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Against the Odds: Two Against the Odds

The Marlboro Man is dead and those Virginia Slims "You’ve come a long way, baby" commercials that fueled the multi-billion-dollar tobacco industry and the resulting deaths from lung cancer have been outlawed in the United States.

So tobacco companies have taken the show on the road.

While smoking rates among men in the U.S. have dropped to 24%, less than half the 1965 rate, 64% of men in China and Russia are now smokers, as are half of Japanese men. The rate is up to 67% in Kenya and continues to rise in other developing nations.

When Chilean government officials realized that more than 40% of their own citizens had become smokers, including 43% of their adolescent girls, they organized a national conference in July 2005 to address the crisis. They needed someone to tell physicians and health workers what they were up against. They called the Mayo Clinic’s Ivana and Gary Croghan.

An epidemiologist and the coordinator of research programs for the Clinic’s Nicotine Dependence Center, Ivana compared smoking rates in the United States 50 years ago to current smoking rates in Chile. She explained to Chilean officials the 20- to 30-year lag times between increases in smoking rates and death rates.

"In the U.S., smoking rates increased in the 1950s and 60s, and it wasn’t until the 1980s and 90s that lung cancer rates rose so high," Ivana says. "Chile is where we were 10 years ago—I’m hoping by making them aware of this, they won’t make the same mistakes we did."

Medical oncologist and researcher Gary Croghan told Chilean officials how lung cancer develops and showed a slide: "The Top 10 Causes of Lung Cancer." Smoking is the source of all 10.

"Look around the room as people hear these facts and you’ll see some of them visibly gasp," Ivana says. She saw the same reaction in the Mayo Clinic’s hometown of Rochester, MN, when Gary helped convince county health commissioners to pass one of the nation’s first smoke-free restaurant ordinances in 2001. And she’s seen it over and over in the smoking cessation studies on which the couple works.

"He just tells them the truth, and he’s very effective," Ivana says. "He walks in and lays out the facts, and it finally clicks in our patients’ heads, this is serious, I’d better stop. He brings reality home to them."

That reality stares Gary Croghan in the face every day as he treats patients fighting a disease that, in its primary state, still kills 90% of its victims within five years.

"Lung cancer kills more people than the next five cancers combined," Croghan explains. "No one really wants to do lung cancer treatment and research."

The prognosis is particularly dire for patients with small cell carcinoma.

"In the past 35 years, the cure rate for small cell has improved only one- to two-percent," Croghan laments. "We just haven’t been very successful."

At the Mayo Clinic, where many come seeking a miracle after unsuccessful treatment elsewhere, Gary Croghan is too often, as he calls himself, the "bad news guy."

"91³ÉÈ˶ÌÊÓƵ got me started"
Croghan was well acquainted with the bad news of cancer long before he arrived at the Mayo Clinic. His father, Robert, an industrial welder, died of lymphoma. Three months later, Gary’s mother, Catherine, was diagnosed with the same cancer. She’s since survived a second bout with the disease.

Croghan’s vocation as a researcher seemed clear to him even in his undergraduate days.

"91³ÉÈ˶ÌÊÓƵ actually got me started in cancer research," Croghan says, recalling summer grants he received from the College to work with the electron microscope.

Graduating as a biology major with a minor in Russian, Croghan decided to forego medical school for research, earning his Ph.D. in experimental pathology at SUNY-Buffalo. Awarded fellowships at the Roswell Park Memorial Cancer Institute, he was part of the team that found and characterized the prostate specific antigen (PSA) still used so effectively today for prostate cancer screening.

The researcher earned his M.D. as a summa cum laude graduate of Buffalo School of Medicine in 1990 and was invited by the Mayo Clinic to do his residency in Rochester in 1991.

Married since 1982, Ivana and Gary moved to Rochester, where Ivana began her work in the Nicotine Dependence Center with Dr. Richard Hurt, a leading authority in the field and the former chair of the Minnesota Partnership Against Tobacco. The Center needed physicians to conduct physicals on patients in their studies, and Gary became the Clinic’s first in-house "moonlighter."

"He began to spend a lot of time with people who were trying to quit smoking and he learned what their issues and concerns were," Ivana says. "I think his parents having lymphoma is what drew him to the cancer field, but working with us more or less sealed his career fate."

Croghan’s experience as a cancer victim’s son, voracious reading habits that keep him abreast of the latest treatments, and his own research at Mayo all converge at his patient’s bedside.

"He doesn’t see his patients as cases or numbers—each one is somebody’s mother, father, son, or daughter, somebody’s wife or husband," Ivana says.

"We have to really prepare these people," Gary says. "I can count on one hand the number of patients with small cell I’ve seen in my practice make it to five years.

