diagnosis exponentially magnifies and steepens this vertiginous fear. Both Tom and Michael were aware that, although their shared disease was curable, the risks of induction chemotherapy were substantial.
The nub of Michael’s fear, though, was not loss of life…. It was loss of his ability to create. The only questions he asked me were whether his leukemia was caused by the solvents and dusts necessary for and created by his work and whether his recovery would be sufficient to permit him to continue to work in this medium. When told that I was uncomfortable with him handling red-hot, hefty slabs of steel during his nadirs and that an indwelling central catheter would limit the weights he could carry, he decided he would use this time on treatment instead to plan future works.
One was an introvert, one was an extrovert—but with the same rare cancer, the same doctor, and the same treatment. Surely, there would be much to discuss and to share…. I could not have been more wrong.— Alison W. Loren, MD, MS
He set about creating miniature paper models of the sculptures he envisioned; dozens of them covered his workspace at home, Lisa told me proudly. His alarm when he developed the chemical conjunctivitis sometimes seen with cytarabine—fearful that his vision might become affected and he would never work again—was greater than that with which he received the news of leukemia.
Tom handled his emotions as one might expect from a former athlete: surprise, followed shortly by anger, leading swiftly and finally to a grim resolve: I will win. Beneath the bravado, though, was also a kernel of fear. In Tom’s case, his fear was rooted in the loss of control inevitably brought on by cancer. He would also stop working and lose the addictive rush of his high-pressure job, the thrill of the deal, the satisfaction (and aggravation) of managing teams of people, and the financial rewards (and losses) that shaped the architecture of his days. Tom dictated the terms of his life, not the other way around. Finding value in the ordinary would be a great hurdle for Tom, overshadowed only by the humbling—truly, eviscerating—recognition that the influence he held over his own life was fleeting and inconstant. For now, leukemia was going to call the shots.
Strangers Finally Meet
After their induction courses of therapy, each one went on to four cycles of consolidation. Although almost every patient with leukemia is assigned a single room for these treatments, these patients every so often are assigned to one of a very few double rooms, remnants of a simpler time, when hospital-acquired infections were unappreciated if not uncommon.
One week, Michael and Tom caught up with each another. Their consolidation treatments aligned, their admission dates were identical, and they were assigned to be roommates. I thought this would be interesting. Five days is a long time to get to know a stranger. One was an introvert, one was an extrovert—but with the same rare cancer, the same doctor, and the same treatment. Surely, there would be much to discuss and to share; surely, they would bond and perhaps even appreciate their differences. I could not have been more wrong.
Tom approached this hospital stay with boxes of snacks and Diet Pepsi in tow. Ever sociable, even when he received chemotherapy, he entertained friends, coworkers, and family. When alone, he was on the phone or following his teams on TV. Michael spent his 5 days in meditative silence. Chemotherapy always disturbed him, and he focused on compelling himself to accept its necessity. He was determined not to let this soulless experience deplete him of his creativity and his passion.
They spoke so little to one another that neither became aware that I was the other’s doctor. Oscar and Felix got along better. At our respective follow-up visits, I heard about this 5-day stint from both of them.
Tom: “Doc, I had the worst roommate this time around, you gotta make sure I never bunk with that guy again. He was such a drag, wouldn’t talk to me and kept telling me to turn off the TV.”
Michael: “Please don’t ever let me have a roommate again. He was loud, kept screaming at the game on TV, which was always on. He had visitors all day long. He was so disruptive, it was exhausting.”
Cut From Different Cloth
Knowing them well by now, I smiled to myself: They were both right, and they definitely were cut from different cloth. I murmured some niceties about the unpleasantness of hospitals and how leukemia makes strange bedfellows, and I left it at that.
After they finished their grueling treatments and one final bone marrow biopsy, both Tom and Michael got some great news: They were in remission—no leukemia to be found. Naturally, this brought enormous joy and relief. Michael was anxious to get back to his work and had many questions about the safety of his welding and molten metal. Tom was equally eager to resume his life—maybe with a little less Diet Pepsi—and itched to charge back at the markets and his clients.
At a follow-up visit a few months later, Michael brought me a postcard that featured a new sculpture from his latest series. The works were to be displayed at a prestigious local museum, and he was inviting me to the show. The title of his show was “Phoenix”— heavily influenced by the 6 months of harrowing treatments that had brought him to the brink of death and then delivered him back to life.
The next week, I had the pleasure of seeing Tom. He, too, had begun the process of returning to normal, and he and Karen regaled me with amusing tales from the belated Disney trip they had at last taken with their extended family. At the end of the visit, Tom said he had something to show me. “Doc, you’ve got to see my new tattoo.” Tattoo? Shouldn’t he have checked with me first? Those needles … his chemotherapy so recent…but, before I could open my mouth to (playfully) scold him, he pulled his shirt up over his head. There on his back, spread across his recently replenished trapezius muscles, was the inked image of an enormous bird with flames at its feet—a phoenix. ■