THE FINAL VERDICT

So, one of the great things about my day job is that on Tuesday afternoons I have the privilege of taking care of patients with prostate cancer. It is not always easy or uplifting, but it is always a pleasure. These men and their families allow me to enter into their lives and to guide them through the journey known as incurable cancer. They each bring their life experiences and values to the table, which makes each person and each "case" so fascinating. It is entirely human and entirely epic and that is what drew me to Oncology (Think a Camus novel on a weekly basis).

Today, I saw back a patient, a retired judge, whom I had not seen for about 2 months. He had metastatic prostate cancer that had progressed despite multiple treatments directed at interfering with levels of male hormones, which act as fuel in prostate cancer cells. He had quite a bit of left hip pain this summer and early fall, and we had radiated his hip on two occasions with minimal relief. It was at that point that I strongly advised him to try chemotherapy, which essentially is chemicals that target quickly dividing cells, including cancer cells, too, we hope. The Judge was not interested in chemotherapy at that time, as several of his friends who had died of cancer had been treated with chemotherapy. Mind you, they died of their cancer rather than side effects of the chemo, but the Judge, who realized this, felt like the side effect profile of chemotherapy outweighed any potential benefit. He sought another medical opinion and had been doing well until this weekend when he developed pretty severe pain in his opposite hip. He called the clinic and made an appointment to see me.

We discussed my concern that the cancer was growing in new places and likely causing his symptoms. He expressed understanding but still seemed hesitant to try chemotherapy. This case seemed closed, if you will, in his mind. It was at that point that I recalled an article by Jerome Groopman, the oncologist and writer from Beth Israel Medical Center and Harvard Medical School, whose pieces I have read in the New Yorker for years. I remembered one article in particular, which was later published in his book "The Measure of Our Days," when Groopman tried to help a patient, who was a businessman, decide on treatments by describing the options in financial terms. My patient seemed to have made up his mind and had been prejudiced by his friends' unfortunate experiences and the modest palliative benefit for the average person in prior clinical studies with this type of chemotherapy.

I apologized for potentially sounding like a cross-examining attorney, but I asked him to objectively weigh the evidence- I explained to the Judge that yes there are possible side effects and harms of chemotherapy but that these needed to be weighed against the certainty of harm with doing no treatment. In essence, I asked him to put back on the robe and serve as judge of the case of his life. I asked him whether something that had once seemed heinous (early days of chemotherapy) could have possibly improved or reformed over time- whether it deserved a "second chance?" What was to be gained or lost by treatment versus observation, I questioned? What did his internal law tell him?

I told him the answer was not to be found in a medical journal or textbook. It was not to be found in his head. The verdict, by which I was prepared to stand, was only to be found in his heart.