In Pursuit of Perfection

“Upon what instrument are we two spanned, and what musician holds us in his hands?”

Rainer Maria Rilke

This past week was a very busy yet very interesting time for me.  Early in the week, I had a visit from an old medical school classmate who is now one of our nation’s leading researchers in diabetes and other endocrine diseases.  Although most of his time is spent in the lab, he still prides himself on being an outstanding clinician, and I can attest to that.  I would choose him for my own personal physician any day, were he not based at Duke in Durham, NC.  He told me the following story:  a few months ago he was the attending physician on the endocrine consultation service.  The fellow on duty was called for a consult on a middle aged man who needed an amputation for vascular complications related to his diabetes, and the surgeon needed to make sure his blood sugars were under control before taking him for surgery.  The endocrinology fellow assessed the patient’s insulin requirements, and also mentioned that the man was complaining of some mild upper back pain, which seemed insignificant at the time. The case was presented to my friend, was assessed to be routine, and the patient went to surgery.  Shortly after the operation, the man suffered a cardiac arrest due to a myocardial infarction in the posterior circulation.  He did not survive.  My friend, whose job was NOT to assess the patient’s cardiac status, but rather his diabetic control, is still beating himself up about the patient’s death, many months later.  He insists that he should have asked the surgeon for a cardiac work up prior to the surgery.

On Thursday, I flew to Kalispell, MT to attend my nephew’s graduation from Montana Academy, a boarding school dedicated both to academic excellence, and the therapeutic mission of helping teenagers with problems learn to cope in positive ways. At the graduation ceremony, I was moved to tears several times, first by the headmaster’s recounting of the tale of Odysseus and the Cyclops as an analogy for the importance of finding and declaring one’s true identity, and later by the speeches of some of the parents whose children had benefited from this school, set in the green pastures and foothills of Montana. Finally, and even more importantly, some of the students themselves spoke, hesitating at first and stumbling over their words, but gaining strength from the support of the gathered crowd as well as their teachers, counselors and the founders of the school sitting behind them.  The students spoke of the failures which led them to the academy, each small but increasingly significant success they met there, and their hopes and dreams for the future.  These students were articulate and impressively intelligent. The last student who spoke was particularly moving, when she said, “Here I discovered that I am worthy of love, and that I DESERVE to love and be loved in return.”

We all strive for perfection, and yet for most of us it is our failures which teach us the meaning of life and of being human.  Some of us are lucky enough to learn this at eighteen, but many of us are still learning these lessons at sixty.  Last night, as I prepared for bed a row of necklaces I have hanging from pegs in the bathroom caught my eye—fossil mammoth ivory turned blue from arctic hoarfrost, and set with a fire opal, lapis prayer beads from Bhutan, ancient carnelian beads from the mountains of Nepal, and an old Chinese quartz crystal set in silver with enameled symbols of yin and yang.  I wondered, for myself, for my nephew and for my old friend, what talismans are these which can keep us safe, which can protect us from our own demons?  And what great musician holds us in his hands?  We can only continue to do the very best we can.

For Ellen

“to live in this world

you must be able
to do three things
to love what is mortal;
to hold it

against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go”
Mary Oliver, New and Selected Poems, Vol. 1

As a parent, you are not supposed to have a favorite child, and since some of us physicians feel a strange but kindred protectiveness for our patients, likewise we feel guilty about having favorites.  But we always do. My favorite patient died last night.  On my last day of work, I gave her my email address and my cell phone number, so we could keep in touch.  She gave me a bright red stuffed teddy bear, so that I would always remember my “wild red headed woman from Texas.”  Except that she had no hair–she had grown and lost it so many times over the six years I treated her that even I lost count.  When I retired, I made sure that she had a follow up with one of my colleagues, who I trusted would give her his best opinion and effort in managing her care.  When he saw her in March, he told her there was nothing more he could do.  She signed on to hospice the following week.

