Cardio-Oncology: When Two Life-Threatening Illnesses Collide

Listen to ASCO's Journal of Clinical Oncology essay, "Cardio-Oncology" by Dr. Daniel Rayson, clinical oncologist at Queen Elizabeth II Health Sciences Center. The essay is followed by an interview with Rayson and host Dr. Lidia Schapira. Rayson shares a personal experience working with a patient who has two life-threatening diseases.

TRANSCRIPT

Narrator: Cardio-Oncology, by Dr. Daniel Rayson (10.1200/JCO.21.00971)

I was asked to see a 64-year-old man in the coronary care unit (CCU) 4 days after he collapsed in his driveway after a seemingly normal day at work. His wife told the paramedics that he had been having episodes of chest pain in the past 2 weeks leading up to his dramatic homecoming and he was diagnosed with a myocardial infarction in the emergency room. An urgent cardiac catheterization revealed critical three-vessel coronary artery disease, and on the basis of his otherwise pristine past medical history, he was recommended to undergo coronary artery bypass surgery.

His admission blood work, however, revealed a hemoglobin level of 91, much lower than the last available value of 137 roughly 1 year before. When questioned, he described having difficult bowel movements over a 3- to 4-month period with occasional blood-streaked stool. A computed tomography scan quickly diagnosed his second critical problem, a locally advanced sigmoid colon cancer with multifocal hepatic metastases.

I was asked to see him urgently to help adjudicate the appropriateness of proceeding with the cardiac surgery in the face of a second competing life-threatening condition and to help the cardiology team elucidate the goals of care in the context of his oncologic prognosis.

I had not been inside a CCU since the depths of my residency days and walked in awkwardly while trying to convince everyone that I belonged amid the ventilators, central lines, and constantly pinging monitors. Shuffling through the nursing station, I passed a bank of video surveillance screens that would not have looked out of place in a high security prison and despite being completely disoriented, I managed to find my patient. As I squeezed into a chair between the IV pole and the movable side table upon which lie the prized possessions of the hospitalized, I took mental note of the photo of his beaming family gazing up at him. I introduced myself and tried not to let the pinging cardiac monitor distract me from the discussion or add to the headache that was already beginning to pound. He seemed to become paler before my eyes as I slowly explained the scan findings to him. His liver was peppered with variably sized metastases, too many to reliably count, I explained in answer to his question. Although there was no biopsy confirmation of his disease, the constellation of clinical symptoms, blood work, and imaging left no room for doubt.

"So, what am I in for," he asked.

I carefully explained why all therapies for his cancer would be noncurative in intent and why surgery would be limited to an urgent need to remedy bowel obstruction but would not change his overall prognosis.

"Can't they just fix this at the same time they'll be fixing my heart?" he then asked.

I circled back to why surgery could not deal with all of his disease and then spent the rest of the discussion talking about chemotherapy and the goals of treatment, which were to help him live as long and as well as he could with his cancer.

"Until …?"

"Until you die from the cancer," I responded bluntly.

"So let me get this straight … they want me to have surgery on my heart so that I can end up dying from my cancer? Do I have that right doc?"

Oncologists are experts in reframing prognosis and expectations in the face of metastatic, incurable disease. It is an important part of our jobs to be able to convince people that the median survival time of 2-3 years for metastatic colon cancer is something to cheer about. It is equally important that we are able to clearly explain that a median is just a point estimate, without direct relevance to the individual in front of us, and that we are often unable to predict how close to and on what side of that median the future holds for them.

"I guess that's right," I replied, my eyes not leaving his.

"It's a question of what would get me first," he stated.

I nodded, "In a sense, you know the answer already."

"Yes, I could have died in my driveway, that's true. I guess I just about did."

"As close as anyone can come to just about dying in their driveway, yes, you just about did."

"But if my heart does it, it will be quick, right? No pain. No drama. Just an ending, like almost happened?"

I nodded.

"But cancer-that's a whole other thing. Pain, vomiting, chemotherapy, weakness. Suffering. For me and my family."

I explained the lengths to which we try and control pain and other symptoms, from both disease and treatment, and reviewed the medical and supportive care that is designed to minimize suffering.

