By: Dr. Anna Franklin
A 19-year old man I was treating for acute lymphocytic leukemia (ALL) had all the risk factors for non-adherence: young adult, non-white race, low socioeconomic status, raised by his grandmother (for whom he became the caregiver after her recent stroke), absent parents. But he always came to his appointments and was a great patient. His girlfriend was always with him, in clinic or the hospital, unless she was at work.
Then, one day, there was a sudden change. He missed several appointments; important ones for chemotherapy, not just routine follow-ups to check his blood counts. When he returned to receive the chemo he’d missed, he actually disconnected himself from IV fluids in between chemo doses and snuck out of the infusion area. And I noticed, although it was seemingly unrelated, that his girlfriend was no longer attached to his hip.
I called him; no answer. I kept calling and, finally, he answered a few days later. He was profoundly apologetic, but said he had to leave with his girlfriend to pick up her dog at the groomer before she went to work. I asked whether he understood how important the chemo was, as picking up the dog was not as important to me as saving his life.
After a long talk at his next clinic visit, he finally disclosed that he was having erectile dysfunction (ED), which was affecting his relationship with his girlfriend—NOT something I hear from my 5-year-old patients, but finally something I could work with: the ED was probably related to the anti-hypertensive I had started him on a couple of months before.
I changed his blood pressure medicine and prescribed Viagra. I would point out here that I am probably the only pediatric oncologist in the world prescribing Viagra! But he was back at every clinic appointment and his girlfriend was right beside him.
Another young man with ALL was fond of marijuana. Before his ALL diagnosis, he smoked it occasionally. After the diagnosis, it became a pretty regular thing. When he relapsed, it was an every day thing, sometimes more than once a day. As expected, he ended up in the hospital with a fungal pneumonia. He was told of the link between his lung infection and his marijuana use; he didn’t care. He was told he may not be able to get his bone marrow transplant because of the marijuana; he didn’t care. His mother was beside herself that marijuana was more important to him than his life being saved by a transplant.
Our infectious disease consultant came up with an interesting recommendation: microwave the marijuana for 30 seconds before smoking to kill the fungal spores. The pneumonia resolved. My patient went to transplant. He still smokes marijuana every day, but follows his anti-fungal procedures religiously.
AYAs often have different priorities in life than older adults, and a cancer diagnosis does not change that. I’m not an AYA, so I can’t assume that I know what those priorities are or judge them for it. In my practice, I have found that really getting to know my patients as people will lead them to trust me. When they trust me, they will tell it like it is, which means I really know what is going on in their lives and how that affects their medical care. While our priorities still conflict sometimes, I have learned that making reasonable concessions can often make a world of difference in helping my AYA patients through their cancer journey.
Dr. Anna Franklin is an AYA oncologist at U.T. M. D. Anderson Cancer Center in Houston, Texas.