She was diagnosed with a rare form of cancer of the uterus nine and a half years ago.  By the time I met her, in 2008, she had already developed lung metastases and had undergone several courses of chemotherapy, none of which had kept the metastases in check for very long.  After a trial of radiofrequency ablation which resulted in a pneumothorax and chest tube, she was referred to me for consideration of stereotactic radiosurgery.  We treated her lung lesions one by one, and one by one they faded into scar tissue.  She was happy and relatively without symptoms until eighteen months ago, when she began to recur in the lung, and brain, and soft tissues of her muscles.  She remained upbeat, larger than life, encouraging the radiation therapists to treat each new lesion as it occurred.  My entire staff looked forward to treating her every time she returned to the department.  We joked about awarding her “frequent flyer miles” and she laughed and her blue eyes sparkled. Her chocolate chip cookies were legendary, and she gave us the recipe, but they never turned out the way they did when she baked them.  We accused her of leaving out a secret ingredient and she protested vigorously.  She said she would never do that.

She traveled a lot in the last year of her life—to visit her children, to see a new grandchild being born.  Her last trip was to New Orleans with her husband, where she looked forward to eating beignets and listening to Dixieland jazz, even though her trip was interrupted by an emergency room visit for shortness of breath. When we parted at the end of February, we promised to keep in touch and get together for lunch or dinner but she had complications from her last course of therapy, or from the cancer itself, and when I heard from her by text and by email, the news was not good.  In her last email, she told me she had joined a gym, determined to try to regain some of her strength. She promised to call when she was feeling better.

She did call me, last weekend, to see if I could have lunch with her and her husband on Thursday.  I missed her call, but I knew I was busy that day, so I called her back to reschedule but she did not pick up the cell phone.  And so I was not surprised when I received the news today that she had passed away last night.  Not surprised, and yet astounded, that such a vital life force had left us.  My entire staff is bereft.

In his email to me and I am sure, countless others who knew and cared about her, her husband included two photographs of her.  In the first one, they are cutting their wedding cake—she in her beautiful white dress with her long flowing red hair and he, handsome in his tuxedo and moustache.  Over thirty years must have passed between the first photo and the second, where she stands alone, healthy, beaming, and holding a yellow rose.  After all, she was from Texas. As I looked at the pictures again this evening, it occurred to me that I knew that the ingredient she poured into those chocolate chip cookies but forgot to write down for the rest of us was love.  Simply and purely, love.

Love in the Time of Cancer

I used to be able to paint my own toenails but that was before age and arthritis caught up with me and these days I can’t SEE my toes, much less paint them.  Here in the land of perpetual sunshine and flip flops one is not allowed to have ugly feet, so off I went today to see a lovely woman who takes care of such things.  Today she was very sad over the end of what had been a promising love affair. He had seemed to have all the “right ingredients”—handsome, slightly older than her but boyish still, owned his own business, long divorced with no pesky baggage such as alimony—for a while she thought he just might be “the one.”  I asked her what happened and she said simply, “Anger issues.”

A couple of months ago, writer and radiation oncologist Dr. Robin Schoenthaler shared with me an essay she wrote in 2009, which I had somehow missed when it went viral over the internet back then.  It is simply titled, “Will He Hold Your Purse?” and here is the link because it is a must-read for any woman seeking a man:  http://www.boston.com/bostonglobe/magazine/articles/2009/10/04/will_he_hold_your_purse/  I thought about that article today as my manicurist, age forty-five and gorgeous but still single described walking away from a relationship that she recognized could be harmful.  And I remembered some of my own stories from the cancer clinic, and I told her one of them.

I recall one couple distinctly, from 2003.  They were both in their eighties, and she had breast cancer. One reason they were so memorable as a long married couple was that he was African American, and she was Caucasian, and back in the 1940’s when they married, two schoolteachers in love, they must have faced nearly insurmountable prejudices and racism.  He was an attractive soft spoken gentleman, with a sweet smile and wiry close cropped gray hair.  She must have never been a great beauty, but time had thinned her hair, and added on pounds, and osteoporosis had twisted her spine. When I saw her after her surgery, she had had a wound infection, and her breast had become misshapen as a result.  He held her hand tightly though out the consultation, and when I left the room so that she could get dressed, he followed me out into the hall and grasped my own hand in both of his. With tears in his eyes, he asked, “Will she be alright?”  I replied, “Yes, she will.  Her cancer was caught at an early stage, and I think she will be fine.”  He sighed with relief, and still holding my hand, he said of his wife, “She is my princess and my queen and my better half and my best friend.  I could never go on without her.  Thank you, Doctor, thank you.”   We walked back into the exam room and he beamed at her.  She blushed as she met his gaze.

