Cancer and AIDS, AIDS and Cancer

Posted on May 2, 2013 by miranda

For Dr. Abraham Verghese, who inspires me.

This evening on the way home from Boston I finished a book that I had started more than a month ago, on my way back from Albuquerque. Well, that is not entirely truthful. I stopped reading on page 408, because if I had kept going everyone on the plane would have seen me cry. I finished it at home a few hours later. The book is called “My Own Country—a Doctor’s Story” by Abraham Verghese. I had read his novel, “Cutting for Stone” last year and wanted to read more. This book, “My Own Country” is autobiographical, detailing the author’s early years after residency and a fellowship in infectious disease in Boston, as doctor caring for the first HIV positive and AIDS patients in rural Tennessee in the early 1980’s, when there was no treatment for the infection, and doctors watched helplessly as each and every patient they cared for died.

I am old enough to be all too familiar with this scenario—in 1982 I was a resident in radiation oncology married to an attending in pulmonology and infectious diseases and we were both seeing the ravages of this disease for which there was yet no blood test, only a constellation of symptoms and opportunistic infections that had heretofore been seen only in the most immunosuppressed cancer patients. It would be a few years before the medical profession figured out the exact mode of transmission, and discovered the retrovirus that caused the illness—and a few more years before the first treatment, the drug AZT was approved. In the meantime, we watched the patients die, and it was not pretty. In lighter moments, I would joke that we were the “fun” couple at the cocktail party—cancer and AIDS, AIDS and cancer. In private, I realized that if I had to choose between one or the other, I would choose cancer. At least most of my patients had a fighting chance. My husband’s, at the time, did not.

Verghese left Tennessee, and a job he loved but which had clearly taken its toll on him personally, in 1989. My husband left his post as the Chief of Pulmonary Medicine at the New England Deaconess Hospital in 1992. If you ask him, he will say it was the lure of the biotech boom, and the promise of stock options and an early retirement. But I think there was another side to it, the side that is difficult for doctors to talk about, that part of the job where each time a patient dies, a little part of the soul of the doctor dies with him. In Boston, the pediatric oncologists at the Jimmy Fund were my heroes—to me, watching children die would be the hardest job of all. The AIDS doctors, before the development of the drug combinations which have turned HIV infection into a chronic disease, had the second hardest job.

I’ve moved around quite a bit in my career—five years here, five years there, Houston, Boston, San Diego. Every five years or so, I start to get a bit restless, and I look for something new, something different. I like to say I need a new challenge. Tonight, finishing Verghese’s book, I realized that he was able to put into words that nagging need for transformation, relocation, and change so I will quote him: “It all happened so suddenly. I left my own country, my beloved Tennessee. Perhaps my perennial migrations, almost hereditary, are a way to avoid loss. With deep roots come great comforts. Yet deep attachments are the hardest to lose. Maybe that is why drifters avoid them.”

For most of us doctors, leaving is easier said than done, for medicine is our own country.

The Waiting

Posted on February 10, 2013 by miranda

“The waiting is the hardest part
Every day you see one more card
You take it on faith, you take it to the heart
The waiting is the hardest part.”
Tom Petty and the Heartbreakers

I’ve never been good at waiting for anything. Instant gratification has been my middle name, and I’ve gotten in lots of trouble because of it. I think that I have improved with age—I am less likely to become apoplectic when the stoplights fail to coordinate to green, or when the driver in front of me creeps along at a snail’s pace, or when the line at the movie theater is longer than I expected, or, God forbid, the line for the heavily buttered newly roasted popcorn AFTER I’ve gained entrance to the theater means that I might miss the opening scene. Knowing that the popcorn is always better than the movie, I wait.
When it comes to my patients, though, the waiting is still unacceptable. We have a rule in my office—a referral MUST be seen within a week of getting the phone call or faxed request—sooner if that patient is in pain, or has symptoms of airway obstruction or spinal cord compression or is bleeding from his cancer. The problem for many of my patients, especially here in Southern California, is that they have often waited far too long already. The paperwork and time and energy spent making phone calls and filling out forms is staggering. Primary care doctors are overwhelmed. Insurance companies are obstinate. It is not uncommon for a patient to have been diagnosed for over a month or longer before they are seen by me.

When we moved here from Massachusetts in 1993, I had already grown accustomed to patients having to wait for treatment. Massachusetts is a “CON” state, meaning “Certificate of Need”. In order to purchase and install new radiation therapy units, which are considered “high tech” and very expensive, one had to petition the state, and undergo scrutiny and a series of tedious hearings held by self-important politicians who clearly never had a close friend or relative with cancer. I remember treating upwards of fifty patients a day on the linear accelerators, and having to triage patients with cancer into urgent, and less urgent cases. Lung cancer and brain cancer first, prostate cancer last, and everything else in between. How does one place a value on a life hanging in the balance?