"But doc, how often does that happen? How many times can you truly say that you were able to minimize suffering? And not just for your patients, what about the suffering you don't see? For my wife, my kids. How do you take care of their suffering as they spend the next 2-3 years, if I have that long, slowly watching me die of cancer?"

By then, my headache was screaming at me. A hammer behind each eye was slamming down on chisels angled to the center of my brain. The incessant pings, beeps, and buzzes of the monitors and machines were laughing at my discomfort. We kept circling back to the competing timelines of two life-threatening illnesses, the dramatically different trajectories they take to death, and the different types of fallout and collateral damage to be expected.

After an hour together, he had decided that death later would always be better than death now, and as we warmly shook hands, he turned the family photo toward me as final confirmation of the motivation behind his decision.

I spent a few minutes collecting my thoughts and trying to soften the hammer blows to my head with some deep breathing and ibuprofen before venturing to the work room to dictate my consultation note and find the attending cardiologist.

"Thanks for seeing Mr L, what do you think?"

The chief cardiac surgery resident had found me first. It was not everyday that an oncologist is needed in the CCU. I was not as incognito as I thought.

I explained the onco-scenario in detail and could sense the disappointment when I came to estimates of life expectancy. A median survival of 2-3 years after a bypass would be woefully inadequate from the perspective of a cardiac surgeon, whereas, for an oncologist, it represents a realistically optimal outcome with current therapeutic options. If an otherwise healthy patient survived cardiac surgery—an increasingly expected outcome given current technology—they are fixed and unlikely to ever suffer a cardiac death. An otherwise healthy patient with a metastatic cancer, however, is never healthy again. I could never fix Mr. L.

I spent some time trying to convince the resident that the value of whatever time is left for any one patient is known only to them. And that the risk-benefit equation that underlies any medical or surgical decision is always assessed from the vulnerable position of the unwell with the ultimate decision usually made on the basis of parameters beyond medical or surgical outcome expectations. I noticed his eyes looking beyond me and knew that he was barely listening to my philosophical explanation as to why I recommended proceeding with the surgery.

In the end, Mr L underwent a three-vessel coronary artery bypass graft, which he sailed through without complication.

I took care of him for the next 4 years, sequencing both chemotherapy and targeted therapy as his disease waxed and waned in threat until finally there was no stopping it. I got to know his wife of 31 years who along with their three grown children celebrated the arrival of their first grandchild during one of his visits to the chemotherapy unit. I saw photos of family milestones along the path of his cancer journey and laughed with him when he was teased about his chemo-good looks. I wrote letters that he took with him on family trips to give to border control if he was asked about his narcotic medications or to medical personnel if they needed background and guidance if he got sick. He always told me that the letter was more important than his passport, knowing that there would be someone at the end of the line to help him and his family if he got into trouble.

A few weeks after he died, I ran into one of my palliative care colleagues who I knew was involved in Mr. L's last weeks. He confirmed that he passed away peacefully and in comfort. His wife and three children were with him, and his favorite music was playing as he became unresponsive. I gave him my thanks for helping with his care and for allowing him to die in peace and turned away to walk back to the clinic.

"Oh, one more thing," he called out.

I turned back in mid-stride.

He told me to tell you that he was glad he did not die from a broken heart.

Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Shapira, associate Editor for Art of Oncology and professor of Medicine at Stanford University.

Today we are joined by Dr. Daniel Rayson, clinical oncologist at Queen Elizabeth II Health Sciences Center. In this episode, we will be discussing his Art of Oncology article, Cardio Oncology. At the time of this recording, our guest disclosures will be linked in the transcript.

Daniel, welcome to our podcast and thank you for joining us.

Dr. Daniel Rayson: Thank you very much for inviting me to be here with you today, Lidia.

Dr. Lidia Schapira: It is a pleasure. I'd like to start by asking you some questions about your process for writing. You have written essays before and published them in many venues. What sorts of clinical episodes trigger your desire to write, reflect, and then what leads you to want to share them with readers?