I don’t wish for any couple to have to undergo the litmus test of a cancer clinic.  But when my manicurist said to me today, “I don’t think I even believe in love anymore,” I sure wish we had a proxy for that partner who, in Dr. Schoenthaler’s words, “will sit in a cancer clinic waiting room and hold hard onto the purse in his lap.”  That’s the one we want.

A Different Kind of Mask

“I want them to live again to the point where pain becomes art.”

Lawrence Durrell,  “Justine”

I have always loved masks.  Near sighted likely from birth, a fact which was discovered significantly later, I never minded stumbling around our neighborhood on Halloween, my already deficient depth perception further stunted by my Bugs Bunny mask.  To don a mask was a chance to become someone else,  and as I grew older my disguises became more exotic—a gypsy fortune teller with gold hoop earrings in high school, a Turkish harem girl in college.  My imagination, fueled by the old stories of the Venetian Carnivale dating back to 1162, knew no bounds, and I secretly dreamed of a masked ball where I would glide gracefully and soundlessly, recognizing and being recognized by a handsome prince, by touch and scent alone.

 

In 2002 I took the occasion of my daughter’s graduation from high school as an opportunity for us to visit Venice, and more specifically, the mask shop known as La Bottega dei Mascareri at the base of the famous Rialto Bridge where a lively market persists to this day.  Elizabeth Barrett Browning may have been speaking metaphorically when she said, “the soul’s Rialto hath its merchandise,” but I was subject to a more literal interpretation.  I wanted to buy a mask from the famous brothers Sergio and Massimo Boldrin, who fashion papier mache masks in the old Venetian tradition.  I picked out a good one, made by Massimo himself, and given the history it depicts—perfect for a doctor.

 

The mask is larger than my face and flat, hand painted with a crackle glaze to look very old, and it pictures a man in medieval clothing dancing around a bonfire,  wearing the peculiar bird beaked mask known to physicians of the plague years.  The beaks were stuffed with medicinal herbs thought to ward off the dread disease.  In just one scene, the mask depicts the horror of bubonic plague—the bird beaked man, the fire to burn the contaminated bodies and clothing, the “ring around the rosie” cheeks of the afflicted.  With some difficulty, I brought my prize home in a suitcase, only to find that it gave me nightmares.  Today it sits on a bookshelf in the study off our garage.   I can’t have it in the house.

 

My patients with head and neck cancer are all too familiar with the concept of the mask, but for them the mask has a different significance.  Fashioned of a material called Aquaplast, the mask starts as a thick sheet of perforated plastic.  Warmed in a hot water bath, the material becomes soft and pliable, and is stretched over the cancer patient’s head and shoulders where it shape shifts to appear like a woman’s fish net stocking, but without the softness.  The mask hardens to become a rigid immobilization device which is bolted to the treatment table.  In my field, precision is everything and the mask, custom made for each patient, allows the radiation oncologist to accurately target the cancer while sparing critical structures such as the spinal cord and the eyes.  Not for the claustrophobic, the mask is a temporary prison for seven weeks of daily treatment.  At the end of treatment, each patient is offered the opportunity to take his or her own mask home.  Most actually do.

 

Today at the biannual Multidisciplinary Head and Neck Cancer Symposium in Scottsdale, AZ, I saw something quite extraordinary.  In order to assist patients financially with these cancers, an organization out of Washington DC called 911 4 HNC mounted an exhibition called “Courage Unmasked”  (www.courageunmasked.org).  Cookie Kerxton, an artist who was treated for head and neck cancer herself enlisted other artists to transform radiation masks into works of art.  The results, several of which are on exhibit at the meeting, are objects of exceptional beauty, turning human suffering into inspiration and hope for others.

 

At the meeting, volunteers were handing out free posters depicting forty two of these beautiful masks.  When I get home, I will have my poster framed and I will hang it in the room where I examine my head and neck cancer patients.  I am hoping that the bright colors of the beautiful masks will lessen their fear, and transform their pain.  There is indeed great progress in the treatment of their cancers.

