How Old is Too Old?

Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

I Was Just Checking

WordPress has this little program called “Counterize”, which allows bloggers like me to see how much traffic our sites have, and which “pages” are viewed the most.  Every so often, I like to check the stats so I can figure out which of my essays are the most popular.  You know—so I can play to the fan base and that sort of thing.

Lately, the number one and two spots for all time Crab Diaries most viewed pages are, drum roll please, “The Things They Put On Their Skin”, followed by “He Was Just Lucky.”

Well at least I know what MY readership is interested in!  On the other hand, what do I expect, having titled this The Crab Diaries.  Perhaps I need to rethink…..

What Comes Next?

Multi-tasking has never been my forte and so I like to keep my schedule organized.  Mondays, I see all of my on-treatment patients.  Tuesdays and Thursdays I see new patients in consultation.  Wednesdays are reserved for treatment planning and research projects.  But Fridays—well, Fridays are usually the best day of the week.  Not only is the weekend approaching, with time to spend on my menagerie and the ever present home improvement projects, but on Fridays I see my follow up patients.  Nothing is more gratifying than seeing a patient who was near death from a locally advanced head and neck cancer a year ago leading a normal life now, back at work, and grateful not only to be free of disease, but also for the excuse to leave work early on a Friday afternoon for a follow up visit.  Together we’ve shared many a TGIF moment!

Sometimes, however, the first follow up visit that a patient makes is not such a cheerful encounter. Yesterday was such a moment.  A young breast cancer patient came in for her first follow up a month after completing all treatment for her early stage, but high risk breast cancer—she had her lumpectomy and sentinel lymph node dissection, followed by four rounds of dose intensive chemotherapy, and finally, her radiation therapy to the breast. She is a beautiful young woman, and despite her hair loss from the chemotherapy, her presence and broad smile lit up the radiation therapy department every day when she came in for treatment.  But when she arrived yesterday, something had changed.   Despite her artfully sculpted short fringe of hair, her colorful bangle earrings and her pretty red lipstick, she answered my nurse’s questions with terse replies, fighting back tears.  When I entered the exam room, the floodgates opened.  I was horrified, took her in my arms and said, “What has happened?  What is the matter?”  Through her tears she managed to blurt out, “I just don’t know what comes next!”

There have been many scientific papers written on the phenomenon of depression post cancer treatment, mostly relating the depression to physical symptoms such as fatigue and other side effects of treatment. I know that there is a different reason because I see it at least once every Friday.  Cancer, especially those like breast cancer and head and neck cancer which require multimodal treatments, is a disease that keeps you busy.  Once the diagnosis has been made, and the treatment plan is laid out, the patient has a new career.  Just as with any other job, there is new terminology to be learned, new orders to follow, and new sensations, both emotional and physical to experience and cope with.  People are surprisingly resilient—after the initial anger and “woe is me” moments, most patients get their game on.  They take care of their incisions, they appear for their blood work, they shore up their reading material and their support systems for their chemotherapy, and they organize their schedules around their daily radiation treatments.  In short, they put one foot in front of the other, one day at a time, and they count the days until their treatment will end (and trust me, never argue with a patient who tells you they have only 12 more radiation treatments when you think they have thirteen—the patient is ALWAYS right!)

The hard part is when the treatment ends.  Fears that have been shoved deep under while the patient is so busy just getting through each day of treatment surface with a vengeance.  The demons of what might have been, and what might yet be creep through the doorjambs and windowsills of dreams.  For patients who overcame the shock of their diagnosis, and who battled through the side effects of their treatment—this is their time for pause, contemplation, realization and reaction.  And when it happens, I tell patients that there is only one thing to do and that is to seek professional help. Cancer is a life changing event. Denial only carries us so far.  Caring for the emotional needs of a cancer patient is not easy, and cannot always be managed by a spouse, a parent, a child or a well-meaning best friend.  When this happens to my patients—when they fall into this post treatment abyss– I tell them to get the help they need, even if it requires antidepressant medication.  This, even more than the treatment that I have offered, can be life-saving.  There is no shame in it.  From what I have seen, lux ex tenebris.  Whatever comes next, come what may.

Nurses Talk

I think you all know how I feel about nurses now.  If not, go back through the archives of this blog and read my essay “Nurse!”  My patients and I have been supported throughout my career by some of the finest people on the planet, my oncology nurses.  As a medical student, as an intern and resident in internal medicine, and as a radiation oncologist, nurses have saved my neck and my ass as often as they have saved my patients’ lives.  “Advice to New Interns From a Nurse Turned Medical Student” http://www.kevinmd.com/blog/2011/07/advice-interns-nurse-turned-medical-student.html  should be required reading for any new medical school grad starting an internship.

