What is the treatment plan? (11/16/24)

 Previously I had described how the uncertainty that clouded the next steps of our journey had made the path seem even more difficult to travel. Now that the fog is lifting, I’m not sure things look any easier. The road ahead is well marked, but with thousand-foot cliffs on either side. Yesterday we were given the good news that this tumor is PD-L1 positive, meaning that it will respond to immunotherapy. I’m learning that unlike pregnancy tests where there is very little value-add by rendering anything other than a binary verdict, many of these tumor markers are presented like Wisconsin polling data. In this case, the PD-L1 positivity was pretty clear, so we didn’t even have to run it past immunohistochemistry’s version of Nate Silver. I need to emphasize that this finding is the best news we have received since the diagnosis of breast cancer was confirmed. I remember reading Steve Rosenberg’s book, “The Transformed Cell,” as a medical student and thinking how improbable it would be if immunotherapy ever materialized as a meaningful option for human patients. It is profoundly encouraging to see how far we’ve come on that front.

With this new information, we were finally able to learn which agents would be the first ones deployed when Joyce initiates chemotherapy (we’re hoping for next Wednesday but also trusting God’s timing if it ends up getting delayed). The first cocktail will include two-drug chemotherapy (carboplatin and gemcitabine) along with immunotherapy (pembrolizumab). Keep those names in your back pocket next time you’re playing Bananagrams. I don’t think generic drug labels count as proper nouns. With a specific treatment regimen in hand, we can also get a much better idea on where to set our expectations when it comes to outcomes. The best data on this comes from a manuscript published in the New England Journal of Medicine in July of 2022. In the group of 566 patients that were treated with this same type of regimen, median overall survival was 23 months. I can’t decide if that glass is 0% full or 100% empty. On the other hand, you can follow the Kaplan-Meier survival curves out to 54 months and it looks like there are still a number of patients (maybe even north of 25%) that are holding on to that line with a Kung Fu grip before it intersects with the X axis. I’m pretty sure I can speak for everyone who is fighting alongside us in this battle that we are CONFIDENT Joyce Sanchez will be included in the survival cohort even when the numbers dwindle down to just one member of the resistance.

Even as I desperately cling to that possibility, it’s like there’s a voice in my head that is working relentlessly to steal my hope. “What did Richard Thaler teach you about OVERCONFIDENCE?” I believe the term he used was “mother of all biases.” We all know that nine out of ten startups will fail, and yet how many entrepreneurs believe that when they set out to launch a company? Ask any married couple independently what percentage of the household chores they perform. Add those numbers up and it always comes out to more than 100%. I could go on, but this trend is never more pronounced than when it comes to how consistent people are in overestimating their life expectancy relative to the actuarial tables. Maybe I am being unrealistic, but if you want my opinion the most egregious example of overconfidence you can find in the scientific disciplines is our overconfidence in science itself. If “evidence-based medicine” can’t explain it, we write it off as though we have complete understanding of all the variables and there is no chance that we might have missed one or two things when it comes to healing someone from a disease. Did the recent global pandemic not leave us with even the smallest amount of humility when it comes to how much of this we believe is under our control?  

The truth is I know better. I can still vividly remember the first time I could feel a patient’s life literally slipping through my fingers as I performed internal cardiac massage, praying fervently and desperately for God to intervene. Without even a spark of electricity, as I prayed I could feel the rhythm change from ventricular fibrillation to a beautiful, organized contraction right under my fingertips. I can’t even count the number of times since that night that I’ve been reminded of what a small role I play as a cardiac surgeon when it comes to a patient’s outcome. Of course, this is not to say that all of my prayers have been answered in those difficult moments.

As I pray for Joyce, I’ve been searching for the balance between confidence and humility that Shadrach, Meshach, and Abednego demonstrated in Daniel 3:17-18 when they were about to be thrown into a literal furnace: “Our God whom we serve is able to deliver us from the burning fiery furnace, and he will deliver us out of your hand, O king. But if not, be it known to you, O king, that we will not serve your gods or worship the golden image that you set up.” As Tim Keller explains: “On the one hand, they express a strong belief that God not only is able to rescue them but actually will rescue them. But then we are puzzled by their next sentence, beginning “But if not.” If they are confident in God, why would they even admit the possibility of not being delivered? The answer is that their confidence was actually in God, not in their limited understanding of what they thought he would do. They had inner assurance that God would rescue them. However, they were not so arrogant as to be sure they were ‘reading God right.’ They knew that God was under no obligation to operate according to their limited wisdom.”