I'll Play This Hand

Recently, as I do numerous times every week, I knocked on a clinic exam room door, opened it, and walked in. The tall cowboy put his hands on his knees and slowly unfolded himself from the chair. He gave me a warm smile and a crushing handshake. Before I could say a word, he initiated the conversation, “Howdy, Doc. You look worried.”

He had read the look of consternation in my eyes. Not a difficult task; I am not adept at forcing an emotionless facial facade. I sat down on the rolling stool in the room, and the cowboy sat down between his two sons. “Get ready boys, the Doc has some news for us.”

The cowboy is in his early eighties. He is the real deal. He has worked on ranches throughout Texas, the western United States, and Alberta, Canada for over sixty years. When he stood to greet me, he was wearing a pair of faded blue dungarees, a long sleeve patterned western shirt, lizard cowboy boots, and a sweat-stained black cowboy hat with the front and back brim pulled down low.  The hat featured a turquoise-encrusted leather hatband with a large feather protruding jauntily from the right side. The feather is a turkey feather. I asked him about the feather when I first met him eighteen months ago. He explained his nickname since he was a teenager is “Turkey.” The cowboy is six feet four inches tall and weighs about 160 pounds. He has a long neck and protruding Adam’s apple. He earned his nickname as a young man riding in rodeos when other cowboys would tease him telling him he looked like a turkey astride a horse. The cowboy had chuckled and informed me the nickname got him into plenty of fist fights as a young man, but he had finally decided it was more gracious and easier on his knuckles to accept the sobriquet and celebrate it. The finishing piece of the cowboy’s apparel was an engraved leather belt with a large silver and gold buckle denoting one of his many wins in rodeos in years gone by. 

When I first met the cowboy a year and half ago, I noticed the buckle he wore that day (the buckle changed at every subsequent visit), and asked him about his rodeo experience. He nonchalantly informed me he had won hundreds of buckles, saddles, hats, and “occasionally a little money” in rodeos throughout the western United States and Canada. He had competed in almost every rodeo event including bulldogging (also known as steer wrestling), calf roping (as both a header and heeler), bull riding, but his specialty was bronco busting. He called it “bronc bustin’.” He had also ridden cutting horses, shot from the saddle at targets, and had worked plenty of arenas as a pick up rider. He had told me briefly about his rodeo days in a calm and non-boasting fashion. When he finished, his two sons, who were present every time he came to see me, proudly informed me their father was one of the best bucking horse riders of his era.

The cowboy’s response was to wink at me and say, “Hell, Doc, it was no big deal.”

The cowboy’s primary care physician referred him to me to treat a primary liver cancer. The doctor from a small town in central Texas had followed the cowboy for a hepatitis C virus infection that was diagnosed over a decade ago when some routine liver blood tests were abnormal. The cowboy has a variety of black ink tattoos on both of his arms and across his back and chest. He had obtained these over a period of many years in various towns and cities across the country. He had never used drugs of any type, but did admit to “a fair amount of hard drinking” in bars and honky-tonks throughout the west. He also admitted to spending a few nights in county lock ups after “brawlin’, bustin’ up some chairs, and breakin’ a few noses” in bar fights. He had suffered numerous injuries working as a cowboy, but never required a blood transfusion. The cowboy probably acquired his chronic hepatitis C virus infection from an unclean needle used during one of his tattoo sessions, but it is impossible to know exactly how long he had carried the asymptomatic infection.

As it frequently does, the chronic hepatitis C virus infection had ultimately produced damage to his liver.  A decade ago he was diagnosed with early stage cirrhosis. When the hepatitis C virus was diagnosed, the cowboy went through a year of treatment with interfon, a medication injected several times weekly to eradicate the virus. The treatment is not uniformly effective, and is associated with significant side effects. He suffered through the year of treatment silently and stoically, but confessed to me that one of the happiest days of his life was the day he received his last interfon injection. Fortunately, the drug had done its work and the virus disappeared from his blood. But the damage to his liver was already done, so his local doctor had dutifully been following him with annual visits and blood tests. Cirrhosis is an insidious disease and can worsen over time, and cirrhosis related to chronic hepatics B or C virus infection increases the risk to develop hepatocellular cancer (HCC). 

The local physician measured the cowboy’s serum alpha fetoprotein (AFP) yearly. Eighteen months ago the AFP level was elevated for the first time. The doctor ordered a computed tomography (CT) scan which revealed a tumor in the left liver with the classic radiographic appearance of HCC. The family medicine physician consulted with an oncologist in the region who instructed him to refer the cowboy to me.