"You meet with a patient for the first time for about an hour and a half. You’re giving them the worst news they’ve ever gotten in their lives. At the same time you’re trying to gain their trust. You have to read the family dynamics, see who has coping skills and who doesn’t. It’s one of the toughest things we do."

Croghan eases his patients towards hope.

"I’ll explain the situation honestly, explain the options, and tell them that I’m glad to try to help," Croghan says. "When they learn the odds, I’ll also tell them, ‘Look, I couldn’t do this job on a daily basis if I didn’t see people beat the odds.’"

He recalls one "amazing lady in her 70s" who came to him diagnosed with extensive small cell lung cancer metastasized to the liver and bone.

"She said, ‘I know it’s serious, but I want to try,’ so we gave her chemo," Gary recalls. "She took treatments that my 20 year-old patients couldn’t take. She died just recently, but she got what she wanted—two years, two cruises, time to see her family. She was one tough lady."

Faith often inspires that "toughness" in his patients.

"If you’re not religious when you go into oncology, you are shortly thereafter," Croghan says. "People who say, ‘I believe I can find strength’ actually do better. That person’s sense of well-being, views on an afterlife, are very reassuring. It’s a whole different mindset."

But even faith only rarely beats small cell.

"If it looks like the disease isn’t responding, I have to set the stage, be a little more direct, and start making that transition so they finally realize that they’re not going to survive this disease," Croghan says.

"I tell my patients this doesn’t mean giving up hope; it just means that chemotherapy and radiation will no longer play a role. It doesn’t mean we can’t treat and improve your quality of life. You still want the best quality of life you can, whether it’s diabetes, heart disease, or cancer."

Pushing science forward
Giving up hope isn’t an option for Gary Croghan, who in his 20s and 30s put his own life at risk in hot pursuit of a cure for cancer in the laboratories at Roswell Park.

"When you did hardcore cancer research back in those days, you took a lot of chances," Croghan says. "We were using benzenes, working with viruses, and we didn’t wear moon suits like they do now. That was my profession, and that was part of the risk."

Croghan still spends one day each week in the lab and oversees numerous clinical trials at Mayo. He’s currently leading a study that uses F-3622, an antibody he developed as a graduate student, to treat patients with lung cancer in the liquid of their pleural cavities, one of the deadliest manifestations of the disease.

"I still love doing this experimental treatment that pushes the front of science forward," Croghan says "But you’ve got to know when to stop—when to treat, and when not to.

"I had a patient who just six weeks ago was this dynamo contractor," Croghan recalls. When he examined the man, the oncologist found an extremely aggressive cancer.

"I pulled his wife and daughter aside and said, ‘I’m sorry, but I think he only has a couple of days to live.’ Of course, they couldn’t believe it. I felt terrible telling them; they just didn’t have enough time to adjust. I tried my best to explain it to them, that there was no treatment that could change this."

The man died two days later.

"His daughter works here, and she thanked me for being honest with them," Croghan says. "I think a lot of important stuff got done those last two days, a lot of goodbyes were said. If they hadn’t known how fast this was coming, there would have been an even greater loss."

Such losses don’t sit well with the cancer researcher in Croghan.

"Sometimes you’ll have a day when you’re giving bad news to five out of your eight patients, and you know they’re not going to see their next birthday, and a lot of them have young kids. You stop in the middle of the hallway and you don’t know where you are. You’re just so emotionally drained, but you don’t realize it until the end of the week."

"On certain days I’ll see that it has really taken a toll on him," Ivana Croghan says.

"You support each other"
"I hit a wall about three years ago," Gary says. "One of my older colleagues said that we all go through it, that if you want to stay in this field, you have to find out what saves your sanity."

So Croghan bought the farm. Literally. In nearby Wisconsin.

"I go up and farm, put up a fence, or cut firewood," Croghan says. "I feel like I’ve accomplished something there."

To avoid burnout, the physician/researcher takes a break from his 14-hour days every eight to nine weeks, either at the farm, at a conference, or on a family vacation. When his daughter came home for spring break from college this year, the two attended his medical conference in Florida.

"The one thing I regret about being a physician is that you lose about one-third of the time you’d otherwise have with your kids as they grow up," says Croghan. "You try to do quality things. Sometimes that’s enough, and sometimes it’s not. But my kids are good kids.

And Ivana is an amazing person."

You sense the respect Ivana and Gary Croghan have for one another the moment you meet them. Ivana believes that respect, and the love it inspires, are the heart of the couple’s 24-year marriage.

"We were friends before we started to be romantically inclined," says Ivana, who was born in Calabria, Italy and lived a relatively sheltered life in Newburgh, New York before college and grad school. "Roswell Park is not in a very nice part of Buffalo, and Gary used to escort me from our dorm to the bus, make sure I got on without anyone hassling me, and he always waited to make sure I got back okay. He protected me—he realized I was just a little too naive to make it in a city."

