Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Tunnel Carver


"Carve a tunnel of hope through the dark tunnel of disappointment." ~ Reverend Martin Luther King Jr.

Cancer is a devastating diagnosis that takes an immense psychological toll on both the patient and their loved-ones. For many malignancies this means, at the very least, months of unpleasant treatment such as major surgery, possibly radiation, and chemotherapy. Moreover, there is the pervasive threat of treatment failure or recurrence. Finally, this is compounded by not really knowing if the treatment resulted in a cure until the passage of time. The tension for the patient, family, and the physician awaiting the results of follow-up studies is often as difficult to handle as the treatment itself.



The burden of a pancreatic cancer diagnosis

All of these aspects are magnified with the diagnosis of pancreatic cancer. Nearly 80% of people will be told at diagnosis that they are stage IV and have no chance at a cure. The “lucky” 20% who are diagnosed with localized disease are faced with at least six months of chemotherapy, one to five weeks of radiation therapy, and a major operation that carries a 50% complication rate, a risk of operative mortality and a two to three month recovery period. In passing this major hurdle of treatment, the ever-present threat of relapse looms large, as 50% of patients will go on to die of disease in about two years, and less than 20% will make it to five years.



From the physician’s perspective, the treatment of pancreatic cancer is complex. The staging needs to be absolutely accurate. The stage determines the general treatment course, but the details of the treatment course are highly variable and multiple options exists. What chemotherapy is the best for this person? Surgery first followed by adjuvant, or neoadjuvant and then surgery? Will this person benefit from radiation? Should we perform molecular profiling of their tumor? Does this patient fit into any clinical trial that may potentially benefit them? Will this patient tolerate the most aggressive therapy? Does this patient have the social network to run the treatment gauntlet? In pancreatic cancer treatment there are very few clear paths and no one approach has been shown to be obviously superior. Certainly, the ultimate optimal therapy develops from multidisciplinary input of a team of clinicians.



Providing hope

At times, in caring for patients with pancreatic cancer the mental and emotional burden is overwhelming. A clinic day consists of repeatedly delivering this news to newly diagnosed patients, or, reviewing each follow-up imaging in angst of the all-too-often recurrence. In light of all of this – what is the single most important thing I can do, aside from the best clinical management, to help this person? I believe it is to provide hope.



The power of hope

I have learned over the past 15 years in caring for these patients the importance of providing hope. Hope even in the face of overwhelming odds is a powerful thing. It shifts focus away from the high chance of failure to a focus of we are going to give it our best shot.



Hope for many patients extends beyond their own fate. I am constantly amazed by the altruism within human nature. Many are sustained by the notion that through learning about how they responded to a treatment, they may help others in the future.



Reverend Martin Luther King Jr. is quoted as saying, “Carve a tunnel of hope through the dark mountain of disappointment.” I believe this quote epitomizes my most important role as a clinician for these patients. Of course I will do everything in my power to deliver the best care possible, to support the patient and family emotionally and to be realistic in the chances of a cure, but all of us in the clinic room know the odds are stacked against us. However, our patients need me to enthusiastically grab a shovel and start digging through the dark mountain. They cannot negotiate the darkness alone. In showing we have hope we strengthen their hope and will to fight.