The Glass Is Half Full

A couple of weeks ago my nurse came to me with a request for a consultation.  Since our schedule has been packed full lately, she’s been asking me where I can squeeze patients in.  She said, “I’m not sure about this one—he says you treated him twenty years ago and he wants to see you.  But there is no new pathology so I don’t know how urgent it is.”  I looked at the consult request and did not remember the patient but there were several handwritten jottings on the cover sheet from the referring physician that listed phone numbers and beside them, “no answer at this number X 3,” and “Dr. Fielding hasn’t worked here since 2004.”  Apparently some effort was made to track me down, since I have changed jobs a few times in the last twenty years. I said, “Well get the latest information on the patient and put him in the open emergency slot a week from Friday.”

So Friday came yesterday and this patient was scheduled at one o’clock.  I like to review the charts before I see new patients, so I picked up the chart during a hurried lunch and read through it with a growing sense of recognition, and no small amount of dread. The man had been treated for advanced head and neck cancer back in 1994.  He had presented with cancer on the lateral aspect of his tongue, which was excised by his surgeon.  Six months later, he recurred both on the tongue, on the soft palate, and in his neck, with a large tumor wrapped around his jugular vein.  His surgeon tried, even sacrificing the large vein, but he could not resect all of the cancer and the patient was referred to me for post-operative radiation therapy.  Given that the man was only fifty one years old, his medical oncologist made the decision to give him chemotherapy along with the radiation, a decision which was considered quite radical at the time.  Treatments for head and neck cancer back then were crude by today’s standards, and fraught with complications, and this man had had all of them.

By 2000, he could no longer swallow, and his esophagus had to be dilated.  This happened again in 2008, and another procedure provided relief.  His saliva never fully returned after treatment, and so in 2012, plagued with tooth decay, he began a series of extractions, augmented by hyperbaric oxygen therapy to prevent osteoradionecrosis of his mandible.  Unfortunately this did not work, and he ended up having a portion of his jawbone removed.  A year ago, he began to have a new issue—when he tried to swallow the food was going down “the wrong way” and causing him to choke, resulting in several episodes of aspiration pneumonia.  It was becoming hard for him to go out socially, and enjoy a meal with friends and family. His carotid and vertebral arteries were narrowed, putting him at risk for stroke. Multiple recent studies showed no evidence of recurrence of his cancer, but there was scar tissue in the back of the throat which prevented the epiglottis from closing over the trachea when he swallowed.  These were the things I read in his chart before I saw him, and I anticipated that our session together would be an angry one.

Tall, older and thinner than I had last seen him, the patient greeted me with a huge hug.  His wife smiled warmly.  As we sat and talked in our sunny consultation room, he described his current difficulties and told me that his surgeon had referred him back to me for electrical stimulation therapy of the throat muscles, which might help his aspiration.  Our institution has an entire department for the rehabilitation of head and neck cancer patients.  I groped for the right words to say to this man who had suffered through complications which are rare by today’s standards of care.  I apologized profusely, and explained that now we have better ways of shielding normal tissues to spare patients the terrible late effects of treatment.  I told him I would be happy to put in a referral to our swallowing and speech rehabilitation specialists.  He looked at me in surprise, and said, “Doc, I didn’t come here for that.  Dr. M (the surgeon) already put in the referral. When I found out you work here, I came to say thank you.  I was fifty one when I was told that my chances of survival were 10 per cent.  Now I’m seventy one years old.”  He squeezed his wife’s hand and said, “We’ve traveled the world together.  We’ve seen our grandkids graduate high school.  We’re going on a cruise to San Francisco next week.  Yeah, I’ve had my problems but we’re still having fun!”

Some folks are just “the glass is half full” kind of people.  Having always thought of myself as one of them, I’m surprised it took me a whole consultation to recognize that in my patient. Taking care of cancer patients has always been a good way to remind myself that my own life is not so bad.  Lesson learned, again.

The Good Books

Where I come from, when most people refer to The Good Book, they are referring to the Bible.  This is not true for my father, because to him, the Good Books are something else entirely.  He describes a scene early in his career as a plastic surgeon, when he had taken his doting mother to see his new office. Coincidentally, a lovely thank you note had just arrived from one of his patients.  He read it appreciatively and passed it on to my grandmother, so that she could “kvell” over her son the doctor even more, as if that were possible. His secretary, having a penchant for scrapbooking and noticing the mutual positive reinforcement going on, decided that from that day on, when Dad received a thank you note or letter of appreciation, she would put it in a scrapbook, which he anointed as his “Good Book.”  By the time he retired from full time practice at age 75, he had accumulated a series of five very thick Good Books.  And he advised me to do the same.  He said that when he felt tired or depressed, he would read his Good Books and feel revived.

