Makomed's Weblog

Hope for the Best, but be Prepared for the Worst

Posted on: September 1, 2007

Nobody wanted him in their research because his disease was so aggressive and he had no real health insurance, but he ended up with me anyway. I got his CT scans back in July and gave him a Temodar prescription to offset his metastatic melanoma which was on his adrenal glands and brain. I also gave him the study drug, per protocol. It was a VEGF inhibitor that I hoped would block the blood vessels feeding the tumors, essentially starving them into remission. He was lucky enough to go into the study arm that allowed him to receive both drugs simultaneously. He was ready to start the cancer research program.

A month later he complained to me of a pain on his left side, but it was hard to increase his methadone because I couldn’t get a hold of his pain specialist, who only volunteered at the free clinic and was all that was available to the patient since he only had Medi-Cal insurance which is difficult to work with. It was almost moot, anyway, because his dilantin would decrease the efficacy of his methadone.

Two months later, we redid his CT scans. It turns out that his left adrenal node grew larger, and he had a new tumor there, which was what probably caused the pain. Not only that, but a dedicated brain CT showed that he had new brain lesions (his Medi-Cal took too long to approve an MRI).

The research completely failed him.

When the doctor and I went into the examining room to talk about the results with him and his sister, it was difficult to see his reaction and disappointment. The patient took it pretty damn well. This was devastating news, after all. This kind of calamity doesn’t even come close to what anybody else in that room has ever experienced. He had cancer, not us. When the doctor and I deliver the bad news to a cancer patient, it’s not like hearing that your girlfriend or boyfriend wants to break up, or that you didn’t get to go into the college of your choice, or that your favorite American Idol contestant got voted off. No, it’s pure, unequivocal shitty news. The new research drug did not work, and so far, you’re still going to die soon. We didn’t say it exactly like that. We just said that the drugs didn’t work and his tumors are increasing/getting bigger, but I imagine that’s how it was received. You can’t sugarcoat a pile of dung.

His sister is a strong woman, his complete polar opposite. She is kind of a bitch, in fact. But I know she has to be. Her brother is dying. After the doctor leaves, she searches my face for answers, but I tell her that we have to defer to whatever the doctor suggests.

“Would he lie to me? Has he given up hope on my brother?”

I tell her no, that’s not the case. I reassure her that the doctor is a level-headed one. “He’s a classical doctor. He’s not swayed by emotion, so it might look like he’s apathetic, but he’s actually thinking of alternative modes of treatment for your brother. He’s a good doctor.” I believe this.

She calls me every three days for news about what to do. I tell her we haven’t had any new trials come up yet. A quietness fills the telephone line.

“Should I…should I be ready if my brother…?”

I think of a textbook answer. I can’t because I’ve never read of a clear, concise answer in a book before. I think of what the doctor would say. I can’t, because I’m not a doctor. I think of what a friend would say. I can’t, because I don’t even really like her, although I sympathize with her. I wish she wouldn’t ask me these questions. I wish she wouldn’t give me so much trust. I wish she would just ask the doctor, and not me. I don’t want to be sued for saying things like this over the phone.

Then, I think of what I would say to myself, and I say to her: “Yes, why not. Hope for the best, but be prepared for the worst.” I tell her something like that.

This seems to alleviate her worries a little. I can’t tell, but I sense her nodding her head over the phone. She begins to sound less apprehensive, but I continue to stay wary. I’m still quite aware that I am powerless over the whole situation and I am careful not to get drunk over my desire and ability to comfort someone who really can’t be comforted since her brother is terminally ill.

“What does he want to do?” I ask her.

“He still wants to try a new research trial. He doesn’t like to talk about, you know. Palliative care.”

I told her that since that’s what her brother wants, I’ll keep looking for a new trial for him to get in to, although I think to myself that it will be exponentially difficult since drug companies prefer patients who haven’t had more than one cytotoxic chemotherapy. But I promised her that we will trudge on. If that’s what he wants. I instruct her to support her brothers wishes, but to also–you know–brace herself. Then I shower her with new and exciting possibilities of treatment that are coming down the pipeline. I infuse my voice with an enthusiastic inflection, but only after I’m satisfied that she knows the gravity of the situation.

The research study may have failed him, but if we keep trying, we may still succeed. But I can’t ignore the rapping of the reaper at the door. Hope springs eternal, but cynicism never gets the credit it deserves.


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