In 2008, I met a delightful 88-year-old patient accompanied by her daughter. The patient had been successfully treated for advanced ovarian cancer with surgery and post-operative chemotherapy and achieved a complete remission.
She remained well until a follow up visit revealed a rising CA-125 and a new pleural effusion (fluid in the lung). She was told by her treating physician that at 88, treatment would be punishing and likely ineffective. He recommended against intervention and told her that she had only a few months to live.
The patient, a kind and gentle woman, took the advice of her physician in stride, but her daughter did not. Despite the gravity of the diagnosis, the patient was extremely vigorous. She had no symptoms and was carrying on a normal life. The daughter decided that they were not going to give up and they arrived in my office for an opinion.
I reviewed the findings and the chest x-ray that revealed an obvious pleural effusion. I suggested that we aspirate the fluid right there and then in the office. Approximately 1000 cc of fluid were removed without difficulty and I submitted the cancerous cells to our laboratory to examine treatment options.
A Look at Past Research
During the 1990s, I had become extremely interested in the synergy between the platinum-derivatives (Carboplatin, Cisplatin, etc.) and chemotherapy drugs known as the anti-metabolites, including 5-FU and Gemcitabine.
The concept was that cancer cells could be induced to suffer lethal injury while the normal tissues like the bone marrow would survive the toxic effects of the drug treatments. The combination of choice was Cisplatin plus Gemcitabine. In the laboratory it was highly effective, but we needed to test it in people.
My first opportunity came when an ovarian cancer patient from Tel Aviv, Israel traveled to California to be treated after all known therapies for ovarian cancer had failed.
Great Results Lead to a Landmark Clinical Trial and FDA Approval
Her stunning response, lasting almost five years, led me to then write and conduct the first clinical trial of that combination in ovarian cancer that I published in 2003. I then wrote the national clinical trial of the combination for the Gynecologic Oncology Group and published the results in 2006.
The FDA went on to approve the closely related Carboplatin plus Gemcitabine for ovarian cancer and over the ensuing years it has become a standard of care for recurrent disease.
This patient's profile fit the 2-drug combination perfectly, but because she was a member of an HMO, I could not treat her myself. I offered to write the orders using our reduced-dose-doublet schedule and submitted them to her HMO infusion center staff.
Determination Pays Off
Apparently, when the HMO staff reviewed the recommendation, they told the daughter that they “had never used this doublet combination for ovarian cancer” and “could not imagine using such low doses”. The daughter was adamant and the staff agreed to administer therapy according to our written schedule. After four cycles of treatment, the patient achieved a complete remission. She had no hair loss, nausea or vomiting. In fact, she had almost no toxicity whatsoever. Two years later, I was delighted to be asked to join the family to celebrate the patient's 90th birthday. She was then two years in complete remission and the picture of health.
Over the years, we kept in touch. She became a regular guest at our Vanguard Cancer Foundation fundraisers. Each year, I would introduce her as one of my best (and certainly one of my oldest) examples of “the right treatment at the right time”.
Celebrating A Life Well-Lived
On Saturday, October 5th 2019, I joined Marjorie’s family for a celebration of life. Marjorie had suffered an unrelated medical illness that resulted in her death in July just three months short of her 100th birthday that would have been on October 3rd.
Lessons Learned
In medical oncology I regularly confront serious illness. Patients young and old can present diseases for which there are no readily available treatments.
While we do our best to find options, many that others might not have considered, no approach is perfect and some patients, even young patients, succumb to their illnesses.
Here however was a patient who had lived 11 productive years after she received a laboratory-directed treatment causing virtually no toxicity that was selected based not on her age, her stage or even her diagnosis but based entirely on the biology of her disease.
She Always Kept Giving
In addition to attending our fundraisers, the patient kindly offered to knit wool caps for our patients who suffered hair loss from chemotherapy. These brightly colored caps were distributed to our patients as a gift to keep their heads warm in the cooler months. It was just one of the ways that Marjorie felt that she could “pay it forward”.
Marjorie and her family have been great supporters of our work, attended our events and helped to promote our personalized cancer care. It was an honor for me to attend her celebration of life.
Although I will miss Marjorie, I am comforted that she lived 11 excellent years and that she was there for her family and friends. This was indeed a life well-lived.
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