Dr. Daniel Rayson: That's a loaded question, but thanks for asking it. So, as far as the clinical scenarios, it's those episodes in routine practice that somehow get under my skin in one way or the other, whether it's due to a strange diagnosis, an unusual reaction or interaction I've had with the patient and/or their family, a challenge in clinical management, an end-of-life experience that's particularly touching or emotional, or increasingly for me, the juxtaposition of different stories amongst a group of people with perhaps somewhat similar diseases. So really very varied. It's interesting because sometimes it's only weeks after the fact I realize that something had affected me, and then I'll make a note in my phone and at some point I'll come back to it and start fleshing out themes that I think are worth exploring. And over time, and it's usually quite a bit of time, a story basically evolves.

Dr. Lidia Schapira: You're an amazing storyteller. So let's focus a little on this particular story that you're telling and bring us to the bedside.

Dr. Daniel Rayson: Yeah, so this is a story - all my essays are really absolutely true life - and I was called to the CCU for a patient who had just suffered a myocardial infarction and needed a three vessel bypass and at the same time was diagnosed with metastatic colon cancer. And probably the last time I had been in a CCU was maybe 15 years ago, I certainly can't recall. But, the juxtaposition of this fellow being faced with two life-threatening diseases, one of which would kill him very quickly as he collapsed in his driveway, leading to the CCU admission, and one of which would kill him in years to come, became a juxtaposition, if I can use that term again, that really stuck with me, both in terms of decision making, competing threats to life, the personal motivation of the patient, and trying to discuss the time frames with the cardiologists who have very different perspectives on clinical success by what they do.

Dr. Lidia Schapira: I thought it was so interesting that you write that you have this hour-long conversation and more with the patient at bedside, and the patient says to you, 'So, are you recommending that we fix my broken heart so I can die of cancer?' And that is just about as direct as it gets. And then you're explaining to the chief resident in cardiology for whom the two to three-month median that you're saying is likely life expectancy for somebody with this diagnosis, it just doesn't seem to be good enough. And there you are sort of juggling time estimates and trying to assign value to time left and time spent without ever having met him before. And then you tell us, and this is the part that I wanted to ask you a little bit about, that you have a splitting headache. How did that moment feel to you?

Dr. Daniel Rayson: Well, even walking into the CCU, we get used to our environments, right? I'm sure that you as well, you walk into your cancer center, your home, everybody knows you, you know, everybody knows what everything is. Try walking into the CCU after having not been there for 15 years, and you are like a rat in a maze, completely out of your environment. So I was uncomfortable in the first step into the CCU. It just exponentially increased from there. Once I got to the bedside, face to face and talking in my little zone of oncology, everything seemed to settle. But as the discussion became more complex and all the monitors and all this stuff around this patient, yeah, I had just a pounding headache. And it didn't help talking to the CCU resident, who really had a hard time grasping what I think I was trying to convey.

Dr. Lidia Schapira: And so your patient chose to have the surgery, and then he was under your care, you tell us for four years, during which you must have built a very solid therapeutic relationship. So did you and your patient, I wonder, ever go back and discuss what that consultation was like for him?

Dr. Daniel Rayson: He was a very jovial kind of fellow with a great sense of humor. So we would come back to it every now and then, but only very glancingly in a way, 'Remember how I looked then, Doc, before your chemo got me? I looked pretty good in the CCU compared to now, right?' That was his kind of attitude as we went through. It would come back to him, but not in a negative way at all. The interaction actually ends up being extremely positive, even that day. And we built on that going forward.

Dr. Lidia Schapira: And his last words spoken to you through your colleague in palliative care just made me tear up. We often wonder if we did the right thing by our patients, and he basically told you so. Can you tell us what those last words were and how they felt to you?

Dr. Daniel Rayson: Yeah. So this is again all true fact, basically running into the palliative care doctor who took care of him just his last days. And I was turning back to go to the clinic after thanking my colleague and he literally called out, 'Oh, and one more thing. Mr. L told me to tell you that he was really glad he didn't end up dying from a broken heart.' I still kind of tear up when I think about that. It was kind of the ultimate thanks, really. I mean, he was very grateful all the way through, as was his family. That was probably the ultimate thanks. And that stayed with me for a long, long time. Obviously, still has really.