I’ve never been as organized as my father, who keeps meticulous files on everything that interests him, to this day.  Nor, as a young female physician just starting practice in the early 1980’s, did I ever have a secretary that I would DREAM of asking to “scrapbook” for me, much less bring me a cup of coffee.  But I had many appreciative notes from patients, and I read and treasured each one.  I put them in the top drawer of my desk, and would reread them when I came upon them while searching for a highlighter, or a directory of local doctors.  And when I left that particular job, or that particular city, or that particular office, I would read them one more time, remember the patients who wrote, and let them slip into the recycle bin.  There’s only so much you can take with you, apart from the memories.

Exactly two weeks ago, I received a letter at my office addressed to me personally.  The letter originated in Bradenton, FL where I know no one. I did not immediately recognize the name or the return address, but I opened it and read:

“Dear Dr. Fielding:

It has been 25 years since I completed treatment by you for Stage 4 Hodgkin’s Lymphoma.  I came to the Leonard Morse Hospital from Turkey with a tumor in my chest.  I was treated by Dr. Jao and referred to you for radiation therapy.  My treatment included radiation therapy and chemotherapy from November 1987 to October 1988.

I will always remember that when I would meet with you during my radiation therapy I usually felt “lousy.”  You would come into the exam room and tell me I looked great.  Your positive and caring manner always lifted my spirits and renewed my confidence that I would overcome Hodgkins.

I retired in 1995 and have enjoyed good health and my retirement in Florida.  Your caring and medical expertise saved my life and I am forever grateful.  I thank you and wish you a Happy New Year.    Sincerely,  RB.”

The letter was accompanied by a photograph of my patient and his wife, riding gilded carousel horses on a merry-go-round, hands held high to reach for the golden ring.  They appear to be very happy.

I have been thinking a lot lately about retirement myself.   There are places I want to go, people I want to see, and things that I want to do while I am still healthy enough to do them.  When I got home the evening I received that letter, I showed it to my husband who said, “I bet you won’t want to retire now!”  I thought about it for a minute and said, “No, you are very wrong about that. That letter made me cry, but not because I want to continue to do radiation therapy forever.  It made me cry because it made me feel that what I have done since I graduated from medical school in 1978 was worthwhile.  That it MEANT something. That I have not wasted my time.”

To my patients who have taken the time to write over the years—you have no idea how much that means to us doctors.  To my daughter, struggling through a tough internship year in Boston, and to my medical students—stick with it.  Thirty years from now you will be very happy you did, with or without some Good Books of your own.

When Age is a Relative Thing

I remember when I was a medical student and an elderly patient would be admitted to the surgical service through the emergency room with a bowel obstruction, or a lung cancer, or blockage in the coronary arteries so severe that only a coronary bypass could save him.   The students and residents would gather around the attending, and debate the merits of operating on the patient, or “keeping him comfortable”, ensuring certain death.  One of the things I remember hearing, typically from the mouths of those advocating for aggressive management was always, “But he’s a GOOD ninety!”  Meaning, the patient may have been ninety years old, but he looked younger, and had no competing medical problems, and had been living independently and enjoying life.  As I grew in my radiation oncology career, and medical students and residents would debate the same with me, one of the things I always try to remind them is, “There’s nothing like radiation and chemotherapy to turn a GOOD ninety into a BAD ninety really fast.”  It’s the truth.

So when I returned from my mini-vacation at the dog show in Palm Springs at the beginning of last week, the first thing I did was check my schedule to see if any of the patients who were seen in my absence were on the simulation list for treatment planning so I could review their history and physical exams.  I found one unfamiliar name, so I picked up his chart.  It turns out, this man is an 86 year old retired figure skater, still active as an international figure skating judge, who had recently been diagnosed with an early stage intermediate risk prostate cancer, Gleason grade of 3+4=7, PSA of 9.  He had come in under duress to see one of my partners because, you see, he didn’t WANT radiation therapy.  He wanted a prostatectomy.  Now, in my world, and in the world of my referring urologists, 86 year old men do not get prostatectomies, robotic or otherwise.  There is too much risk of fluctuation of blood pressure and bleeding, and consequently heart attack and stroke. Dr. Donald Skinner, retired Chairman of Urology at the University of Southern California used to say, “I won’t even operate on a 70 year old man, unless he brings his 90 year old father to the consultation with him.”  This patient’s choices were watchful waiting, now known as “active surveillance”, hormonal therapy, or radiation.  After a long discussion with my partner, he chose radiation therapy.

