The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. The Bomb, Andrea M. Watson. I sit paralyzed at my desk. Everyone has left the clinic. I can hear the sound of the broom in the hall as the after hours cleaning begins. No phones ring. No patients hurry to appointments. No chatter lingers in the air. The silence is oppressive, the air is heavy, and the distance from my office to the hospital an eternity. I've just hung up the phone with the radiation oncologist. His words echo in my head. "Radiation will cause more harm than good. I'm sorry. I wish there was something more I could offer." Dread rises like a tide as my last hope recedes. I want to share the burden of this terrible news. But all my colleagues have left for the day. And I am alone. I'd been taking care of Mallory for nine months when the progression of her disease took me by surprise. Her tumor had responded so well to upfront radiation followed by nine months of intensive chemotherapy. With just a few months of treatment left, the end was in sight. Mallory was an avid JRR Tolkien fan. And plans for a Make a Wish Foundation trip to New Zealand were underway. She wanted to see the Lord of the Rings filming location and visit the small hobbit village she'd read about in travel books. She wanted to wait until it was summer there, our winter time, to travel. When Mallory's disease progressed on therapy, that fall, the timeline shifted. Goals shifted. There was no realistic hope for cure. There was just hope for time. The trip became the goal. And she bravely chose to continue with aggressive treatment, hoping it would open a window of time for travel. But further progression got in the way. When the futility of chemotherapy became clear, hopes were pinned on radiation to buy time. Now hanging up the phone, I realized that this strong, brave, beautiful 16-year-old girl who had been through so much will never get to New Zealand. And I have to tell her that tonight. I start out toward the hospital. But walking through the hall, my steps slow, my chest becomes tight, and my head swims with the devastating message I carry. I stop and look blankly at the man sweeping the floor wondering if he can tell I am carrying a bomb meant for a young girl and her family. He keeps sweeping, unaware. I trace my steps, fighting back tears. Back in my office, the sobs come. I cry for Mallory, for her parents, for her little brother and her best friend, her sister, for all they would never share together and for all the sorrow they had already faced. I cry for myself and for the terrible burden of delivering the blow, extinguishing the candle of hope that this trip had become, and speaking the words they'd dreaded since the moment we met. And when the tears finally stopped, I am empty. I take a deep breath and walk out the door. Mallory is not surprised by my news. Her gaze shifts away from me to a far off place. Silent tears stream down her face. And she says, "I know." That's all she says. I meet with her parents alone in the family room. Their reaction is raw and palpable. Flooded by tears and sobbing, they cling to one another lost in a storm of grief. When her brother and sister join us, I unfold the news slowly, choosing my words with great care as the disbelief on their faces quickly melts into sorrow and then tears. My heart feels as if it will break. I sit quietly by trying to fade from the scene that plays out before me. I fight back the tears but lose. I have done my job, delivered the bomb. There is nothing more to do but bear witness. Then something beautiful happens. Mallory's parents silently hug one another with new resolve and in turn embrace their children. Without a word, they stand up and walk together into Mallory's room. Hand-in-hand, they pull her in and encircle her with fiery love. I quietly take my leave feeling the power radiating from the room as I walk down the hall and out of the hospital into the night air. Mallory's funeral program bore a poignant quote from the Lord of the Rings film in which Gandalf assures Pippin that death is not the end, but rather another path we must take. The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver grass. And then you see it. "The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver glass. And then you see it." "What, Gandalf? See what?" Pippin asked anxiously. "White shores and beyond, a far green country under a swift sunrise." Shortly after Mallory died, her sister reflected that although she never saw the lush green of New Zealand, Mallory's journey had taken her somewhere even better. Likewise, the journey of those left behind continues. Families lives are forever changed after a child dies. And our lives are never the same either. Each patient we care for can teach us lessons about how to live well even when you die young. The privilege is great and the responsibility that comes with it greater. Delivering devastating news to beloved patients and their families may be the most dark and difficult moments of one's career. But compared with the burden that families carry, it is light. And if you stay long enough and you listen hard enough, you