Redefining Success

My Monday morning belongs to “Tumor Board.” In this weekly meeting, gynecologic oncologists, radiation experts, radiologists, pathologists, nurse managers, fellows and residents join forces to develop treatment blueprints for our cancer patients. Crowded into an old conference room, our collective mission is to tackle the challenge: “What can we do for our patients?” Pathologists scrutinize slides of tumor under the microscope. Radiologists show images to elucidate the extent of cancer invasion. Researchers critique the merits of the latest clinical trials. Radiation experts evaluate the opportunity for radiotherapy. A senior clinician summarizes the action points, and the fellow meticulously documents the discussion in the chart. Then, the residents get their marching orders to execute the strategy. We are a fiercely technical and data-driven army, churning out evidence-based recommendations for 20+ patients in under 2 hours.

Invariably, one or two of the patients we are talking about will have exhausted the full spectrum of treatment options. For a brief moment, the cancer-fighting machine grinds to a halt. A frustrated clinician will break the awkward silence by declaring, “Fine. I guess she goes to hospice.” We quickly move on to the next patient. No one wants to dwell on the defeat.

Recently, I embarked on a research project to look at the health care resources our patients received in their last year of life. I reviewed 100 medical charts of patients who had died from cancer. It turns out our patients spend most of their final days in clinic or awaiting diagnostic tests. Some have over 50 blood draws, 20 clinic visits, 5 chemotherapy infusions, 2 CT scans, and an MRI in the last 2 months of life. I imagine them in immodest hospital gowns, sitting in cold hallways, nervously fidgeting before their 10+ invasive procedures that may or may not buy them more time.  Stepping back and looking at these raw numbers made me question what sort of environment we have created for our patients’ final days. Must our patients be rushing around the hospital, or could they be at home with their families and friends?

In fact, in all the years I’ve sat in Tumor Board and listened to the hundreds of plans being hatched, I have never heard anyone recommend doing nothing. Even when we are dealing with incurable cancers, we can’t help but think ‘doing nothing’ or even ‘doing less’ is equal to admitting defeat. It is never voiced that maybe the patient should NOT spend their final days with us. We assume that all patients want everything done until they explicitly state otherwise and sign the appropriate documents. When cancer enters the picture, we act as if the rest of life stops.

I understand why we are reluctant to talk about the end. After years of making personal sacrifices, surviving sleepless nights, performing complicated surgeries, requesting hundreds of hours of nursing care, and ordering hundreds of thousands of dollars of medications, tests and hospitalizations all to beat back death, we have no tolerance for failure. So, we construct intensive defense tactics that basically make patients’ last months about conquering cancer. It is unthinkable that anything else could be more essential.

I remember Debra, a true warrior patient in the fight against ovarian cancer, the most destructive and fatal of all gynecologic cancers. Debra endured 5 different courses of chemotherapy only to discover that the cancer had obstructed her intestines. She proceeded to have a surgical opening created in her abdominal wall where feces could be collected in a plastic bag. When the cancer overtook her lungs, she consented to having thick tubes inserted into her chest to drain out the malignant fluid. Debra would come in and out of the ICU multiple times in her final month, battling infections, kidney failure, and loss of consciousness. With each episode, she acquired a new device to support the function of another failing organ, including feeding tubes and larger IV access for daily blood draws. She slipped away quietly in the night, fighting to the very last moment.

When a cancer patient dies in the hospital like this, she often has a variety of artificially created holes in her body to get air, fluids, food, and drugs in and out. After the tubes and gadgets are removed, all that remains is a shell, hollowed out and replaced by cancer. While I have seen this many times, for the patient, it’s her only shot at death. She doesn’t have the benefit of stepping back and seeing what all the interventions will add up to.

The reality is, we oncologists are not trying to gain control of a chronic disease like high blood pressure or diabetes for which there are proven therapies and the time to check out various regimens. Advanced cancer almost always kills, and kills swiftly. What would happen if we leaned into the truth that we can’t save particular patients? Is there space in Tumor Board for social workers and palliative care experts? Is there room for death planning instead of disappointedly turning a patient over to hospice? Rather than obstinately sticking to pre-existing algorithms, what if we redefined what it means to succeed at providing exceptional cancer care?

Perhaps optimal care is more than chasing down every last cancer cell, packing patients’ schedules so full of appointments that there is no time to wonder if this is worth it to the patient or society at large. I believe that patients do come to us for answers. They are terrified of their cancer. They need help figuring out what to do about it. They will listen to practically everything we say because we see this every day and they have never seen it. So, it seems that when we don’t have cures to offer, it becomes crucial to support the patients and their families through the experience as compassionately as possible. The ultimate marker of success might not be days of survival, but something less measurable and infinitely more meaningful -- something like helping a patient fill every remaining moment with joy, peace, and connection, instead of blood tests, imaging studies, and hospital visits.

My research this week forced me to pause and realize that my role isn’t just to be a cancer expert. I also have the responsibility to manage a patient’s hopes, a family’s need to feel like they did everything they could, research scientists’ necessity for experimental data, and my personal mission to “do no harm.” Being successful in striking that balance means purposefully keeping “do nothing” in the arsenal of therapeutic options. Sometimes, that may be the most aggressive thing I can do for a patient’s wellbeing.