via The New York Times:
"I had to admit I was more than a little excited to see my next patient. This was a big day, for both of us.
Five years earlier, when he was 68, he had come to the emergency room, feeling terrible. His white blood cell count was higher than his age, and he was profoundly anemic — really, to a degree that was almost incompatible with life. He was transferred to our hospital, where we performed a bone marrow biopsy that clinched the diagnosis of acute leukemia.
“You sat on my bed,” he said to me, “and you gave it to me straight. You laid out my options.” He stared up toward the fluorescent lights in the clinic room, thinking back to this seminal moment. His wife sat next to him, focusing on his face, her smile frozen as she probably thought about that same moment from her own perspective.
For people approaching their eighth decade, the decision of whether or not to take chemotherapy for leukemia is anything but straightforward. The treatment can be brutal, confining a person to his or her hospital room for a month, and it can accelerate a death that might have taken months if the leukemia were left to its own devices. People go through with it to try to win the golden ticket — the chance to be cured of leukemia. In someone my patient’s age, that occurs only 5 percent of the time.
Two handfuls of people of the hundreds I have treated over the past decade.
Our definition of “cure” is a functional one. I can’t look a patient in the eye and tell him right after a round of chemotherapy that I was able to remove all of the cancer, as a surgeon might after an operation to excise a tumor. “Cure,” for us, means a person has lived five years without the leukemia coming back.
For my patient, that meant this day.
“I think you made a good decision to take the drugs.” I said, and he and his wife laughed at the understatement.
In the past, with other patients who had achieved this five-year goal, I would come bounding into their exam rooms exclaiming, “We can say it now! We can use the C-word. You’re cured!” And we would all celebrate noisily. Oncologists, like baseball players, tend to be superstitious. Until this time point has been reached, we tend to avoid tempting the fates by using words like “cure,” preferring instead convoluted phrases like “long-term disease-free survival.” But after this five-year mark, I would tell my patients that, as much as I enjoyed their company, they no longer had to fight the traffic to see me anymore.
But then, a couple of these patients showed up on my clinic schedule again, eight or 10 months later, having gone to their primary care doctors complaining of fatigue, or of just not feeling “right.” Routine blood work again showed abnormalities, and they returned to my office, confused and devastated.
Sometimes I realized that we hadn’t really cured the leukemia so much as reset the clock to a time just before the leukemia diagnosis, when they had an underlying bone marrow disorder that turned into leukemia, and that this was responsible for the recurrent abnormal blood counts. Sometimes they really did have leukemia again, and I wondered if we had caused this second bout with the chemotherapy we had used to treat the original leukemia.
I would be equally devastated. As a result, I have become more reserved in the joy I used to have for my patients. Rather than rejoicing, I caution them that there is still a chance the leukemia may return. Is it fair of me, though, to continue to burden them with this threat of relapse, to hold the sword of Damocles over their heads, when we all know how special it is to reach this five-year mark?
My patient, his wife and I basked in the silence for a few seconds, quietly enjoying his good health, his normal blood counts, what he had been through, and how far he had come.
“Ordinarily, we would say you’re cured now,” I told him, “because the chance that the leukemia will come back is so low. But…”
He interrupted me. “Doc, I’d feel more comfortable if we kept seeing you,” he said, almost intuiting my hesitation, my muted enthusiasm, and what I was about to say. “Just to be on the safe side.”
I nodded, relieved. “I’d like that, too,” I said."