“I’M the dying guy!” Mark Duplass’ character screams at his best friend, played by Ray Romano.

“I’m the OTHER guy!” Romano’s character screams back.

Paddleton, a low-budget independent movie about a middle-aged loner facing down a terminal cancer diagnosis with his upstairs neighbor, debuted on Netflix on February 22nd, 2019. While most such movies focus on the patient’s experience, Paddleton is about cancer as a shared journey and a testament to the healing power of human companionship.

FAIR WARNING: if you haven’t seen the movie yet and want to avoid spoilers, stop reading now!

The film opens with Andy (Ray Romano) accompanying his friend Michael (Mark Duplass) to the doctor. There’s a tumor in Michael’s stomach and it’s already spread to his liver. The doctor’s recommending referral to an oncologist but won’t answer questions about prognosis.

Andy isn’t satisfied and pushes the issue on behalf of his friend. “How about this? How ‘bout I’m gonna make a statement, and if it’s a true statement you don’t have to correct me?” he asks the doctor, who’s obviously annoyed.

“Is what Michael has…incurable?”

“Dude, that’s a question. It has to be a statement,” deadpans Michael.

And that’s how it goes with the two of them. They take their liquor straight, and with a wry smile.

They’re an awkward but endearing couple – though they’re absotively posolutely not that kind of couple (as clearly spelled out in two awkward and hilarious scenes). They’re just neighbors. They just happen to have adjoining apartments…and spend most of their free time together, heating up frozen pizzas, watching Kung Fu movies, and playing a homegrown paddle-ball variant (which they call paddleton) in their every spare minute.

They’re something much more important.

Their relationship is uncomplicated and placid, because neither really likes to talk all that much. They don’t trouble each other with messy emotions. Michael is aloof about his cancer diagnosis -“It’s just meh” he says. He’s determined to maintain their normal routine as long as he can, and opt for physician-assisted suicide when he can’t.

It’s impossible not to love them, because they ask for very little and demand even less. We sense they both took a hard look at life a long time ago and came to terms with it in their own peculiar way.

The movie doesn’t condescend to them, or to us. There’re no epiphanies or dramatic gestures, nor is there a last-minute miracle. The end goes down just as Michael planned it. The story is simple, bordering on predictable. But yet we can’t stop watching these two oddballs fighting through the day as best they can.

The suspense comes from wondering how these two emotionally stunted people will handle something as devastating as death. And this is where Ray Romano really shines.

It’s beautifully painful to watch Romano’s face. He’s agonized to be there, watching his friend fade. It’s agonizing for him to bear witness. But he knows that not being there would be much worse. There’s never a moment of suspense about whether he’ll see his friendship through to the end. The suspense is in wondering what it’ll cost him.

Watching him, I couldn’t help wondering about what being involved in caring for the dying does – and maybe should – cost me.

Medical professionals involved in end-of-life care are often urged to “maintain healthy boundaries”. We’re not supposed to make the patient’s suffering our own, or mistake their family’s grief for our own – though in a very real way we never can. The patient is never our spouse/parent/sibling/child. The pain of losing a patient can never approach that level of personal loss no matter how much affection we’ve developed during our professional relationship. But yet we’re counseled to keep emotional distance.

It’s for our own mental health, we’re told.

And we cannot realistically sit 24/7 vigil with the dying. There simply isn’t the time. We have much work to do. And we cannot presume to take the seats of those whose grief takes primacy over our own.

But Paddleton reminded me how absolutely critical it is to stay with people emotionally at such times – no matter the cost.

Dying is sacred. There’s ritual and ceremony to it. And whatever the faith tradition, there’s a chalice brimming with grief that patients and their loved ones take turns drinking from. The cup is deep, and they need help getting to the bottom of it.

And I think we, as medical professionals, have to be willing to take a sip ourselves from time to time.

Nobody likes chemotherapy: not patients, and not oncologists.

We’d all rather avoid it if we can – and now we’ve identified another group of women who can safely do without it.  

Some early-stage breast cancers can spread throughout the body before the tumor is removed surgically– even before the cancer is diagnosed. Those small, spreading cells (called micrometastases) aren’t detectable by current technology. But micrometastases can seed tumors that show up a few years later in the bones, liver, or brain – and ultimately cause death.  

If we give chemotherapy to patients who have micrometastases, we can kill off those little seeds before they take root and improve the chances of cure. But it’s only worth it if the risk of having micrometastases in the first place is sufficiently high – usually around 18% or more. That’s why accurately predicting risk is so critical in treating early stage breast cancer. 

So for people at high risk of having micrometastases (e.g. those with lymph node involvement, or high-risk mutations on the Oncotype test), we recommend chemotherapy.  

For people at low risk of micrometastasis, we don’t. 

So what’s the news flash?  

The Oncotype test reports a patient’s risk of micrometastasis as low, intermediate, or high. We’ve always known what to do with the low and high risk patients, but we’ve been less certain about the intermediate risk group.  

But the largest trial of its kind was just reported in the New England Journal of Medicine, and it looks like we can safely skip chemotherapy in Oncotype-intermediate patients. 

Bottom line: 

• Women with early-stage breast cancer only seem to benefit from chemotherapy if they have lymph node involvement, or if the Oncotype test indicates they’re at high risk for micrometastases. 

Picture a common movie scenario: the police have the bad guys surrounded, locked down inside a building – but there are hostages in there too, and if the cops go in shooting they won’t be able to tell the victims from the villains.

