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INDIANAPOLIS (AP) — Until John Cleland looked at his chest X-ray, it had never occurred to him that he might die.
He had endured 11 months of surgeries and chemotherapy, but he figured it was just an ordeal he would get through. After all, Cleland was only 23, recently married.
But his physician, Dr. Lawrence Einhorn, had pulled out the latest image of Cleland's lungs. There, front and center, Cleland saw cancer's shadow.
"You didn't have to be a medical expert to know that that person was in trouble," Cleland told The Indianapolis Star (http://indy.st/1plYrGN ), "and that person was me." Cleland's heart started pounding in his chest, beating so furiously he felt as though he could hear it.
Einhorn said as gently as he could: "John, I'm sorry. There's not much more we can do."
Then he paused. A long pause.
Outside the room Cleland's father sat. Cleland couldn't imagine how he would tell him. He couldn't fathom sharing the news with his mother, his wife.
It was Sept. 27, 1974. Einhorn told Cleland there was one other thing they could try. But it was far from a sure thing.
Einhorn didn't promise a cure. The most he hoped for was a "minor miracle," a way to a better quality of life and more time for those with cancer.
And Cleland didn't realize that only one other patient with widespread cancer had tried the therapy. And he died.
But that conversation 40 years ago resulted in something Einhorn would come to consider a "major miracle." One that not only changed the course of Cleland's life, but Einhorn's, too. And the lives of thousands of other men with testicular cancer, including cyclist Lance Armstrong, figure skater Scott Hamilton and baseball player John Kruk.
Within a few years, it would transform testicular cancer from a disease that was often deadly to one that can be cured 96 to 99 percent of the time if it has not spread too far. Even in cases where the disease has spread to other organs or lymph nodes, the survival rate is 74 percent, according to the American Cancer Society.
"This is the only time this has ever happened in 40 years in oncology," said Einhorn, who is today the Livestrong Foundation Professor of Oncology at the Indiana University School of Medicine.
Four decades later, the work that stemmed from that conversation between Cleland and Einhorn has earned Einhorn a place in oncology history.
And it started with a wrenching decision made by one young man.
John Cleland was a 22-year-old Purdue senior, recently married, when he discovered a hard spot on one of his testicles in the shower one day in August 1973. At first he thought nothing of it; perhaps he had been kicked while playing basketball that summer and just not noticed.
The spot grew but Cleland's mind was on other things.
He was interviewing for a job as a herdsman at the University of Missouri's dairy farm. He decided to put off a doctor's visit until after the interview. At his first visit to Purdue student health, the doctor he saw said he was almost sure nothing was seriously wrong. But just in case, he sent Cleland to a urologist.
In the two weeks that Cleland waited for the specialist appointment, the pain and size of the spot on his testicle seemed to multiple daily. It was impressive enough by the time he reached the urologist in November that the doctor had him admitted to a Lafayette hospital the next day. The next day, Cleland had surgery to remove the testicle.
When Cleland came out of the anesthesia, the doctor told him he had cancer.
"It was pretty much shocking, unimaginable that you could be 22 and have cancer," Cleland said.
The urologist referred Cleland to Indiana University Medical Center, where Dr. John Donohue had developed a radical surgery to try to arrest testicular cancer by removing all the lymph nodes into which the cancer might have spread. The surgery took nine hours and left a long scar.
But the good news was that only three of Cleland's nodes were cancerous. Donohue thought he had gotten it all. Cleland did a week of chemotherapy and on Jan. 1, 1974, he started the job in Missouri.
In March, Cleland came back for a routine checkup and asked Donohue about a hard spot he had noticed in his scrotum. John, the doctor said, I think the cancer is back.
The Clelands moved back to Indiana so he could start chemotherapy.
Einhorn tried three forms of chemotherapy and the disease returned each time.
The regimen was brutal, with on-and-off hospitalizations. Cleland developed such bad sores in his mouth and throat that he could not bear to swallow, spitting into a cup instead. He was often nauseated. In three months, he went from 158 pounds down to 106.
During the roughest of times, his father, who had been a prisoner-of-war during World War II, would share his stories. For Cleland, hearing that his father had weathered such ordeals offered some solace.
By July, the chemotherapy was taking such a toll, that Einhorn decided to switch treatments.
"It was killing the cancer cells," Cleland said, "but it was also killing me at a faster rate."
Still, at no point did Cleland remember considering that he was going to die. Survival was always the hope in his mind.
No doubt it helped, he said in an interview on a recent sunny morning, that the Internet didn't exist in those days. He couldn't Google "testicular cancer" and "death rate" and see the dismal statistics.
"I don't remember Dr. Einhorn saying, 'This is going to cure you or anything,' but certainly that was the hope, at least that was the goal in my mind," Cleland said. "I never took my cancer real seriously, I thought I was always going to get cured."
Then came that day in Einhorn's office, and his offer of one last chance. You can be one of the very first people to try a new chemotherapy called cisplatin, Einhorn said, a platinum-based drug.
"When he said, 'one of the first,' I figured I'd be in one of the first 500 or 1,000 or something like that," Cleland recalled. What Cleland did not know was that he would not be the 1,000th person to try the treatment. Nor would he be the 500th.