When I walked in the exam room to get the patient to sign a consent before we started, I was fully prepared to try to convince him that at his age, it wasn’t likely to make a difference in his overall life span to be treated for this early stage prostate cancer.  What I wasn’t prepared for was a man who looked twenty years younger than his stated age, in great condition, holding hands with his equally attractive wife, also a retired skater.  My speech about the treatment being unnecessary “at your age” went unsaid.  Instead, I gawked and said, “Ice dancing or pairs?”  From then the discussion veered from the upcoming Winter Olympics, and then to the fact that he grew up in Seattle and came to San Diego on vacation, whereupon he discovered that there was a place where it didn’t rain every day and decided to stay. He was twenty when he met his fifteen year old bride to be at a skating rink in Orange County.  He was tall, with an elegant physique. She was petite and a beginner. He smiled at her as he told me the story of the “best pick up line EVER!”  He found himself next to her at the edge of the rink and said, “What are you doing there, standing in a HOLE?”

Perhaps it was not the best pick up line ever. But his vivacity, vitality and joie de vivre certainly bought him a definitive course of intensity modulated radiation therapy.  After all, he’s a GOOD eighty six.

Curmudgeonly Me

I didn’t like my flu shot very much this year.  Some years they hurt worse than others, and I haven’t yet figured out whether that depends on which nurse gives me the shot, or which strain I am being vaccinated against.  This year was a bad one—within 24 hours my arm was so sore that I couldn’t raise it above my head.  I received it on a Friday and with it, my little sticky badge to be placed on my hospital ID that proudly proclaims me duly vaccinated and safe to see patients. The next day I left on a Southwest flight to Albuquerque.  It is rare that I ever check luggage these days, after an unfortunate mishap in 2006 when my family ended up in New Haven, CT for my daughter’s college graduation, but our luggage went to Florida. As I hoisted my own suitcase into the overhead rack, I felt an acute twinge in my shoulder anteriorly in the region of the biceps tendon, same side as the flu shot.  By that evening, I couldn’t sleep because of the pain, and two months later, it still hurts. My husband says it was a coincidence.  I am not so sure, but I have no choice in the matter.  If I want to keep working, and seeing patients, an annual flu shot is mandatory.

This past Friday through Sunday I was in Palm Springs, CA for the Palm Springs Kennel Club dog show.  For those of us who show dogs, this is one of the biggest shows of the year, the “kick off” to the dog show season, and the prelude to the Westminster Kennel Club show in February.  If you win at Palm Springs, there is a very high likelihood that you will be winning at Madison Square Garden.  Or so they say, because I don’t travel in those rarified circles.  Still, many of my friends were slated to show their deerhounds, and even though I didn’t have any puppies to show, or adults who haven’t finished their championships, I had nothing else to do so I hopped in the car for the two hour drive on Thursday night, leaving my own dogs at home.  Dog shows are ever so much more fun when you don’t have to walk, feed, bathe or groom your own dogs.  I was there to have fun, and maybe do a little shopping at the big outlet mall at Cabazon.

My friend and oft traveling companion Rachel had delivered the last puppy from her recent litter to a woman in Texas who had just lost her own deerhound to osteosarcoma a few days before the Palm Springs show.  By Monday of the show week, Rachel complained of a sore throat and upper respiratory congestion.  She really should have skipped Palm Springs, but she’s a tough one, Rachel, so on Thursday early she loaded two dogs in her car and headed from Arizona to California.  By the time she arrived in Palm Springs, she had a severe cough, fevers, shaking chills, a headache and muscle aches so bad that she couldn’t stand for very long.  I arrived after she did and brought her four bottles of water, which she managed to keep down, but she couldn’t eat anything—the masseter muscles in her jaw hurt too bad.  I said, “Rachel, did you get a flu shot this year?”  I had just seen the television reports Thursday that H1N1 flu was at epidemic proportions in Texas.  She said “No, I never get flu shots.  They make me sick.” By Friday she was feeling faint, and barely managed to get around the ring with two dogs.  One of her puppy owners lives near the show site, and she insisted that I drive her to visit the nice man and his puppy.  Midway through the visit, she turned pale, broke into a sweat and I rushed her back to the motel to see if I could get her rehydrated and some food into her.  As she wiped her brow with her forearm, before making an emergency bathroom stop, she said, “I’ve never been this sick in my entire life.”

