Nicole Miller was no stranger to being inside a hospital. But being the patient was a new experience.
A lump in her breast was about to take this certified nursing assistant on a 12-year journey – from breast cancer to a series of surgeries that saved her leg.
Thankfully, Miller would meet a lot of heroes along the way. Here’s her story.
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The beginning: a quarter-size lump and a few hard years
In 2012, Miller was an active 34-year-old mom – busy parenting two teens, walking 5 miles a day, and working as a CNA in the psychiatric unit at Novant Health Rowan Medical Center, in Salisbury, North Carolina.
Then she found a quarter-size lump on a breast and was diagnosed with breast cancer.
She was treated at Rowan Medical Center and was in remission for almost five years when she learned that her breast cancer had come back. This time, the cancer had spread to her bones, causing her right hip and leg to deteriorate. Eventually, she fell, and her weakened hip fractured.
Top scores for safety in NC
Novant Health just received the most ‘As’ for patient safety in North Carolina from The Leapfrog Group. That includes Rowan Medical Center. With a focus on safety, quality and patient experience, the national, industry-leading nonprofit, evaluates and assigns letter grades ranging from A to F to hospitals across the country. Novant Health’s hospitals with “A” grades outperform 70% of hospitals nationwide for safety and quality.
After having hip replacement surgery in 2017, she faced another fracture – and then another. By February 2020, Miller had been through three orthopedic surgeries, each addressing new or impending fractures in her hip and leg.
And then the infection began. Miller’s hip was infected, badly, and antibiotics weren’t working.
Surgeons reopened her leg three times to try to clear her infection. But her infection continued due to the difficulty of clearing infections in a previously-radiated treatment field.
Miller was no longer able to work and was in near-constant pain. She was also exhausted. The never-ending train of operations had taken a huge toll.
“It seemed like every couple months, I was having to have a surgery,” she said. “Then I would have to stay off my leg because of the surgeries, and so I wasn’t as active as I wanted to be.”
Then came a “godsend” out of the blue. Miller’s surgeon referred her to Dr. William Ward – an orthopedic surgeon at Novant Health Orthopedics & Sports Medicine – Clemmons, an hour from Miller’s house.
She had no idea what would come next.
‘Let cancer spread, or let the infection spread?’
Traditional orthopedic surgical techniques may not work for a patient with a cancer history.
That’s part of what drew Ward to specialize in orthopedic oncology – providing surgical solutions for patients whose bones, joints, and muscles have been impacted by cancer.
“For a lot of what I do, there's no cookbook,” Ward said. “You have to individualize it for the individual patient – requiring creativity and using existing technology in novel ways to combat problems.”
At first, Ward and Miller scheduled a surgery to address her recurring infection.
But a week before her surgery date, Miller got some terrible news: her cancer had come back. She needed to start chemotherapy immediately.
Worse yet: Both the surgery and chemotherapy would compromise her immune system, making it impossible to do both.
“I had to choose: let cancer spread or let the infection spread,” Miller said. “Either one was going to kill me.”
“If she’s all in, I’m all in”
Ward discussed three options with Miller.
The first was treating the symptoms, but not trying to cure the infection or cancer, and working with a team to make the end of her life comfortable.
The next option? Making absolutely sure that her infection was gone so she could begin chemo. The hitch? Miller, who’d been through so much already, would have her leg amputated at the hip. That would remove the infection and she could begin chemotherapy.
The third option was the lengthiest: First, Ward could perform two surgeries to try to control the infection, putting a temporary “spacer” packed with antibiotics in place of her femur. If that controlled the infection, Miller could begin chemotherapy. After that, once her immune system had healed from the chemotherapy, Ward could perform another surgery to permanently replace Miller’s femur.
Success with this third option was not a given, Ward said, adding that these types of frank conversations can be tough to have. But not with Miller.
“She seems to face her disease with calm resolve. There's no ‘Why me?’” Ward said. “She wanted to live, she wanted to save her leg, but if I couldn't save her leg in a way that allowed her to live – then take her leg off. She was matter of fact about it.”
It was important to Miller to do the chemotherapy to prolong her life. And she wanted to preserve her ability to walk, if possible.
“I had to do some thinking myself: Am I leading her down the primrose path? Or can we actually get this accomplished? And I thought ‘Yeah, I think we can,’” Ward said.
“She wasn’t at a point where she wanted to throw in the towel. If she's all in, I'm all in.”
‘Getting back to my life’
Ward placed Miller’s temporary femur spacer, which he custom-made for her in the operating room –using antibiotics mixed with bone cement applied over a device called an intramedullary nail – in September 2020. The spacer was a temporary bone as big as the femur.