may see the blinding love shining through the darkness. Now the end of the day. After the noise and activity fade, I find myself thinking of Mallory. Some days, it's with a renewed awareness of the heavy burden we carry. Other days, it's with a lightness of being and gratitude for those who go before us leaving their courage as testament to what they've believed in. The silence unearths a deep ache in my heart. Sometimes I cry. Then I hear the comforting sound of sweeping in the hall. I take a deep breath and walk out the door. Welcome to Cancer Story, The Art of Oncology series podcast brought to you by the Journal of Clinical Oncology. I'm Lidia Schapira, editorial consultant for Art of Oncology and your host for this program. With me today is Dr. Andrea Watson, a general pediatric hematologist oncologist working at Essentia Health in the Duluth Clinic in Minnesota and the author of The Bomb published ahead of print, February 11, 2019. Andrea, welcome to our program. Thank you, Lidia. It's a pleasure to be here. I've been looking forward to it. That's terrific. Let me start by asking you a question I ask many of our authors. People who write usually like to read. What are you reading now? Oh, that's a great question. I, on any given day, I do read quite a few children's stories. Not only am I a pediatric oncologist, I have five children. So there's a lot of bedtime story reading, which also cuts into my leisure reading. I don't have a lot of time for fiction. But right now, I am reading a book called Invitation to Love, which is by a Cistercian monk about centering prayer. And I'm in the middle of a series that he has written about the topic. And it's wonderful. That's so interesting. So with that, let's talk about your writing. You have written and published before. So tell me a little bit about how you write and when you write and why you write. Yeah, thank you. I have discovered writing in my career in the past few years, although I recall my grandmother giving me a journal when I was 12 or 13. And it was called The View From my Window. And I really have been journaling on and off throughout my life since that time. And it wasn't until I experienced a series of patient deaths that were all very close and difficult for me three or four years ago that I really took to writing as more than just journaling. And I would say looking back, it really felt like more of a compulsion than anything else. After one of the deaths, a few weeks had gone by. And I just-- I felt physically drawn to it, almost I had to get this out. And I just-- I started on my computer. And from that came the essay that you were kind enough to publish a few years ago called Let It Be Hard. And that was just such an incredibly rewarding experience for me, not only in the process of writing and processing these deaths and all of the events surrounding it, but also in the aftermath in connecting with others who had read it or who were also writers or who had a similar experience. It was a very rich, rewarding experience. And subsequently, I have come back to that kind of as needed. I had another very difficult patient death last year. And she has become the topic of this essay, which was very much more raw and intimate for me. But that's-- I guess that's where I am in my career. It's been 10 years now that I've been practicing in a smaller town in northern Minnesota. And this has been a really important way for me to stay balanced and keep coming back to work every day. That's so interesting. And I really appreciate how you take readers also to a place of deep, deep emotion. I remember in the first essay you published, you talked about how difficult the work is. And you also said, and I wouldn't want to be doing anything else. And in this particular piece, The Bomb, you walk us through the process of delivering incredibly terrible news. And you do it with such sensitivity. Tell us a little bit more about this, the reservoir of emotion and how you handle it, how you keep it from bubbling over. Well, that is the question. And luckily for me, writing is part of the answer. In this essay, The Bomb, I think I really was looking to dive into that time where you as a provider, as an oncologist, are aware of information but have yet to deliver it. And I really hadn't experienced it so intensely before this case, although it happens all the time. It happens every day as we look at scans or look at the lab reports and then meet with patients. But in this particular instance, this whole essay is about the backstory and the aftermath. But I really wanted to focus on those minutes where it's so dark. And it's so hard. And it's so heart-- gut-wrenching and heart-wrenching to carry that without being able to share it or get rid of it or change it. And for me physically, I wanted to paint that scene to try to bring people to what it feels like and physically walking from one building to the next and how everything around you is life as normal-- life as usual. The janitor is sweeping and cars are passing by. But in fact, it's this horrendous bomb that you are delivering. And then the incredible grace that comes after, I