Skip to Main Content

Advertisement intended for health care professionals

Skip Nav Destination

Listen to Your Patient … Perennially

November 2, 2023

November 2023

Naseema Gangat, MBBS, is a professor of medicine in the Division of Hematology at Mayo Clinic in Rochester, Minnesota.Naseema Gangat, MBBS, is a professor of medicine in the Division of Hematology at Mayo Clinic in Rochester, Minnesota.

 

 

 

On a recent trip to Lake Como, Italy, I spent some time reminiscing on my time in clinic. Taking in the sights and sounds served as a poignant reminder of the powerful impact of quiet listening.

Sailing on Lake Como, Italy, offered some peaceful reflection time.
Sailing on Lake Como, Italy, offered some peaceful reflection time.

Over the years, the practice of medicine has undergone a metamorphosis with increasing clerical burden on physicians, which takes away from actively listening to patients. In my column this month, I share a memorable patient encounter that exemplifies Sir William Osler’s advice, “Listen to your patient; he is telling you the diagnosis” and “He might be telling you the best management too.”

Summer 2020

I first met Mark A. in the summer of 2020. After a routine fasting blood test, he received a call from his doctor requesting that he repeat the test. Mark A.’s physician suspected a possible laboratory error and wanted to be sure. The second test confirmed pancytopenia, so he was referred to hematology. After two bone marrow biopsies, Mark A. was diagnosed with acute myeloid leukemia (AML) with myelodysplasia-related cytogenetic abnormality with del12p and STAG2 mutation.

At 67 years old, Mark A.’s regular routine included 20-mile-plus bike rides, hiking, and golf.

Based on his medical history of coronary artery disease and preference to preserve his quality of life, I suggested azacitidine and venetoclax combination therapy. After completing two cycles of treatment, the subsequent bone marrow biopsy showed no evidence of disease; Mark A. was in complete remission without measurable residual disease.

Summer 2021

A year later, Mark A. had received eight cycles of azacitidine and venetoclax and remained in complete remission. Accordingly, our discussion centered on treatment discontinuation, an unresolved issue with azacitidine and venetoclax therapy for AML.

“The science and multiple layers of excruciatingly complex blood and cellular data, almost from day one, have been a genuine source of comfort for me,” Mark A. shared. “The numbers from countless CBCs [complete blood counts] and bone marrow biopsies are always pure, honest, and crystal clear. Rather than endless opinions and varying points of view, the science and the numbers are the rocks that I’ve learned to lean on.”

Most of that clinic visit was spent reviewing his insightful questions:

With each passing month in remission, the odds increase that I’ll stay in remission, true?

What, if any, conclusions can be drawn from the fact that after two full months without chemotherapy, the bone marrow biopsy still shows no evidence of disease?

Assume it has been three, four, or five months without any evidence of disease; that changes the perspective, true?

Given the dearth of data on azacitidine plus venetoclax discontinuation, particularly in the absence of favorable risk disease, after an open and logical dialogue, Mark A. and I elected to continue with chemotherapy.

Spring 2022

“If this new drug combination (azacitidine plus venetoclax) is truly equal to or superior to induction therapy, it naturally follows that, given this equal efficacy, after remission is achieved, the decision to halt chemotherapy in a similar sequence or manner would naturally follow,” Mark A. reflected.

“Ironically, Dupuytren contracture has been more physically and emotionally challenging than AML. As a result, I’ve already sold two of three guitars I consigned, affecting something I’ve done nearly all my life,” he added. “Could chemotherapy be relevant for these symptoms?”

A continued conversation on cessation of chemotherapy led to a switch in therapy from venetoclax plus azacitidine to azacitidine alone.

Winter 2022

Twenty-seven months with no evidence of disease, using the most sensitive tests (flow cytometry) available on earth, speaks volumes, in my opinion. And yes, at some point, if the larger hematology/oncology community cannot agree or make up its collective minds, Mark A. will, based on all of the encouraging facts (not opinion), make a unilateral decision to cease all injections of poisons into his body and let the marrow factory do its job, unencumbered, as nature intended.

“I am a cancer patient and a pioneer in a very real sense with this drug combination and, based on the facts and very real data, am willing to take a risk, even if no one else is so inclined,” said Mark A.

Hence, we elected to change to careful observation and stop the chemotherapy.

Summer 2023

Mark A. is biking and golfing again. His last cycle of chemotherapy was in November 2022, and the last bone marrow biopsy was in March of this year and showed no evidence of disease.

Sailing along Lake Como this summer, I thought about how being a leukemia physician has been and continues to be powerfully humbling. I am eternally grateful to my patients for imparting pearls of wisdom that are invaluable to my practice!

Naseema Gangat, MBBS
Associate Editor

Acknowledgment

Mark A. provided informed consent for this piece. I deeply appreciate his time and assistance in putting this together.


The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.

Have a comment about this editorial? Let us know what you think; we welcome your feedback. Email the editor your response, along with your full name and professional affiliation if you’d like us to consider publishing it, at [email protected].

 

Advertisement intended for health care professionals

Connect with us:

CURRENT ISSUE
November 2024

Advertisement intended for health care professionals

Close Modal

or Create an Account

Close Modal
Close Modal

Advertisement intended for health care professionals