Dr. Lidia Schapira: What I found so artful, if I may use that word, is that you take the reader to this very, very emotional, private moment and then you chose a title that couldn't be less emotional, 'Cardio Oncology'. And I remember in the review process we asked you about that. So tell us a little about that choice.

Dr. Daniel Rayson: I don't know if I can answer that clearly in a way that's satisfying to anybody except to say that Cardio Oncology has become this sub-practice of cardiology. Many centers have Cardio Oncology programs, research, et cetera. As I was writing this, I thought this has to be the title. This is the ultimate Cardio Oncology. This is it. And I stuck with it despite some discussion back and forth. I still think I'm glad we kept the title as it was.

Dr. Lidia Schapira: It's so factual, right? And it's distracting because you read the title and you don't expect this essay, which is all about communication, connection, human relationships, and lived experience.

Dr. Daniel Rayson: Exactly. And again, I think every subspecialty or little niche in oncology has got to have those basic communication and the whole story at the heart. And I guess maybe that was part why the title.

Dr. Lidia Schapira: Yeah. You just mentioned the word communication. I wonder if you can reflect a little on the art of communication and communication skills for those of us working with patients with life-threatening illness and the art of storytelling. Do you see a connection and how do you experience that connection?

Dr. Daniel Rayson: Oh, I really do. I think being open to the story is not only meaningful, but is really imperative to optimize communication. Oncology, particularly in the era of precision based medicine and all the high tech things, is very easily led down a very technological pathway. But in the end it's the patient in front of us, or family, like we all know. And the story is what grounds all the connection, all the understanding of preferences, motivations, decision making. And in the end it's what impacts us as people and as clinicians as well as our patients and families. So I see the story as integral in terms of teaching communication skills and taking time to listen, taking time to feel the story and be open to the story unfolding and realizing that, yes, it is a story. Every single case is a story I think is a helpful way to look at, broadly, communication.

Dr. Lidia Schapira: There's another thing that I wanted to ask you, and that is, do you have any idea of how long it takes for the full story to emerge? It seems to me that you've been very patient with the stories you tell. You wait until years pass, sometimes until the relationship is complete, until there's a natural end to the story. How long does it take for these stories that you tell so beautifully about clinical practice actually to mature in your mind and then on paper?

Dr. Daniel Rayson: That's a great question. And sometimes I'm very jealous of authors who seem to be able to really churn out work that's important to them. I've learned that's not me. In most cases; it takes a year or two beyond my first note and my phone call to come back to it. And I think what I've learned is that giving it time always, for me, maybe just for me, optimizes quality. Rushing, sending it out too early, just doesn't work. Just doesn't work. For some reason, I need to give it the time it takes, and it's a good one to two years on average.

Dr. Lidia Schapira: It's interesting to hear you say that. It's taking me about twenty years to write the story that I'm trying to tell. And so it's good to know that there are some of us who seem to need that extra processing time.

As somebody who has been so thoughtful about the stories and practices, how do you see the storytelling helping us sort of stay fresh and find joy in practice as, in a way, an antidote to burnout?

Dr. Daniel Rayson: Yes, I think that stemming from a bit of an earlier question, is that being open to the story and the heterogeneity of the experiences that we deal with is affirming in humanity and our clinical practice. I think we can all get very tunnel vision and very tunnel focus so that everything starts sounding and feeling the same, which is, I believe, a prelude to sub-clinical burnout. Whereas taking the time to understand and feel the stories, and looking at people in their situation as stories, is a bit of an antidote to that. I like that word. I like that word. Not fully effective, sure, but, I think, a tool in our box.

Dr. Lidia Schapira: My final question is this: after all these years and all this time thinking about it, if you were to walk into that CCU and could replay that scene, would you have done anything differently?

Dr. Daniel Rayson: I think the only thing I probably would have taken a couple of extra strength ibuprofen before I ventured into the CCU.

Dr. Lidia Schapira: That's so wonderful. And with that, until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of ASCO's shows at asco.org/podcast.

Dr. Daniel Rayson: Thank you very much, Lidia. It's been a pleasure.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.

Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Show Notes:

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Guest Bio:

Dr. Daniel Rayson is a clinical oncologist at Queen Elizabeth II Health Sciences Center.