Ivana returned the favor when Gary was offered a residency at Mayo, a move that took Ivana from very rewarding work in her own field.

"You support each other," Ivana says. "There have been sacrifices—as much on his part as mine. Ultimately, it worked for the best."

And in more ways than one. As Gary became more involved with the Nicotine Dependence Center’s work, he began to make a profound difference in the fight against cancer.

"Ivana talked me into helping out there, and that’s really helped me," Croghan says. "We do the best we can in cancer treatment, but if I can teach someone about this disease before they have it, if I can help someone stop smoking, I’ve probably done more good than any chemotherapy I could give them down the line."

In addition to presentations at international conferences, the couple has worked together on studies of nicotine patch effectiveness, teen smoking, and inpatient smoking cessation programs. Mayo’s program—with 48 percent of smokers coming clean—is the nation’s most effective.

"I’m one of the few people here who will help my terminal patients stop smoking," Croghan says. His studies have proven that smoking cessation improves treatment outcomes and quality of life throughout treatment. But breaking the habit is just as important to his patients’ emotional and spiritual well-being.

"Cancer comes down to a loss of control," Croghan explains. "We get these CEOs here at Mayo, people who have been in control of their lives and of others, and suddenly they are facing a disease they have no control over. But they can stop smoking. Even if they’ve just got a month or two to live, they can take control back from the very thing that gave them cancer in the first place. People are rightfully proud when they can stop smoking. It’s a big accomplishment."

And one that addresses guilt, an often-overlooked symptom of lung cancer.

"We didn’t realize how deep this went until a recent study," Croghan says. "But our patients are dealing with something they see as self-induced."

Coming face-to-face with the mechanism of their addiction and beating it sometimes does for the heart and soul what chemotherapy is unable to do for the body.

"Psychiatry is a huge part of our work every day here," Croghan says. "And we have excellent chaplains who talk with our patients any time of day or night.

We have a nurse who specializes in massage, energy treatments, music, and imagery. It’s been extremely helpful for a lot of people as a way to cope.

"The complexity of oncology for many of my patients is really the complexity of dying. You need a multidisciplinary approach."

"The most important thing I do"
The Croghans participate annually in Rochester’s Relay for Life cancer fundraiser.

"It may be the most important thing I do every year," Gary says. He’s always moved when the candles are lit in the paper bag luminarios—one for each person the city has lost to, or who is battling, cancer. "We’ve got 5,000-plus in Rochester, and I knew a lot of the people whose names are on those bags.

I owe it to them to be there. I owe it to me. And I’ve always taken my kids."

He often encounters patients’ families there.

"Gary couldn’t continue to do the work he does without the contact with patients’ families, without the possibility of seeing them through all of this," Ivana says.

She dreams of the day smoking rates in the United States drop below 20%.

She hopes the public will better realize the addictive power of nicotine.

"The tobacco companies knew all this decades ago," Ivana says. "You can read it in their own documents—how Marlboro sales shot up after they added ammonia to the paper so that, when it’s lit, it essentially freebases the nicotine. They knew how addictive this was years ago."

She bristles at the language in many documents that were released to the public as part of Minnesota’s settlement with tobacco companies.

"In one you read, ‘The smoking behavior of women differs from that of men. They are more highly motivated to smoke. They find it harder to stop smoking. Women are more neurotic than men. There may be a case for launching a female-oriented cigarette with high deliveries of nicotine.’ Now consider this in the context of lung cancer deaths among women rising 150% over the last two decades and killing more women than breast and ovarian cancers combined.

"That sort of thing, if nothing else, gives you the adrenaline you need to keep going in this work."

Gary Croghan continues to work toward improved treatments for lung cancer, but sees his vocation in transition.

"When you’re young, you’ve got to cure the world, but the longer you’re in this field, the more you’ve got to have those little victories," Croghan says. He seeks those victories for his patients from "the whole spectrum of their lives."

Croghan hopes to become certified this year in palliative and hospice care, a move some of his colleagues find unconventional.

"But if there is any group in this field that should have knowledge of palliative care, it’s those who do experimental chemotherapy," Croghan insists. "On Day One I treat, but you always have to prepare for this other part of the spectrum, the end of life. It’s all part of the same process. My mission is to take better care of my patients, and if palliative care provides that, I need to learn it."

Gary Croghan dreams of a day that oncologists will all be out of the job, their grim work never needed. Until then, he looks for small victories.

"A good day for me is when I help one patient stop smoking," he says. "Or maybe better yet, help one patient’s son or granddaughter to stop."

Read at 91³ÉÈ˶ÌÊÓƵ Online.

Contact Gary at croghan.gary@mayo.edu