mean, for me writing really is a meditation and a way to honor these children, these families, and their strength and their resiliency. And I think without taking that time away, that time apart, to look at that and to tell that story, you don't really appreciate it. I don't. And when I am able to do that, that turns all the intense sorrow and grief and just the horror of it all into something quite beautiful. And I think many of your guests have alluded to that in oncology. Whether it's adults or children, there's such great suffering but so much life and growth and love that comes out of that that that's what I think is just an amazing aspect of what we do. And that's certainly what keeps me coming back every day and picking up a new patient and kind of moving through it again because there's no end. So you have brought up so many very deep and insightful, wise pearls there. I think this idea of connecting through love and beauty and that is sort of almost like the antidote to the sorrow. It's beautiful. But I want to take you back a little bit to this idea that you are holding this bad news, this bomb, because delivering the bomb sounds so dramatic and so explosive. Is that, in fact, the way that you experience this delivery of bad news? Well, it certainly is a dramatization of it. I wouldn't say that every day, I feel like I'm running across the field with a bomb. But when I was first drafting this essay, and I went to save it, that title just-- I said-- it just came-- it's The Bomb. That's what I'll call it. And in that case, because we had such a strong relationship, and it was just-- it felt so tragic in part because she was such a special girl and so, so just wise beyond her years and this wonderful family. She was also the age of one of my children, my oldest daughter. And that, as many of us in pediatric oncology at least know, that makes the-- it turns up the intensity. And it's a much more emotionally challenging situation. So that particular news delivery I think was probably the most poignant for me, the most difficult. And it happened as I describe it. But that's not what every day is like thankfully. No, I-- thankfully not. But what I want to bring us back because you say that the bomb is really the way it felt to you. And then you also talk about the fact that, I mean, one of the things that I loved about this essay so much is you talk about starting to walk towards the room and then having to go back to your office and close the door and sob and feeling empty. Because I do think that the emotional impact is huge on us as well as you describe as the oncologists here. And then of course, you pull yourself together in the most professional way to deliver this therapeutically. But it is important to remember that it is emotionally a very dramatic. And it feels that way. And you certainly have made that so beautifully clear to the readers. Thank you. I think one of the things I learned from the first piece I wrote, Let It Be Hard, was just that. And that was something that one of my palliative care idols said to me one day when I was struggling with this case. He said, let it-- it is hard. Let it be hard. And that I think is what got me to where I am now with the story about Mallory and that I learned from him it's OK to shut the door and cry. And it's OK if those cries are sobs. Now we can't function on a daily basis if we're emotionally out of control. And that certainly wasn't my-- what I was trying to depict. But that let-down I think and just letting it hurt is moving through it. And from that, I-- that and by the grace of God had the strength to go over and very calmly and peacefully relay this news, which, of course, as often is the case, she already knew and help be a support person as the family really absorbed the reality that was unfolding. And that's, for me, all we can do is walk through it. We can't run away. We can't escape it. And it has only made my work and my relationship with these families richer and deeper. And that's another important piece for me. With both of the families, actually, many-- three kids that I talked about in the first one and this one, we maintain a relationship with these families long after the children have died. And they are part of our healing as much as we are part of theirs and keeping that memory alive and honoring their struggle and what they taught us. So personally, for me to do this difficult, very painful work has been offset by those relationships and the knowledge that you're growing through a very difficult time, the worst time in a family's life, and a hard time in your career. But there is growth. And there is hope. And there is meaning. And you beautifully did your work as a writer by framing this high-intensity emotional moment against that sound of that gentle sweeping, the man who was cleaning the floor. And you just remind us that there is normalcy all around this chaos and this crisis. But it's a beautiful piece. Thank you so much for sending it in and for sharing your wisdom. I want to thank Dr. Watson and hope you will join me next time for another conversation about The Art of Oncology.