The one other patient to have tried the therapy had died, but it was still considered worth a shot because that patient's cancer was so advanced.
At first, Cleland didn't know how to respond to Einhorn's offer. He knew he didn't want to die, but the last few months had been harder than he ever imagined.
Before, he said, the disease and its treatment had beaten him physically. Now for the first time, he felt beaten mentally.
What are the odds this will work? he asked Einhorn.
We just don't know, the doctor responded.
Platinum was a promising experimental drug. Einhorn hoped that adding it to another drug for testicular cancer might move the dial somewhat when it came to the 95 percent mortality rate for men in whom the disease had spread outside of the testicles.
But Einhorn did not know what to expect. He did know what to expect if Cleland didn't try it. Cleland would feel better for a short while as he ceased the chemotherapy, but then the disease would spread through his body and he would be dead within nine months to a year.
Exhausted by his illness, Cleland weighed not enrolling. That would mean telling his parents, telling his wife, telling himself, he was quitting.
Instead of telling his father he would surely die, Cleland left the office and told him he would be starting on a new trial of chemotherapy.
Cleland will tell you Einhorn is a hero. Einhorn sees Cleland as the hero.
"It takes a remarkable inner strength to say, 'I'm going to still fight this and realize that the fight is going to be a losing fight, but it may help other patients,'" Einhorn said of his patient.
With no guarantees, he agreed to enroll in the trial.
Two weeks after his first shot, Cleland spiked a high fever, something that had happened during his other treatments. His wife and a few friends took him to the IU hospital. As usual before he was admitted, the emergency room ordered a chest X-ray.
The next day, the fever was under control and Cleland was in his room. He saw Einhorn coming down the hall with his nurse Becky Furnas Bond. The two seemed in an uncommonly good mood.
Wherever they were headed, Cleland thought, it was to deliver good news.
They walked into his room.
Cleland's chest X-ray was clean, so clear in fact that they had checked several times to make sure it was really his.
"It was the best feeling I have ever had in my life," he said. Just recalling the moment, he choked up.
For Einhorn that X-ray with its "dramatic regression" was promising but not yet proof of a cure.
"We knew that we had at least achieved our minor miracle," he said.
After that, Cleland required two additional rounds of chemotherapy, each consisting of daily injections for a week. His next round fell in the week of Thanksgiving, when the out-patient clinic would be closed for two days.
Bond, now a nurse at the University of Utah, had plans to see family. But Einhorn asked if she could stay in town and ensure Cleland's continuous treatment. On Thanksgiving morning and the next day, Cleland and his wife went to her apartment, Bond recalled.
He lay on the couch. Bond, who was a consummate intravenous nurse, remembers how worn out the veins in his arms were. So she injected the chemotherapy into his ankle.
Eleven months later, Einhorn finally felt comfortable using the word "cure" with Cleland.
"Since he had three prior treatments and none of his remissions lasted more than a few months and because his cancer grew so rapidly, we were pretty sure at the one-year level that he was cured of his cancer," he said.
Medical breakthroughs cannot hinge on the experience of one patient, however. It took a few more years and many more patients before Einhorn published the results that secured his place in history.
"Dr. Einhorn was a pioneer in a disease which was initially largely and rapidly fatal," wrote Dr. Philip Kantoff, director of the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Institute in Boston, in an email. "The paradigm that Dr. Einhorn created has served as an exemplar for the development of treatments in other cancers."
Others were looking, but Einhorn was the first to conduct a systematic study of the new drug and report the data, said Dr. George Bosl, chairman of the department of medicine at Memorial Sloan Kettering Cancer Center. Once the data were in for testicular cancer, the work that Einhorn did helped prompt more research into other drugs for other cancers.
"It kind of set the stage for the thinking that if it can be done in testicular cancer, why can't it be done in other malignancies and it set us off on a course of investigation," Bosl said. "This was a breakthrough without a doubt."
For Cleland, it took some time before he felt comfortable planning for the future. He and his wife did not talk about starting a family for some time, waiting to make sure the cancer did not recur. And he always felt a little nervous when he went for routine checks.
Life proceeded for him and his wife. They had a son first, then boy-girl twins, and much later a grandson. Cleland went back to school to become a biology teacher. He taught at Zionsville High School for 30 years until he retired in 2011.
"I haven't had too many bad days," Cleland said with a smile. "I look at life a little differently. Not too many things bother me a whole lot."
Over the years, Cleland and many of those who had treated his cancer remained close, holding reunions on major anniversaries such as this one.
"When you go through what we went through, you own a little piece of each other," Bond said.
At the 25th gathering, Cleland's son, then in high school, heard the stories about his father.
"'Dad,' he said, 'I always knew you were sick but these people told me how sick you really were,'" Cleland said.
During that gathering of about 100 people in the Clelands' backyard, another survivor called on the phone to congratulate Cleland and thank him for what he did.
It took Cleland a few minutes to believe that the voice on the other end of the receiver was not one of his friends pulling a prank but Lance Armstrong.
Years later, Cleland's mother fell ill with colon cancer at 79.
For her to survive, she said, would require a miracle.
And, she said, looking at her son who would outlive her, we've had our one miracle.
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Information from: The Indianapolis Star, http://www.indystar.com
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