Now it is my turn to help out.  An innovative new talk show has been created, aimed at raising the level of the public understanding of important medical issues from the perspective of nursing experts, educators and front line practitioners.   The show is entitled “Nurses Talk” and three TV quality episodes have been produced along with a trailer which can be viewed on their YouTube channel via their website www.nursestalk.com .  If you are as tired as I am of the talking doctor heads on network tv (and no offense meant, Dr. Oz and Dr. Phil!) have a look and if you like what you see as much as I do, please contribute to the campaign to keep this great effort going.  For more information, and for a way to contribute, go to http://www.indiegogo.com/Nurses-Talk-Real-Perspectives-from-Real-Nurses . Time is running out for funding.   Thank you, and back to my regular programming soon!  Miranda.

Really, It’s Not About the Bike

“This is my body, and I can do whatever I want to it. I can push it; study it; tweak it; listen to it. Everybody wants to know what I am on. What am I on? I am on my bike busting my ass six hours a day; what are YOU on?”    Lance Armstrong

When Lance Armstrong dumped his wife Kristin Richard, who had stood by him throughout his cancer ordeal, for Cheryl Crow in 2003, I was not amused. Apparently I had not heard that being cured of cancer gives a person a free pass to cheat on his spouse.  Just call me old fashioned.  I began to have my suspicions that perhaps Lance wasn’t the nicest guy in the world.  Those ubiquitous yellow Livestrong bracelets made me slightly queasy, but heck, he was raising a boatload of money for cancer, especially for a cancer that no one dared speak its name.  I didn’t buy his memoir, It’s Not About the Bike, when it was first published in 2001.  Generally speaking, I feel the same way about cancer books as I do about cancer movies—I give at the office.  But one day, one of my patients was just finishing the book as he waited for me for his weekly on treatment visit.  I asked him how he liked the book, and he raved about it.  Then he gave it to me, so I read it.

As I said, I didn’t think Lance was the nicest guy in the world, but I didn’t think he was stupid.  At least, not until I read the book.  Apparently this grown man went around with a testicle the size of a grapefruit for nearly a year, thinking it was just from bruising himself on the bike seat. Then one day, while in the bathroom of his beautiful home in Austin, Texas, he coughed up blood into the sink.  This actually alarmed him.  He called his best friend and neighbor, who just happened to be a doctor.  In all fairness, the good doctor and good friend did not KNOW that Lance had a testicle the size of a grapefruit.  He diagnosed a sinus infection.  Lance was very relieved.  It wasn’t until he had a blinding headache from his brain metastases that he finally sought medical attention and learned that he had Stage IV testicular cancer.  After undergoing removal of the diseased testicle, he underwent chemotherapy at Indiana University by Dr. Lawrence Einhorn, who had pioneered curative chemotherapeutic regimens for late stage testicular cancer.  Following chemotherapy, he had what was left of his brain tumors removed surgically to complete his treatment.  Miraculously, in 1999 he came back to cycling to win his third Tour de France by over seven minutes.

Rumors of doping in the rarefied world of competitive cycling abound.  Floyd Landis was stripped of his 2006 Tour de France title after he tested positive for performance enhancing drugs, and began to systematically name his teammates who also doped.  Misery does love company.  Lance Armstrong was one of those teammates who got the Landis finger point.  In late October, despite his protestations of innocence, Lance Armstrong was stripped of all of his Tour de France titles, and other dishonors followed.  Still, those of us who spend our lives caring for cancer patients were not convinced of his malfeasance.  J. Leonard Lichtenfield, deputy Chief Medical Officer of the American Cancer Society wrote back in October: “Let us never forget that for me and the many others he has impacted through his accomplishments on behalf of cancer survivors worldwide, Lance Armstrong will always be a hero.”  I may have had misgivings, but I “liked” that on Facebook. And then, finally, there was Oprah.  On January 13, Oprah Winfrey asked if Lance took banned substances.  He said, “Yes.” She asked, “Was one of those substances EPO?” “Yes.” Did he do blood doping and use transfusions? “Yes.” Did he use testosterone, cortisone and human growth hormone?  “Yes.”

EPO, or erythropoietin, increases the red blood cell volume, thus increasing the oxygen carrying capacity of the blood.  It also is now known to be associated with a higher risk of cancer treatment failure when given to cancer patients.  Testosterone is known to fuel prostate cancer growth.  Human growth hormone is still a huge unknown—now being used to improve the height of kids with short stature, there are concerns that a possible side effect could be tumor induction later on in life.   In the end, it was Oprah Winfrey who elicited Lance Armstrong’s fall from grace.  And in the end, hearing about what he was ingesting and injecting after a stupendous victory over advanced testicular cancer, I can only conclude one thing:  Lance Armstrong is really, REALLY stupid.

