The prognosis for John Middleton isn’t good.

The 43-year-old engineer from Asheville, North Carolina, has a type of bile duct cancer hidden inside his liver called cholangiocarcinoma. It’s rare, diagnosed in about 8,000 people each year in the U.S., according to the American Cancer Society.

And it’s deadly. The National Cancer Institute says that just 22% of patients live five years after their diagnosis.

Middleton has maybe 18 months.

“I know we’re not promised tomorrow,” he said, “but I feel like I’m watching a stopwatch that has an expiration on it. It’s very frightening.”

His oncologist, Dr. Martin Palmeri of Messino Cancer Center in Asheville, says Middleton’s best hope is a liver transplant. Middleton has a willing donor: his identical twin brother, James. Middleton, right, with

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