Back at work after two colon cancer recurrences

Before leaving for work, Charlie checks that he has his blood glucose supplies and insulin.

He used to think mostly about what needed doing that day and whether he would get to his appointments on time. Now meals, medication and hospital visits have to fit into the schedule too. Sometimes he has to stop halfway through a task to look after himself. At first, he found that irritating. He did not want to keep explaining, or to have every conversation begin with a question about his health.

Still, there had been a time when a full working day seemed too much to hope for.

By then, Charlie had undergone two cancer operations and two courses of chemotherapy, each lasting eight cycles. Twice, his colon cancer had spread to his liver. Immunotherapy eventually brought a sustained response, along with a serious complication that would require daily treatment of its own.

In the spring of 2011, Charlie was 60. He had been passing blood for several months, initially attributed to hemorrhoids, and had lost about five kilograms in six months. His clothes had grown looser around the waist. He had not thought much of it until a colonoscopy revealed a tumor in his sigmoid colon.

He was used to taking medication for high blood pressure. The prospect of putting everything aside for surgery was less familiar.

Cancer itself was not. His mother had developed colon cancer in her fifties, and a sister had died of it in her twenties. Until now, those experiences had belonged to other people in the family. Sitting in the consulting room, he wanted practical answers: could the tumor be removed, what would happen afterward, and how long would he be away from his usual life?

In April, surgeons removed the cancer. The pathology showed stage IIA mucinous adenocarcinoma, with no distant spread found at the time. He then received oxaliplatin and capecitabine, completing eight cycles of chemotherapy in October.

Life was divided into appointments and treatment cycles. Before making plans, he checked when he next had to be at the hospital. His family offered to take things off his hands. He appreciated the help, but wanted to keep some responsibilities to himself.

For several years, follow-up tests found no evidence of cancer.

He remained anxious before each visit. The latest report went at the front of the same folder; once he knew it was clear, he could make the calls and arrangements he had postponed. Gradually, he began planning further ahead.

Then, in 2017, a tumor was found in his liver.

He had another operation that September. Pathology confirmed that the liver lesion had come from the colon cancer. Another eight cycles of chemotherapy followed.

This time, he knew what to bring to appointments and how to prepare for tests. That familiarity helped with the practicalities. It did little to ease the disappointment of a recurrence after years of reassuring results.

When friends asked how he was, he became more careful with his answer.

“The latest tests were all right,” he would say.

In August 2022, scans again showed cancer in the liver. There were now several lesions, along with spread to lymph nodes near the liver and dilation of the bile ducts within it. He had not noticed symptoms that prepared him for the extent of the findings.

As the doctors discussed what to do next, he thought back over the operations and chemotherapy. He wanted to continue treatment. He also wanted to understand why a different approach might work, and what it might cost him physically.

The team revisited his pathology and family history.

Testing in 2017 had already shown a defect in the tumor's system for correcting errors when DNA is copied. Further testing in 2022 identified a genetic variant associated with inherited cancer risk. Together with the other findings, it led to a diagnosis of Lynch syndrome.

The unfamiliar name gave some explanation for a family history he knew all too well. Besides his mother and sister, a brother and niece had also had cancer. He remembered who had undergone surgery, who had made it through treatment and who had died. The doctors needed a different kind of detail: which cancers, at what ages, and in which relatives.

Those memories now had a bearing on his own care.

His cancer showed mismatch repair deficiency and microsatellite instability. The doctors explained that these features could make the tumor more recognizable to the immune system. Pembrolizumab, an immunotherapy drug, could release some of the restraints on immune cells, helping them attack the cancer.

Charlie did not need to remember every abbreviation on the report. What mattered was that the choice rested on something specific about his tumor.

He began pembrolizumab in September 2022, returning for treatment every three weeks. After two recurrences, he was reluctant to tell friends that a new drug meant good news. He put the appointments in his calendar and waited.

After three cycles, his laboratory results and physical condition improved substantially.

He began taking an interest in things he had set aside. When someone mentioned work, he listened more closely and sometimes joined the discussion. Hospital appointments still had to be kept, but they no longer occupied all his attention.

Then, after his seventeenth cycle, he developed diabetic ketoacidosis, a medical emergency. Tests showed that his insulin production had fallen to extremely low levels. The doctors diagnosed fulminant type 1 diabetes associated with immunotherapy.

The treatment helping to control his cancer had also damaged his body's ability to make insulin. He would now need several insulin injections a day.

Learning to manage it took more than adding another prescription. He had to check his blood glucose, give injections and plan meals around medication. A late lunch during a busy day could no longer pass without thought.

He found the new restrictions frustrating. After years of cooperating with treatment, there was another condition to learn about and another set of instructions to follow. He also feared that the complication might force him to stop a cancer treatment that was working.

“The cancer is getting better. How have I ended up with this as well?”

Both things were true. He had benefited from immunotherapy, and he had suffered a serious adverse effect that required continuing care.

Multiple daily insulin injections brought his blood glucose under control. He continued pembrolizumab, eventually completing 30 cycles. Cancer treatment and diabetes management became part of the same routine.

By May 2024, follow-up scans showed no evidence of metastatic lesions. Tumor markers that had previously been elevated remained within the normal range. Charlie was more active and had returned to full-time work.

He still needed follow-up and insulin. Two recurrences had taught him to be cautious about what a clear scan could promise. But work was taking up more of his day again.

He wanted to know whether he could still take responsibility for a task and see it through, whether colleagues would still come to him to discuss a problem. He wanted them to understand his health needs, then carry on talking about the job.

At home, his family sometimes reminded him not to overdo it. He agreed, checked the dates of his next hospital visits and kept those times free.

Before leaving in the morning, he puts his glucose supplies and insulin in his bag, then checks the papers he needs for work. Once everything is there, he closes the bag and heads out.