This Be The Verse

 “Children begin by loving their parents; as they grow older they judge them; sometimes they forgive them.”   Oscar Wilde

 

I buried my mother on January tenth.  After a long struggle with dementia, she passed away in her sleep.  In the end, my father was too ill to attend a funeral service, so my sister and I had a small graveside ceremony in Aspen, Colorado where they have lived, loved, laughed and played for the last twenty five years.  She was buried according to the Orthodox Jewish tradition in which she grew up– wrapped in a burial shroud in a plain pine box.  This is the way that it is done—there are no fancy garments, no treasured jewelry, no viewing of the body and no silk lined coffin reinforced with steel.  Ashes to ashes, dust to dust, according to the Old Testament.   There is no headstone placed at the time of the funeral; that comes a year later, after God has had plenty of time to judge the deceased, to decide which way they should go.  Sadly, I had passed judgment long ago.  And yet, the sight of my mother’s tiny coffin (always a tiny woman, no more than ninety pounds when she died) being lowered into the grave next to my dead brother was almost more than I could bear.

I don’t do funerals well and I never will.  Despite the fact that I am very good at writing eulogies, I cannot and do not deliver them.  I told my younger sister this ahead of time:  “I don’t do funerals. You will have to speak.”  She asked me why.  I explained to the best of my ability that it has to do with the work I do in my everyday life as a radiation oncologist.  Most of the time, I am able to submerge those feelings of grief and sadness at what my patients and their families are going through and my rage at the unfairness of it all.  I shove it right under, bury it deep, don’t think about it and don’t dwell on it.  But going to a funeral, and generally speaking, I do not attend patients’ funerals for this reason, all of the emotions like oxygen starved divers push their way right to the surface, gasp for air, take a deep breath and come pouring out in an uncontrollable torrent.  The ghosts of every patient that I ever cared for and cared about surround me—they grasp for my hands and my legs, they perch on my shoulders and they whisper in my ear, “Let it go.  Let it all out.”  And I do.

I never got along with my mother.  I can say it now.  As an adult, I began to understand who she was, and why she was the way she was, and that in her own way, she loved me and I of course loved her.  I can even laugh about it, in my better moments—in the last lucid phone message she left me, she threatened to disown me and write me and my three children out of her will.  Actually, it was only two of my three children—there was one who was spared her wrath.  I saved that message on my cell phone for two years, and sometimes I would replay it just to hear her voice again, after she had become mute. Then one day I accidentally erased the message.  It’s just as well.  There are better memories of better days.

As my mother was lowered into her grave, I whispered, “I forgive you.” Rest in peace, Mom.

RITA SILVER SPIRA, September 11, 1931–January 7, 2013

No Fear of Flying

Written January 6, 2013

The wake-up call this morning came at 3:45 am.  Ecuadorian standards dictate that international travelers must arrive at check in three hours before flight time in order that the luggage can be thoroughly searched for illicit drugs. Apparently, from the condition of my suitcase, this involves peeking at my underwear.  This meant that we needed to be packed, caffeinated and bused to the airport by 5 am for our eight o’clock flight.  And I am NOT a morning person.  I am currently somewhere over Central America en route to Miami.  In Miami we will pass through customs before boarding a flight to Dallas/Ft. Worth.  After another layover we change planes for our flight to San Diego.  I expect we will be home by midnight or a little later, twenty hours after departing from Guayaquil and forty two hours out from San Cristobal, The Galapagos.

While I am not as unreservedly enthusiastic about air travel as we all used to be, I have no fear of flying.  I attribute my confidence in the air to a recurring dream that I have had ever since I was a teenager.  In my dreams, I am a passenger on a plane which crashes.  Each time I dream of air travel, I dream of a plane crash, and each time, I survive.  The circumstances of the dream change every time I have it.  In one iteration, the plane collides with the sheer walled side of a mountain, coming to rest on a narrow ledge which I must traverse in order to survive.  I am afraid of heights.  In another, the plane comes to a gentler rest on a four lane highway in the midst of a hilly green country, its wings rising and falling as we glide to a stop.  In another dream, the pilot is forced to ditch us over open water. My clothes weigh me down heavily, but for once, I am grateful to be an excellent swimmer.