“Die Hard”, “Inside Man”, and “The Dark Knight Rises” have all done variations on this idea. I bet you can even think of a few more. 

But this familiar movie scenario can help us better understand the difficulty the immune system has trying to fight cancer, and how the new class of cancer drugs called checkpoint inhibitors can overcome it.  

So, let’s apply our “bad-guys-with-hostages standoff” analogy to an immune system trying to eradicate cancer, and see what we can learn:  

1. Your immune system, like a good police officer, must sometimes restrain itself. A SWAT team storming in at every opportunity can cause terrible collateral damage, just as an unrestrained immune system can cause terrible diseases like rheumatoid arthritis and lupus. That’s why your immune system’s T-cells have special receivers sticking out of them like antennae dishes, listening for the signal to “stop” – and when the T-cell gets that signal, it backs off. We call these “stop signal” receivers checkpoint inhibitors – one of which is PD1. 
2. Some cancer cells fool the immune system the same way the villain fooled Bruce Willis in “Die Hard”. When Bruce Willis’ character got the drop on the main villain Hans Gruber (who he’d spoken to but never seen), Hans faked an American accent and passed as a hostage (“Oh no please don’t shoot, you’re one of them aren’t you…”). In a similar way, some cancer cells have learned how transmit the “stop” signal by making a special molecule that sticks from its surface and binds to PD1 on attacking T-cells – which turns them off. We call this “stop signal” molecule PDL1. 
3. Preventing the PDL1 “STOP” signal from reaching T-cells invigorates the immune system enough to attack some cancers.  Drugs like nivolumab and pembrolizumab (which interrupt the PD1/PDL1 interaction) put the fight back into the T-cells, allowing them to attack the cancer – but with much less of the “collateral damage” that we’ve seen in other types of immune enhancers.  

Here’s a video that explains the process visually. 

We should celebrate the success of these drugs, but have to remember that no cancer drug in history has ever been a “cure-all”. We have to remember that there a great many more checkpoint inhibitors than PD1, so there’s many other ways for cancer cells to escape the immune system.  

We have to remember we still need good clinical trials, and patients willing to participate in them.

(Up Next: Pembrolizumab approved for a slew of cancers all at once)

Whenever I meet a new cancer patient, especially one with incurable cancer, pain always comes up in the conversation – whether they have it or not.

It’s the most commonly reported symptom of cancer, and it’s also one of the most widely feared.  

Most patients with advanced stage cancer do, in fact, experience pain; 75-90% according to a 2007 cohort study conducted in the Netherlands and published in the Journal of Pain and Symptom Management. And for much of the history of cancer medicine, most of these patients suffered terribly during their illness – and many died in agony – before the importance of relieving terminal cancer pain was widely accepted. It’s little wonder that the hospice movement began first among cancer caregivers who’d borne witness to one painful death too many and rose en masse to say “enough, no more.” 

Despite the strides made in the last half-century, there’s still a lingering belief out there that having cancer means unrelenting pain– but I’m happy to tell you that hasn’t been true for a long time. 

In honor of Cancer Pain Awareness Month, here are a few important facts about cancer pain (some of which might surprise you): 

• Cancer pain can almost always be controlled. Data from the World Health Organization shows that following simple treatment guidelines and using widely-available medications controls cancer pain over 90% of the time. 
• Though narcotics are usually required to control cancer pain, addiction rates are extremely low in cancer patients – probably no higher than 4% according to several studies. That’s 5-10 times lower than the addiction rates among patients with other types of chronic pain. 
• Pain relief doesn’t require that patients be “drugged out”.  Pain medications can certainly cause sleepiness, for the majority of patients this is short-lived and can be counteracted by dose adjustment. 
• Dying in pain is a thing of the past. With good hospice care, no one need suffer when dying. 
• Using narcotics DON’T hasten death. The best evidence indicates that dying patients – even comatose ones – live longer when given narcotics to control pain.

Among other things the summer equinox means

(besides the sunlight fracturing my sleep at 5:30 in the freaking morning), star-gazers know that the sun’s most northerly position on the day of the equinox is in Taurus – though it wasn’t always so. In ancient Greece, the sun would’ve ridden to its equinox peak in a different constellation: specifically, Cancer. When I stumbled on that tidbit in the paper yesterday, I was reminded how long that name’s been with us.

Cancer’s new prominence in the modern age – in incidence, and in awareness – often fools us into thinking it’s a new illness; but in fact, the disease is as old as our species. It was first named in the fifth century B.C.E. by Greek physicians in the Hippocratic tradition who, frustrated in their attempts to pry tumors free of their patients, called them karkinos (“the crab”) because of the tumors’ claw-like grip.

Greek knowledge formed the basis of much of Roman learning. As Hellenic power waned and Roman influence dominated the world, the Greek word for the disease was eventually replaced by the Latin synonym for crab: cancer.

There may even be another reason these tumors reminded Greek physicians of a crab, though I’ve no proof of this. In mythology, the goddess Hera tried to foil Hercules at every turn – and during his battle with the Hydra (when he needed all his wits and strength) she sent a large crab to bite at his feet during the battle, hoping it would affect his footing enough to cause his defeat. When Hercules instead crushed the crab, myth says Hera memorialized it in the heavens as one of the signs of the Zodiac.

In Hippocrates’ time lifespans were much shorter so cancer would’ve been rare, and would’ve affected the young and otherwise healthy. It would’ve seemed a random calamity of cosmically cruel proportions, biting at the heels of otherwise vibrant youth – like the one Hera sent to torment Hercules – and just like pediatric cancer still seems to us today.