(WARNING: Graphic Content)
As a surgical oncologist and translational cancer researcher, I split my days between the clinic where I spend time with patients, the OR (operating room) removing their cancer, and the lab, where I work with my team and other scientists to bring promising research results to the business of treating and curing this miserable disease. Some days, I try to be in all three places - it is busy….and exhausting and honestly overwhelming.
Many colleagues, my friends and my family ask me why I do cancer research. Why do I sacrifice sleep for late-night grant writing, and trade clinical earnings for unpaid bench work? Why do I spend time pouring over rejection letters from cash strapped funding agencies, instead of thank you letters from grateful patients? I have many answers about it being challenging and rewarding that are appropriate for polite dinner table conversation, but the truth is much more personal. I call it Hope for Tuesday.
It’s Tuesday. No one else is awake. The quiet stillness is a rare privilege at home. In the soft morning light, I see the silhouette of my three sons, piled like puppies in the middle of our king. My husband deserted it hours ago in our nightly game of musical beds. I tiptoe carefully down the stairs, knowing that if even one of my children wakes up, I will never make it to work by 7:30am. Steaming coffee in hand, I breathe white air out into the cold, dull February morning and head to the hospital. Tuesday is my OR day.
I have one big case today - a locally advanced rectal cancer. The patient is younger than I am, with children younger than my own. While still not common, the incidence of this kind of cancer is increasing in the under 50 age group.
We are going to do a pelvic exenteration, which means we will remove all of the organs in her pelvis, including her rectum, anus, uterus, cervix, vagina and bladder. For the rest of her life, she will have a bag on the left, called a colostomy, for her stool, and a bag on the right, called a urinary conduit, for urine. When the tumour is removed, we will take muscle and skin from both her inner thighs to reconstruct her vagina.
I remember her face when I first told her all this - confusion and disbelief. “You can live like that? How?” she asked. “Yes, you can….it will be different….” I replied….as if that wasn’t obvious. By the time she finished her three months of preoperative radiation and chemotherapy, her disbelief had turned to quiet resignation. It is her price tag for life. She has no intention of accepting the alternative.
Today she has a determined look, ready to face the surgery and its aftermath. Ready to be cancer-free. But I can tell from her grip on my hand that breathtaking fear is not far below the surface. Before she drifts off to sleep, she whispers, “I’m going to be okay, right?” She looks up directly into my eyes.
The problem with the OR is that with a mask and hat, you can only see the eyes, and without the support of the rest of the face, the eyes cannot lie. I have prepared for this moment and answer without hesitation. “There is no doubt in my mind that you will be okay. You let me do what I am trained to do. Next time we see each other, the cancer will be gone.”
“How can you be so sure?” asks the surgical resident later… “Because I have to be…”
Positioning, tucking, taping, prepping, draping and the surgery begins. The tumour is enormous. It fills her entire bony pelvis. There is almost no room to maneuver around it. It’s like trying to extract an egg from an eggcup without breaking the shell.
To the gentle whirring of the smoke evacuator, the beeping of the cardiac monitor, and the high-pitched tone of the cautery knife, we do a dance of “too-close-too far”. If we are too close to the tumour, we may leave cancer behind, meaning certain recurrence. If we are too far, we may injure the nerves and blood vessels in the pelvic sidewall, risking a life-threatening bleed or paralysis.
The temperature of the room is set above average, to keep the patient warm during these long cases but this, combined with the bright lights on our heads and our waterproof gowns, creates an experience akin to Bikram yoga. My biceps and forearms fasciculate with fatigue, and I feel beads of sweat running down between my shoulder blades.
By late afternoon, my colleagues from urology and gynecology have joined me. They remain at the abdominal incision while I proceed to the bottom to remove the anus and vagina. We use a hot knife to help cauterize the blood vessels and reduce the bleeding. Regardless, this is the bloodiest part of the operation. My eyes burn from the smoke. I barely even notice that my socks are soaked as blood drips into my shoes. But I am acutely aware of how barbaric this procedure is - cutting out pieces of flesh, along with human dignity. I keep thinking “There must be a better way…”
Finally, the tumour is removed. The margins look good and the bleeding has stopped. Now for the long process of reconstruction – sewing everything back together. When we are finally done, I look at the clock. It’s almost midnight. With dinner, homework and bedtime long over, I creep quietly into my house. I’m starving but exhausted. I trade food for a shower because my hair smells like smoke and my toes are still sticky. I push a small, warm, pajama clad body to the middle of the bed and collapse. Another Tuesday behind me…..”
A famous surgical oncologist, Blake Cady, once wrote of cancer, “Biology is king, patient selection is queen, and surgery is the pauper*, who sometimes tries but rarely succeeds in usurping the throne.” There is nothing like Tuesday to remind me that I am just a pauper - indentured and powerless against the biology of this sinister disease. I cut out tissue, and when the biology allows it, patients are cured.
I am not sure how many more Tuesdays I can do this, but I truly believe that by the end of my career, I will be doing something completely different on Tuesday - a much better way of treating cancer.
Being part of a translational cancer research team, seeing clinical trials make scientific advances that become miracles for a few patients, and then for many more… this is what gives me the hope I need to persevere.
Why do I do cancer research? Because it is the only way I can get through Tuesdays. Today, I am asking you to have Hope For Tuesday too.
Footnote *Blake Cady used “prince” but I feel pauper is more fitting.
"Why do I do cancer research? Because it is the only way I can get through Tuesdays. Today, I am asking you to have Hope For Tuesday too."
- Dr. Rebecca Auer
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