In my fourth year of medical school I became friends with a man who is now a professional artist and photographer, Neelon Crawford.  He honored me with a gift of a black and white photograph taken through the window of an old DC-10.  The picture reveals the airplane’s wing, sleek as a seal, yet blackened with dirt tracking sooty streamers from the rivets.  The day I got the photo back from the framer, I wrote in my journal, “An airplane wing is a glorious thing.”  Despite the inconveniences of air travel, I still believe that.  And if this plane suddenly plummets from the sky, come find me.  I’ll be the one smiling on the way down.  As I said, I always survive.

I’ll get back to writing about cancer soon!

My Brother-in-Law

A few weeks ago, my brother-in-law resigned his subscription to my blog.  Since I am notified when this happens, I grew immediately concerned that I had said something to offend him.  I called my sister in New Jersey to ask her.  She said, “No, of course not!  He’s been really busy at work catching up since the hurricane and he just feels so guilty if he doesn’t have time to read it so I told him he could sign on to the website and read it when he has time.” (Have I mentioned we are Jewish?  Guilt is our middle name.)  I was very relieved.  On our trip to the Galapagos, my brother-in-law said to me, “Write something about me!”  I said, “If I do, you’ll have to re-subscribe.”

So here it is.  Of the eight family members on this trip, my brother-in-law was the only one who did not miss a single activity.  He was up at dawn; he hiked, he swam, he snorkeled, he biked, and he toured. As the rest of us were flagging at the end of the afternoon, he hit the gym.  Perched on the recumbent cycle he exclaimed, “Miranda, come do this with me!  You’ll see, it is SO good for you, even if you only do it for ten minutes.” My rolling eyes did not dampen his enthusiasm.  After his hike, his swim, his snorkel, his kayak and his workout, he hit the buffet table with a zest equaled only by my own.  He was completely unstoppable.

But these are not the most important things. What struck me for the first time about my brother-in-law, this being the first time in years that I have traveled with him, was his genuine concern and interest in his fellow travelers, the crew and staff of the boat, and the people we met on the islands that we visited.  No question went unasked, no person was ignored or neglected and every child was vigorously encouraged.  By the end of the trip, this man should have certainly won an award for Mr. Congeniality, if such an award had been offered.  In a land of exotic creatures, he was clearly and irrefutably the most human of them all.  This one’s for you Michael!

There Comes a Time

Written while returning from my Galapagos trip, posting now.

It’s happening—the moment that we all dread as we age, that point in time where we realize that we are becoming our parents.  When I was a child, my father was a busy man, completing his residency in plastic surgery, establishing a practice, climbing the academic ladder.  He didn’t have much spare time for us kids, but occasionally he would make an effort to take us on an outing—the circus perhaps, or the zoo.  On those outings, I remember one thing above all.  As we walked along beside and behind him, he would methodically point out every physical imperfection he could see on passersby—a bulbous nose here, a weak chin there, a jagged scar perched on an otherwise perfect cheek or a poorly repaired cleft lip.  The world of the unbeautiful was his oyster and he knew what to do to fix it.

On our recent trip to the Galapagos Islands, I found myself scanning faces and bodies in a similar fashion, but I am no Pygmalion out to transform the luckless Galatea’s of the world.  What my roving eyes were seeing under that equatorial sun were skin lesions aplenty—a benign nevus here, a senile keratosis there, but then, more importantly, an obvious basal cell carcinoma above the upper lip of one of my fellow explorers.  And then came my dilemma:  do I say something to the hapless traveler?  Can I convey in a casual sentence or two, “By the way Joe, you have a skin cancer on your face.  You should have that looked at when you get home, but don’t worry about it!  It isn’t a melanoma, the life threatening kind of skin cancer.”  What to me is a simple helpful hint might be to my companion a bomb dropped in the middle of that peaceful archipelago.  I took the easy way out.  I exercised my right to remain silent rather than risk ruining his vacation.

There was one incident, however, on a bumpy Zodiac ride from the good ship Endeavor to our first sandy beach landing for snorkeling.  Our naturalist guide Xavier had applied a coating of zinc oxide over his nose and cheeks so thick it looked like Comanche war paint.  Yet still, that greasepaint could not disguise an obvious bump arising from his right malar prominence.  He admitted to me that his doctor in Guayaquil wanted to “cut it off.”  Quickly I motioned for my father and together we performed the first National Geographic skin examination of the tour.  As the zinc oxide was wiped away, simultaneously we crowed, “It’s benign!!!”

A day later, Xavier admitted to me that he was so relieved he called his wife and children on the mainland to tell them the good news.  Have I mentioned that dermatology was a field I strongly considered while in medical school?   Reporting from afield…. Miranda.