I was traveling last week. After the stewardess pointed out the exits, the broad shouldered gentleman stuffed into the seat next to the seat I was stuffed into, decided to make some small talk. “What kind of work do you do?”
“I am an oncologist,” I said, and prepared myself for what I knew was coming next. There are only two responses to “I am an oncologist.” The first is, “what’s that?” (The word oncology is code. In the 60s it was politically incorrect to say “cancer”. Even today, patients and clinicians stumble around the word, preferring terms like malignancy, neoplasm, tumor, or just lump. Cancer care was entering the dawn of an era where not everyone was going to die and was soon to become a new specialty, so the word “oncology” was coined to avoid saying the “C word.” But when someone doesn’t know the code word you have to be direct. “I am a cancer doctor.”)
If the second question isn’t asked first, it is asked next. It isn’t really said like a question, it’s more like a statement with a question mark. Sometimes the statement is one of wonderment, but as often as not it is pity. “Why did you decide to be a cancer doctor?”
Cancer is a fascinating disease. It is the closest thing, in this life, that we will get to immortality. Take cancer cells, put them in a test tube and take care of them right and those cells can be grown forever. Take our normal cells and care for them the same way and they will be dead in two weeks. We do research on cells harvested from cancer patients 20 years ago. Besides being mortal our normal cells respect the space of other cells. Lung tissue stays in the lung and colon cells aren’t found in the liver, but lung cancer, left alone, grows right through the lung lining and into the chest wall, and colon cancer, given enough time, invades into a blood vessel, circulates through the blood, escapes the immune system, manages to get out of the blood stream and then grow in the liver with great frequency. Understanding cancer and thereby defeating it requires knowledge of cell and molecular biology, immunology, virology, physiology and genetics. No doubt about it, cancer is a worthy foe. I think that most oncologists were first drawn to their field in the early years of medical school by the elegantly intricate science of cancer.
No other field of medicine is changing as quickly as oncology is. New chemotherapy and biological drugs are being introduced at a dizzying pace, sometimes faster than we can assimilate them, through rigorous patient trials, into our treatment regimens. However, it is not just chemotherapy drugs, but the way we administer them that has undergone a virtual revolution in the last 20 years. This has largely been a result of remarkable changes in the way we support chemotherapy patients that has taken most cancer treatments out of hospitals and into outpatient treatment centers. Medicines that, with virtually no side effects, turn off the nausea center in the brain, allow treatments that used to require a three day hospital stay and sedating drug to be delivered in a lazy boy chair during lunch and the patient sleeps comfortably in their own bed that night. Medicines that boost the bone marrows production of infection fighting white blood cells protect patients from complications of chemotherapy when we used to have to compromise the chances of response by decreasing doses. In clinical trials there are drugs to counteract the wasting and cachexia that often accompanies cancer.
But medicines that allow us to give more poison are just the start. Antibodies made in labs are now commercially available that target many lymphomas, some breast cancers, and a few leukemias. Some of them have no toxicity at all. A fascinating drug called Gleevec, and newer “Son of Gleevecs” target, not a particular cell, but a particular oncogene found in some cancers. It is dramatically changing the natural outcome of the cancers containing the gene. Soon we will have drugs that are capable of turning on hibernating tumor suppressor genes and cause cancer cells to commit suicide. We are approaching a day when instead of having a terminal illness, uncured cancer patients will instead have productive lives as they live with a chronic disease. Oncology is a vibrant and intellectually challenging field.
But that is not what I told the gentleman on the plane. As we feasted on peanuts and beverages, I relayed the great pleasure that comes from the work that I get to do. Ultimately what drew me to oncology during my formative medical training were the patients and the cancer caregivers I met. I am convinced that oncology nurses are the epitome of what nursing as a profession should be and I get to work with them and learn from the loving care that they give every day. But it is the patients themselves who teach me the most important lessons. Perhaps their expectations are low, but cancer patients and their families are genuinely appreciative of efforts on their behalf, and the bonds that develop between them and their and professional caregivers, albeit often brief, are intense and extremely gratifying. My patients remind me day after day that there is more than one way to beat cancer. The human spirit is more resilient than the human body and the ability of individuals to rise above the adversity of the moment never fails to impress me that it is not how long we live, but how we live that determines our legacy. Helping patients to come to grips with their disease and to live or die with pride and a sense of peace is often a greater and more fulfilling challenge than fighting the cancer. At times, wrapped up in the minutia of complicated treatments, time pressures, insurance hassles and endless paperwork, we may forget, but that is why oncologists are cancer doctors.