I just heard that a dear friend was diagnosed with cancer. We had dinner together less than 2 months ago and now he was in the hospital, having surgery followed by chemotherapy.  I am shocked and can’t imagine how my friend is feeling.

Earlier this month I was seeing a consult of a younger woman with cancer.  She had been on “treatment” almost continuously for the last 4 years since she was diagnosed.  She had achieved a remarkably good quality of life during that time; never hospitalized while continuing many of her normal activities.  But now options were becoming constrained.  The latest intervention, a new immune modulator, had resulted in some nasty pulmonary symptoms and generalized exhaustion.  Steroids had been needed to rescue her.

The oncology team was not sure where to go from here. Performance status was too low to consider treatment now but just a few weeks ago she had been doing more than most people her age.  Her husband reflected, “That if she could just hold on for a little while longer, the next big breakthrough would be available.” They had in fact seen that happen over the course of her years with this disease.

Ultimately, she thought she would try another immune modulator if she was a candidate. As she said, “I want another bite at the apple!” The alternative… progression of cancer; “I’m not there yet.” she said quietly.

In the recently published study by Simonaggio et al. (2019) almost 100 women with ovarian cancer who had serious adverse events were re-challenged.  Close to 55% had a serious adverse event again but 45% did not. I think that with odds like these more people, like my dear friend, are going to want “another bite at the apple.” Palliative Care teams can help patients and families by clarifying goals of care and being present to celebrate and support whatever the outcome.

https://jamanetwork.com/journals/jamaoncology/fullarticle/2735330?casa_token=Oq8YxlpyMF0AAAAA:DgQJZ1q5XE_8SbE2iz7NwwWnz1_LPALyi1IbQMj8JFctnGjXFcfkFIko6L5UVVNj2TnUm9LbAudrey Simonaggio, MD1; et,al Evaluation of Readministration of Immune Checkpoint Inhibitors After Immune-Related Adverse Events in Patients With Cancer JAMA Oncol. Published online June 6, 2019. doi:10.1001/jamaoncol.2019.1022