Bingo.  That’s the flu.  All these folks who go around with the sniffles saying, “I’ve got the flu” or when your co-worker says, “I spent the weekend goin’ and throwin’—I had the flu”—that’s not the flu.  That’s a cold, or a GI bug, or “I want to take a sick day.”  But when your friend who has served time in the Army and who has driven an 18 wheeler cross country professionally says to you, “I’ve never been this sick in my life”—now, THAT’s the flu, as in influenza.  Get your flu shots folks.  There’s still time if you’re not sick yet.  Don’t delay, because I won’t be around to nurse you through it.  I wear my “flu shot” badge proudly, and hope that my shoulder isn’t still hurting in the spring.

Primum Non Nocere

I don’t have much in the way of eyebrows.  They were victims of too much plucking back in the 1960’s and when you do that, sometimes they don’t grow back.  There’s a very nice woman in Solana Beach who shapes and darkens what I have left, infrequently, when I bother to think about it which isn’t very often.  I was in there about a year ago when she told me, “I won’t be at work for the next six weeks or so—I’m having some surgery.”  Never shy when it comes to these issues, I asked, “What kind of surgery?”  She said, a little too casually, “I’m having double mastectomies and latissimus flap reconstructions.”  I said, “Why are you doing that?”  She said, “Because I was diagnosed with ductal carcinoma in situ on the left, and I just want them both OFF.”  Ductal carcinoma in situ is what we call Stage Zero breast cancer—non life-threatening, but it does need to be treated because in some cases it can progress to invasive breast cancer.  Treatment options range from excision only, to excision plus radiation, to simple mastectomy for more extensive cases.  In NO case, unless the patient carries the breast cancer gene, BRCA 1 or 2, as Angelina Jolie did, is bilateral mastectomy the recommended treatment.

Again, I said to this nice forty year old woman with no family history of breast cancer, “Did you at least SEE a radiation oncologist for an opinion?  This is what I do for a living, you know.”  She said, “No, I did not.  My surgeon drew me pictures of the procedures, and he said I’d be back at work within a few weeks. This is what I want.  I have a six year old son.  I do not want to die of breast cancer.”  Her mind was made up.  In situations like this, I may offer an unsolicited opinion, but here my opinion was clearly not wanted.  This was the right choice for her.  It’s what she needed for “peace of mind,” and I was not going to stand in her way.  She had her bilateral mastectomies, and her reconstructions, and true to her surgeon’s word, she was back at work within six weeks.  She was very pleased with, and relieved by her outcome.

There are a couple of problems with this scenario.  First of all, my breast cancer treating colleagues and I have noted a somewhat alarming rise in the rate of double mastectomies for unilateral breast cancer in non BRCA positive patients.  The rationale for this is typically, “I want to do everything I can to reduce the chance of the breast cancer coming back”, but sometimes it’s “I want a matched set!”  What patients are often failing to realize, and are being failed by their physicians in terms of their education, is that the biggest risk they have of actually dying is from the breast cancer they already HAVE, not the breast cancer they might be diagnosed with in the future.  Once a woman has been diagnosed and treated for breast cancer, the risk of developing a contralateral breast cancer is about 1% per year, and the vigilance is stepped up accordingly—mammograms are no longer designated as “screening” but rather as “diagnostic”, and MRI’s are more frequently covered by insurance, not to mention the frequent blood work and body scans obtained in more advanced cases.

Second, prophylactic mastectomy and breast reconstruction is neither risk free nor does it often result in a “perfect breast”.  Infections can occur, implants can be extruded, flaps can fail, and even if none of these things happen, the resulting reconstructed breast is insensate—in other words, it doesn’t FEEL like a breast to the woman who is wearing it.  Even in a skin sparing, nipple sparing mastectomy, the nerve endings are cut.  If an abdominal flap is used, the abdominal musculature is compromised—important for women who are athletic and need these muscles.  The same goes for a latissimus flap.  Not to mention the fact that many woman who are diagnosed with breast cancer are still of childbearing age and many still plan to have children.  One can breast feed an infant with one breast, but not with bilateral mastectomies and reconstructions.