About a week later, he repeated the surgery, changing the spacer out to a new custom-made one, which he again made in the operating room for her just like the first one, to ensure that there was no infection.
“There’s no place you can read about doing a total femur replacement revision for infection like this that I know of – I was kind of making it up,” Ward said. “They don’t make the stuff to do this, technically, so I had to be somewhat creative. I took what I knew about treating infections in regular total joints and just sort of expanded it. There are now some ‘off-the-shelf’ antibiotic spacers and molds for hip or knee replacements. But there are no molds or off-the-shelf components for an antibiotic-containing temporary spacer for a total femur.”
Because Miller's bone was extensively damaged, an off-the-shelf prosthetic piece wouldn't fit correctly in her socket. So Ward used the molds that were available for a total knee replacement and made his own molds for the upper part of the femur and femoral head, putting it all together to custom-fit Miller’s needs.
Once it was clear that her infection was gone, Miller started chemotherapy. She had to stay off her leg entirely while the temporary spacer was in place. She used a wheelchair and spent a lot of her days sleeping in a recliner. She credits her mom and son for helping her through this time.
“I knew it was going to be a long process, a long journey, and I just made up my mind that I would just take one day at a time and do what I have to do to get better,” Miller said. “I knew if I felt bad, the chemo was working, so that kept me going.”
Miller had two dislocations along the way, so ultimately, Ward performed two more surgeries on Miller– for a total of four surgeries – allowing her to complete chemotherapy, and ultimately, to walk again. For Miller, this made everything worth it.
“My hope was that it would turn out like it did – that she still had a leg, and that she's able to walk on it with no pain, or at least tolerable discomfort – and it's why I still practice,” Ward said. “There are so many patient stories that I've had the privilege of being a part of. It would be hard to have burnout when you've got this incredible reward.”
Today, Miller works out with weights and routinely walks over four miles. She credits her success to her relationship with God, a positive attitude, healthy eating, keeping active and exercising, and her doctors.
Her oncologist, Dr. William Brinkley of Novant Health Cancer Institute Rowan, has told her that her breast cancer will keep coming back, but there are treatments she hasn’t yet tried and more cancer treatments are being developed every day. “So we just keep plugging at it,” Miller said. “I just live my life day by day and enjoy what I’ve got and the quality of life I have.”
Miller wants to thank Brinkley and Ward, “for never giving up,” adding that they both “treat you like their daughters. They do everything they can to give you the best life that they possibly can and try to solve the problem no matter what it takes and how long it takes.”
“When you win, you win so big”: Surgeon helps patients triumph for over 30 years
Dr. William Ward has been performing orthopedic surgeries for cancer patients since the 1990s. Back then, the prosthetic parts weren’t yet available off-the-shelf for big bone tumor replacement surgeries, so he had to design them individually to fit his patient’s needs. He would work with manufacturers to design parts that would fit – using crayon.
“I would draw out my design in crayon on the patient’s X-ray and send it to the manufacturer, and they would send me a blueprint where the engineer took my drawing and my size markings and reduced it to a blueprint that they could manufacture from,” Ward said. “We’d go back and forth until it was right. Then I'd sign off on it and they'd make it.”
Although the process for designing prosthetic parts has changed and there are now modular systems to custom assemble a prosthesis to fit most patient’s needs, Ward still maintains his creative approach.
“A lot of what I do is not black and white – but that’s also the beauty of what I do, because I spend a lot of time thinking, ‘What is the best thing for this patient in this situation?’" Ward said, adding that “young doctors find diseases fascinating, while old doctors find people fascinating.”
A hot topic in medicine today is “patient autonomy”– including patients in decision-making. Ward said he has always done that.
“My job is to lay out the options, and most people want my recommendation: ‘What would you do if this was you or your family?’” Ward said. “I try to give them that answer, but you have to incorporate their values and get to know people, spend a little time with them, talk to them.”
Ward’s team has helped him achieve every success for his patients, he said, mentioning the vital roles played by Tom Jurrissen, the scrub tech who performs every surgery with him; physician assistants Brad Taylor and Caitlin Sheppard, and nurse Karen Wulf, who provide vital pre- and post-operative care; and Julie Allen, who has provided back office support for his practice for 32 years.
He also singled out other physician assistants Laura Orsban, Russell Davis, and Kathryn Battle, who visit and help care for patients like Miller when they’re in the hospital recovering from surgeries.
“People have asked me, how can you deal with cancer all day? That would be discouraging,” Ward said. “But my mentor back when I was a resident said, ‘Bill, I didn't give them cancer, I just try to help them deal with it.’ That's how I've always thought of it. When you lose, you lose big, but when you win, you win so big – and we usually win.”
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