Frank came into the office today. He's a friend of the family who I've been talking to periodically over the last year. He was diagnosed with an advanced melanoma and has undergone chemotherapy. Despite this, he's developed another nodule of melanoma. He's now undergoing experimental treatments for metastatic melanoma; the truth is there are no good treatments for advanced melanoma. Every time we think we've found something to prolong these patients' lives, further studies show this to be untrue, and these chemotherapeutic agents, usually medicines given by injection like the interferon I take myself (cancer patients have to take it in much higher doses) make you feel awful. You get fevers and shaking chills; sometimes your whole body swells up; you ache all over. You may have difficulty breathing or develop a chronic cough or have blinding headaches.
Frank is miserable on his experimental medications, largely because it is driving his psoriasis crazy. Almost his entire body is covered with red scales; he burns and itches and is embarrassed to wear short sleeves. The medications to treat melanoma are designed to super-activate the immune system. The medications to treat psoriasis are designed to quiet the immune system down. He's stuck in a terrible position. Treating his psoriasis would be likely to allow the cancer to spread even further through his body. On the other hand, on a daily basis, he is horribly uncomfortable, though he knows he will not die from his psoriasis.
I hadn't seen him in a long time, years really. We've spoken many times, but I was protected by the anonymity of the telephone. It was a shock to be face to face with him, though I should have known better. I've seen enough cancer patients to know the toll it takes. Overall, they just seem smaller. Obviously, he's not really shorter, but chemo seems to shrink a person; it grays the hair, drains the skin, sinks the eyes. He had always sounded energetic on the phone, but in person I saw him collapsing inward.
I knew he was coming, and I had already searched the medical literature for psoriasis treatments that wouldn't be too dangerous. I knew I didn't have a lot to offer, but we talked. We talked about quality of life issues. He's an intelligent patient, and he's done enough reading to know realistically what his expected lifespan is. The five-year survival for patients with melanoma as advanced as his is a lowly 20 percent to 30 percent—and even that estimate may be high. He has to decide at this point what is more valuable—the hope that the experimental protocol gives him or the comfort of living life with his psoriasis controlled and without the side effects of the medication. When I came into the room, he asked me, "Is it cold in here?"
I shook my head no.
He sighed. "Then it's the interleukin. It's giving me chills."
"It does that," I said.
There is no guarantee—in fact it would be a miracle—that this treatment will prolong his life. The only thing it offers for sure is some hope; it keeps him from giving up.
We came up with a plan that might help. It isn't much, but it's all I could offer. I stood there in my white coat and scribbled out prescriptions, and I looked at him, sitting all watery and sad on the chair, and I remembered that the last time I saw him face to face was over 10 years ago, at my father's 50th birthday party, a roast, when he had been laughing and making fun of my dad's overly competitive nature on the tennis court.
He is probably going to die from his melanoma. He knows it, and I know it, and while I can try to help him and comfort him, he alone has to figure out how exactly one leaves the world.