Andrew von Eschenbach
Fighting Cancer on a Personal Level
by Andrew C. von Eschenbach, MD, Director, National Cancer Institute, and three-time cancer survivor
(photo by Linda Bartlett)
There are many paths to a cancer diagnosis. In one case, it might be a lump found during a self-exam; in another, a mammogram reveals a breast tumor. An elevated level from a PSA blood test can signal prostate cancer. In my case, diagnosis began with an accident.
In 1989, I was chair of the department of urology at the M. D. Anderson Cancer Center, a state-of-the-art facility in Houston, where I served in a number of positions for 26 years. In my time there, I had performed thousands of cancer operations. But, like a long line of surgeons before me, many hours hunched over operating tables had taken a toll on my neck. When the condition turned out to be a herniated cervical disc, I opted to have a procedure called a laminectomy, which relieves pressure on the nerve. The surgery was overwhelmingly successful, but I was left with a badge of courage in the form of a large bald patch. An attendant had inadvertently shaved more hair than needed from the back of my head.
When I returned to work, a good friend and colleague (a head and neck surgeon), noticed a small lesion on my scalp. “Andy,” he said, “we’re going to swing by my clinic right now and remove that thing.” It was just a black spot only visible because of an overly aggressive, pre-operative shave, but the lesion was a melanoma. We had discovered – in my body – a death warrant waiting to be served.
Melanoma is the insidious form of skin cancer. If diagnosed and removed at an early stage (while it is restricted to the skin’s outer layer), melanoma is curable. But once it advances and metastasizes, melanoma kills 97 percent of its victims within five years. Statistics of that sort certainly help explain why cancer is Americans’ greatest fear. For me, of all the forms of cancer, melanoma is the one I most dreaded having in my body.
Experiencing cancer reminded me that doctors don’t just provide care; they are sources of comfort.
For now, it appeared this assassin’s presence had been discovered early enough for its elimination. Following a wide local excision and skin graft, there was no sign of remaining cancer in the surrounding cells. But then, a follow-up exam revealed a small nodule in front of my ear. In a sickening instant came the realization that, if that spot turned out to be a metastasis from the melanoma, I would not be safe. I would likely be dead.
Being treated in the cancer center where you’ve worked for more than a decade has certain benefits. The biopsy of the nodule was easily scheduled. What was not so easy was handling my panic. I knew all the potential implications of the biopsy result. Had the cancer spread to my brain? To my lymph nodes? Was this the beginning of a slide from which I would never recover? I began to tally the pieces of my life I would lose: walking my daughter down the aisle at her wedding; the first glimpse of each of my grandchildren; growing old with my wife, Madelyn. After the biopsy procedure, I had to wait just 10 minutes for the verdict. When Dr. Tina Fanning, the cytopathologist, walked in the room with my results, her smile told me the biopsy was negative. My cancer had not spread. I was safe again – at least for now.
Experiencing cancer reminded me that doctors don’t just provide care; they are sources of comfort and empathy, and even of level-headedness in a moment of crisis. I learned that lesson again when, at the age of 57, I found out I had prostate cancer.
It was a diagnosis with considerable irony. My father was 57 when his prostate cancer was discovered. I was, in part, able to deal with the hurt and upset at his situation by being a doctor, by searching for and helping place my father in a clinical trial. In the end, however, his outcome was one I knew well. My father’s disease had spread. Within five years, cancer took his life.
As the patient – and not the physician – I had to face a list of options, uncertainties, and unknowns I had laid before thousands of men with prostate cancer. I opted for surgery. I also chose to undergo that procedure in my own hospital, to be cared for by colleagues whose knowledge and professionalism I trusted. But that also made me vulnerable in front of friends. I was in superb hands. Doctors and nurses – people I interacted with every day – treated me, as a patient, with respect and dignity. It was the kind of treatment dispensed every day to every patient, but to me they were a tangible representation of dedicated people in hospitals across America who prove each day why it is called health “care.”
As the patient – and not the physician – I had to face a list of options, uncertainties, and unknowns.
My third run-in with cancer was the simplest. Just a few years ago I had the most-treatable form of skin cancer, a basal cell carcinoma, removed. While cancer of any kind is nothing to trifle with or dismiss, this diagnosis was easy to cure; however, the cancer had occurred in a location on my nose that would leave an appearance-changing scar. It was one more reminder that, even when the problem is simple and easy to cure, cancer changes you.
With all of my cancer experiences came another lesson: Cancer prevention, detection and treatment must be improved. And now, that improvement is possible.
For centuries, what medical science knew of cancer was limited to what could be seen or touched. With the advent of the microscope, cancer became visible as a cell. Its existence could be conclusively proved and documented, but the challenge of dealing with cancer was still daunting. Through most of my career, surgery and toxic, debilitating drugs or radiation have often been our only good options.
Even though science has made steady, incremental progress, the fact remains that, today, one American dies of cancer each minute. Half of men will contract the disease, as will one third of women. And yet, knowing those statistics, having watched patient after patient suffer and die, working every day for almost three decades in a cancer center, I can, today, see before us opportunities to prevent, detect, and deal with cancer that surpass anything we have learned so far. My three experiences with cancer are, collectively, the story of the past. The future will be dramatically different.
Research today is coming to fundamental new understandings of cancer at a molecular level. That burgeoning knowledge is helping us see that cancer is not an event: a moment in time when a tumor forms. Cancer is a process. Molecular and genetic research are leading to discoveries of telltale proteins and other biomarkers that signal cancer’s presence long before the existence of something an X-ray can detect or a finger can feel. Scientists are developing nanodevices: machines a tiny fraction the width of a hair that can penetrate cells and signal cancer’s presence or deliver targeted drugs. The decoding of the complete human genome has made conceivable that the genetic code of cancer itself can be unraveled. And today’s exponential progress against cancer is leading to an era of personalized medicine, when we will no longer make broad prescriptions for large swaths of the population. Rather, we will compare the patient’s genetics to a cancer’s genetics and provide the right treatment to the right patient at the right time, with the right outcome, monitored in real time.
Because of what we see happening in cancer research, the National Cancer Institute, which I have been privileged to direct since 2002, has challenged itself – and the United States – to the goal of making cancer a chronic, manageable condition that no longer ends life. In cancer’s future, we will have the capacity to intervene at many points in its process, preventing some cancers, interrupting the progression of others. We will be able to eliminate cancer’s suffering and death, and bring that about in this country by the year 2015.
There is much work to be done, if we are to succeed. It will take dedicated research, the development of new and novel interventions, and the delivery – to all Americans who need them – of lifesaving treatments. It won’t be easy. But I believe cancer care is uniquely poised to lead a revolution in the health of our nation.
Every now and again, someone asks if I pursue this goal so passionately because I am a cancer survivor or, perhaps, because it is a personal mission born of the experience of my father’s cancer death. While those may contribute, the answer is not so simple. I became an oncologist because I was fascinated by the biology of cancer: how it worked, how it progressed, and why it was so virulent. But at the same time, I watched this disease, my intellectual and professional foe, cause too many people to suffer and die. So for me today, the future holds the promise to reconcile the two realities. Progress in biomedical research can make it possible for no one to suffer and die as a result of cancer. It is a future we must work mightily to create, a hopeful vision that will require the leadership of the National Cancer Institute, government, academia, and the private sector.
Cancer is a formidable foe. But with collaborative, concerted effort – and your continued support – we can save millions of lives.
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This article was published in Coping® with Cancer magazine, January/February 2006.