The following essay by Bruce A. Chabner, MD, is adapted from The Big Casino: America’s Best Cancer Doctors Share Their Most Powerful Stories, which was coedited by Stan Winokur, MD, and Vincent Coppola and published in May 2014. The book is available on Amazon.com and thebigcasino.org.
Mr. C is almost 90 now, but every summer the boxes of squash, pumpkins, tomatoes, and other vegetables from his truck farm still arrive like clockwork at our door. The cancer that required treatment 17 years ago has never recurred. He’s now struggling with a new problem, recovering from a broken hip. I’m sure he’ll make it. Mr. C is a tough, tough man—and my friend.
In 1996, he presented with a high-risk colon cancer. A surgeon at our hospital resected the tumor, but because the surgeon found multiple positive lymph nodes, Mr. C required adjuvant fluorouracil (5-FU) chemotherapy, the standard treatment protocol.
Unfortunately, Mr. C had an extremely toxic reaction to the first doses of the chemotherapy, including severe bone marrow suppression and painful oral and mucosal injury, whereby the chemotherapy had essentially wiped out the lining of his gastrointestinal tract. He developed a serious bloodstream infection, was treated with antibiotics, and endured a prolonged and difficult hospitalization. At the time, he was 72 years old.
At that point, his family asked that I take over his care. I’d recently arrived in Boston from the National Cancer Institute (NCI) in Bethesda, Maryland. Mr. C’s family members were apprehensive about the toxicity he was experiencing but eager to see him complete his treatment. I’d done research on 5-FU back in the 1970s and understood its pharmacology—how it metabolized in the body, its conversion to an active form, and its subsequent breakdown. One of the catalysts in this process is the enzyme dihydropyrimidine dehydrogenase, which is polymorphic (and some forms of it don’t work very well).
A small percentage of patients have a dysfunctional form of this enzyme and can’t break down and clear 5-FU efficiently. Mr. C was one of those individuals, but this was not known prior to administration of the drug, which was the reason for his severe toxic reaction.
An Intensely Personal Relationship
During the course of caring for Mr. C, I learned he was an honored person in his community. Although I had many administrative and research responsibilities and did not take personal care of many patients, I decided to take on this difficult case and manage him through the adjuvant therapy. Mr. C was willing to undergo more treatment despite what had happened. We continued the chemotherapy in much-reduced doses. The strategy worked, and he’s remained free of the disease ever since.
In oncology, the doctor-patient relationship is intensely personal, involving factors well beyond the medical competence of the physician and the biology of the disease. So much is at stake, and so much emotion enters into the relationship—hopes, fears, regrets, and above all trust. The chemistry between physician and patient is something special. When it clicks, the experience leads to a sort of brotherhood.
The chemistry between physician and patient is something special. When it clicks, the experience leads to a sort of brotherhood.— Bruce A. Chabner, MD
During the course of his treatment, I became close friends with Mr. C and his family. Looking back, I realize there were several reasons for the friendship: Boston was new to us; my wife, Davi-Ellen, and I had just arrived from Washington, DC, where I’d spent 26 years at the NCI; we knew very few people in our new city; and our two children, now independent, were in the process of marrying and moving away.
Over the succeeding years, we got to know Mr. C’s remarkable wife and family, who welcomed us into their home and shared dinners and family occasions with us. To understand him fully, it is worth recounting his personal story.
Mr. C is the definition of the term “The Greatest Generation.” In Word War II, his infantry unit was overrun in the Battle of the Bulge (January 1945). Wounded, thrown in a ditch, and left to die, he crawled out after the Germans retreated and somehow made it back to his own lines in the midst of one of the coldest winters on record in Northern Europe. It took him days to reach friendly lines, all the while nursing a terribly infected arm from shrapnel. To this day, he still has shrapnel in his arm.
Back home in suburban Boston, Mr. C, the son of an immigrant Italian truck farmer, built several successful businesses. More importantly, he gave back to his community, devoting himself to charitable and community-service projects. For example, he was instrumental in setting up the college system in Massachusetts. He is still friends with many leaders in local political and business circles. As he is a very wise man, his advice on matters of business and politics is universally valued.
Finding Comfort From Patients
In addition, once you’re his friend, you will always be his friend. Going through the difficult times of his treatment and recovery, my wife and I joined that circle. Mr. C and his family became our family; his recovery led to an extraordinary, enjoyable, and important relationship.
Like the best relationships, it’s been a two-way street: Whenever there’s a problem in our family—and like all families, we’ve had our share—he’s the first one to help. And I am always willing to help his family through medical situations. We’ve gone through a lot together.
Mr. C and his wife and children were there for us during our own illnesses and crises. Mr. C was never too busy to make a timely phone call or visit when it was most comforting. Despite the fact that he’s older now, Mr. C still plows his ground and grows a really great crop of squash, eggplant, and tomatoes. We’re always among the first to find crates of vegetables in our garage in the fall.
Mr. C and I have lunch every week. We always go to the same place we have gone for years. Everybody knows him, and, of course, he’s the most popular customer in the restaurant. What I’m saying, in perhaps too many words, is that this friendship—forged in the dire circumstances of sickness and uncertainty—has become one of the most important friendships my wife and I have ever had.
Determined to Survive
Survival. You always wonder whether there is something special about the person who survives a difficult situation or whether it’s pure chance. Mr. C is someone special. Look at his war experiences. A lifetime later, he was determined to survive the episode with cancer and its treatment toxicity. He’s having a tough time now because of a broken hip and is struggling to stay on his feet and to keep active.
He will make it. He’s a person I identify with … more than a patient, more than a friend. ■