When I first met the cowboy, he was wearing the same hat. As a sign of respect, he doffed the hat revealing a full head of long, wavy silver hair to match his lamb chop side burns and bushy mustache. This was also the first of several bruising handshakes I received from this lean, strong man. When I met with him and his sons, we reviewed his CT images. He had a 3 cm tumor in the lateral aspect of the left lobe of his liver. The CT scans also revealed an irregular, shrunken, and cobbled contour of his liver consistent with his known cirrhosis. However, his liver function blood tests were normal and he had never had any of the serious clinical sequela associated with cirrhosis, including bleeding from dilated veins in the intestinal tract (varices), encephalopathy (severe mental confusion), or ascites (build up of fluid in the belly cavity). The CT scan of the chest, abdomen, and pelvis revealed no evidence of metastatic disease from his primary liver cancer, so we discussed surgical removal of the tumor.  I discussed other HCC therapeutic options including chemotherapy, injection of mixtures of chemotherapy drugs and particles into the blood vessels going into the liver tumor to block, or “embolize” the blood vessels to starve the tumor of nutrients and oxygen, injection of radioactive particles into the tumor, and even liver transplant. Patients with early stage HCC confined to the liver may be considered for liver transplant if the tumor is not growing into major blood vessels. A liver transplant is a major undertaking, and being over eighty years old the cowboy was not interested in this option, and frankly would probably not have been a candidate. After patiently listening to me list treatment options, he made a quick conversation-ending decision when he stated, “Hell Doc, just cut the damn thing out.”

Clear direction was provided. Two weeks after I met the cowboy, he underwent a straightforward operation to remove a small section of the liver bearing the malignant tumor. In patients with cirrhosis, hepatobiliary surgeons must be cautious about the amount of liver we resect because the risk of post-operative liver failure is much higher. Fortunately, it was possible to remove less than 20% of this man’s liver, and he recovered uneventfully and without complication. 

I followed the cowboy in our clinic every three months after the operation.  I had informed him and his sons the pathology results from his HCC revealed growth of malignant cells into microscopic blood vessels around the cancer, indicating a higher risk to have subclinical, undetectable metastasis somewhere in his body. He faithfully returned every three months for follow up blood tests and a CT scan. When I saw him a few weeks ago, I was immediately concerned when I noticed his serum AFP level, which had returned to a normal value after the liver resection, was again elevated. I opened his CT images on the computer and quickly learned why the AFP was abnormal. The cowboy had four or five sub-centimeter tumor nodules in each lung, and a new tumor in both adrenal glands, none of which were present on the CT three months prior. 

As he sat between his two sons at our most recent visit, I explained the findings on his CT images. I reported his AFP blood test was again elevated, indicating HCC had metastasized to his lungs and adrenal glands. He inquired about the normal role of the adrenal glands, which I explained in terms he found acceptable. He slowly turned his head and wordlessly nodded to each of his sons, and then turned back to me. Making direct eye contact he stated, “I’ve had a helluva life Doc. I think I’m just gonna play this hand out.“

I understood his meaning.  After his liver operation we again discussed chemotherapy and its side effects, and he responded by making a sour face. I informed the cowboy I would be happy to see him at regular intervals if he desired. He was taken aback and asked why I would do that since I would not be operating on him again. I indicated that oncology physicians follow their patients even during end of life periods in order to provide assistance, medication, or other support for symptoms or problems that may arise. He thoughtfully stroked his mustache, stood up, and offered a final handshake. “Thank you, Doc. I’ll call you if I need you.”

I respect the cowboy’s decision. His lived a rough and tumble life in the outdoors and is a happy and content man. I always enjoyed clinic days when I saw he was on my schedule because I was assured twenty minutes or so of tales about life in the saddle in rodeos and on ranches. I will miss those stories. But, I stand ready to assist the cowboy and any other patient I care for regardless of their status, even if all of our treatments have failed to halt the recurrence and progression of their cancer. I also understand and accept those who eschew surgery, chemotherapy, radiation, or other treatments producing side effects and risks. 

I ushered the cowboy out of the exam room and he walked steadily down the hall and out the clinic exit door. One of his sons followed, and one intentionally lingered. As father and son walked through the door, he turned, smiled, shook my hand, and thanked me for my care. He informed me he would call me when his father’s time on earth had passed, and also assured me he would call if his father had any symptoms or problems requiring my intervention. He turned and walked out the door.

Enjoy your remaining time in the saddle cowboy. None of us knows for certain when we’re going to be bucked off for the last time.