So if you have been diagnosed with breast cancer, please think long and hard about your treatment options and about what the goal is, which is to obtain local control of the cancer typically by either removing the breast, or by having lumpectomy and radiation therapy.  The “peace of mind” obtained by removing the opposite healthy breast in a BRCA negative patient is not only just a pleasant mythology, but is also potentially dangerous, putting a patient at risk for complications when she needs to be healing and considering the adjuvant therapy, whether that be hormonal therapy or chemotherapy or radiation to the chest wall or affected breast, which will truly reduce her risk of recurrence and extend her life.  And we physicians need to remember that principle of “Primum non nocere”—First, do no harm.  We don’t remove other paired organs just because one is diseased, and we shouldn’t be doing it with breasts either.  In my opinion, of course!

Happy Birthday To Me

Ex-marines are some of the toughest patients I ever see, when it comes to dealing with pain from cancer.  And CAREER ex-Marines have the market cornered on toughness.  Take for example, an elderly friend in Kansas who woke up one morning with severe upper back pain, feeling faint, and decided as was his Marine Corps habit that a cold shower would be “just the thing.”   The cold shower likely saved his life, since he was quite hypothermic when the ambulance arrived to take him to emergency surgery for his dissecting aortic aneurysm.  Three months ago when I saw a new patient, a seventy year old former Marine, shifting uncomfortably from his chair to his feet and back to his chair, grimacing with pain, I knew it was serious.

This patient had undergone a radical cystectomy for bladder cancer eighteen months prior.  In layman’s terms, his bladder had been removed and a portion of his bowel refashioned into a conduit to carry the urine outside his body into a bag.  This he bore with no complaint.  After all, Marines adjust.  But a year later he began to have severe low back pain.  His physicians treated him in the usual prescribed manner—physical therapy and anti-inflammatory drugs.  When his pain grew progressively worse, they ordered an MRI of his lumbar spine which was negative, and he was prescribed narcotics.  Unfortunately, when you order an MRI of the lumbar spine, you do not routinely get views of the pelvis.  Finally, he presented to the emergency room with intractable pain and a pelvic X-ray was obtained.  Much to the shock of the ER crew, half of his sacrum was gone, destroyed by recurrent bladder cancer that had invaded bone.  That’s when he was referred to me.

I treated this patient with intensity modulated radiation therapy, in order to deliver the highest dose possible while sparing as much bowel as possible.  He had a very difficult course of treatment—his appetite was poor and he lost twenty pounds; he developed a urinary tract infection which landed him in the hospital; he had diarrhea from the radiation and the chemotherapy which was given along with it; and finally he developed moist desquamation of the skin just over the palpable mass in the right sacrum.  He finished his therapy, but just barely.  I wasn’t sure I would see him again, but I didn’t want his wife to know that I had little faith, so we scheduled him for a six week follow up.

This was a tough week at work.  On Tuesday one of my breast cancer patients was diagnosed with a brain metastasis at age 37, and another breast cancer patient, a lovely elderly woman, suffered a pathologic fracture of her hip from a bone metastasis. By yesterday, I was strongly contemplating calling in sick when I wasn’t for the first time in my life.  After all, today was my sixtieth birthday and I had had quite enough of sadness for one week.  But I didn’t–I came to work this morning to a fully booked schedule of follow ups and my ex-Marine was my last patient of the day. I was pretty certain he would be a “no-show.”  I should have known better.

The man that I had known previously in a wheelchair, disoriented from his pain medications, came in with a spring in his step, color in his cheeks and his wife and sister in law in tow.  He gave me a huge bear hug, and proudly unveiled his behind to show me how nicely his skin had healed. He told me that he was nearly completely off of his pain medicines, and that he felt so much better that last night he had shot a game of pool. He said he was looking forward to Christmas, and to a better year next year.  He told me that the medical oncologist had ordered a follow up MRI of the pelvis, but he was going to wait until after the first of the year—he knew that his respite from pain was a gift horse whose mouth did not need an examination.

I got some very nice birthday presents this year and I appreciate each and every one of them.  But sometimes, for the doctor, the best present of all is seeing her sickest patients feel better.  Happy Birthday to me!