When I arrived in California in 1993, and joined a private practice, the founder of the practice, Dr. Jack Abrams, who hired me had a very simple philosophy: “See ‘em, sim ‘em and treat ‘em.” Meaning that if we got a call from a referring physician, we were to see the patient within 24-48 hours, perform their simulation, otherwise known as the treatment planning session, the same day or the next, and start their treatment the day after that, or even the same day if necessary. This was SERVICE, defined as I had never seen it defined before. The referring physicians and the patients were very grateful and I am quite certain that this philosophy cured more cancer than the waiting, and the wading through mountains of paperwork.

Jack Abrams is long gone now, but the philosophy of service that he ingrained in me twenty years ago remains. If you are one of my primary care physicians who needs your patient seen TODAY, just call me on the phone. I will stay late and see your patient, and so will my wonderful oncology nurse. My superb chief radiation therapist will do that CT simulation the same day if necessary, and my dedicated physics staff and radiation therapists will stay as long as is necessary to get your patient– no, OUR patient treated. No one will suffer needlessly on our watch. This, I promise. The waiting is the hardest part.

Dedicated to Dr. Jack Abrams—we did not always agree, but you were a fine example of our breed.

Don’t Let Me Talk You Into It

Posted on February 9, 2013 by miranda

When I was young and foolish and just starting out in my career, I found it very hard to take “NO” for an answer. If a patient needed radiation therapy, and he or she didn’t want to have it, I did my very best to talk that patient into it. I have always been a very persuasive person—if I didn’t get the go ahead on the first formal consultation, there would be another, and even another, all gratis, with a few phone calls thrown in between. Every question that could be asked was answered, no stone was left unturned. My waking dream was that if I was good enough at explaining, finally the lights would go on and the patient would understand that really, truly, the recommended treatment would be at the very least beneficial and in the extreme life-saving. The indications for radiation are usually fairly clear—sometimes we treat for a positive margin by pathology after surgical removal of a tumor; sometimes the tumor is curable with radiation alone, or the radiation option is less risky for a patient than a surgical option; sometimes radiation therapy is simply the best option for palliation of symptoms. There have been very few, if any times in my professional life when I have seen a patient with cancer, and I say, “By the way, radiation therapy is optional—take it or leave it.”

Gradually, however, over the course of a long career I have been rethinking my strategy of talking patients into treatment. Why? Because it has become clear to me that the patients who I work the hardest to convince to get their therapy are the unhappiest patients I have. These are the patients that, when having their breast treated, ask to see me on the second day and point to a rash on their leg, and say to me accusingly, “You told me THIS wouldn’t happen until the third week!” When I explain that the rash on their calf has nothing whatsoever to do with the radiation aimed at their breast, they roll their eyes in disbelief. I have come to realize that when reluctant participants are undergoing radiation therapy, everything that happens to them during the course of treatment (and for the rest of their lives in many cases) is the result of the evil X-rays. Of course there are genuine complications of radiation, but losing one’s sex drive after having a skin cancer on the scalp treated, or developing a hemorrhoid after treatment of a lung cancer, or the breakup of a marriage after the life threatening illness of a spouse are not on the list. It has to be the same body part that was treated—that’s how radiation works. It’s all local.

Last week I saw a new patient, a genuinely lovely and intelligent woman of 70 years, who was diagnosed with breast cancer five years ago. She had had a lumpectomy and a sentinel node dissection, and fortunately her cancer was found at Stage I. But when it came to completing her breast cancer treatment, which included radiation to the breast followed by anti-estrogen hormonal therapy, she refused, despite the fact that her surgeon and medical oncologist argued strongly that she was depriving herself of standard-of-care management. She stated back then, and again last week, “I will not do anything which will affect my quality of life.” When she recurred, the tumor came back in the axillary lymph nodes, and the surgeon had a difficult time removing the nodes due to her previous axillary surgery, and microscopic disease was certainly left behind. To have taken more tissue would have been to risk nerve damage and certain lymphedema. So she was sent to me for radiation. And, just like five years ago, despite the fact that we covered all side effects, risks and benefits during our 90 minute consultation, and she agreed to treatment, she now is once again questioning what the radiation may do to her quality of life. Yesterday evening I called her on the phone at her request, to attempt to allay some of her fears. I felt myself slipping into my old habits of persuasion, and I stopped. I said to my patient, “You can have five weeks of fairly simple treatment now, or you can wait until you have another recurrence, and require additional surgery and a higher dose of radiation. Which quality of life is worse? Which will give you greater piece of mind? You decide. Don’t let me talk you into it.”

Really—don’t let me talk you into it.

What Comes Next?

Posted on January 27, 2013 by miranda

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.

I Coulda Been a Contender

Posted on November 30, 2012 by miranda

It happened again today. A youngish man, age 59 (youth being relative these days) comes in for a consultation. His history began eighteen months ago when he started to notice hoarseness. Thinking he had laryngitis, he saw his primary care doctor. He was indeed diagnosed with laryngitis despite the fact that he had not been shouting for his grandson at the local soccer playoffs, nor had he had upper respiratory symptoms such as a snotty nose or a cough or a fever. He was treated with antibiotics, and did not improve. Three weeks later, he saw his doctor with the same complaint and was again given another course of antibiotics. Again, he had no relief, but since he was feeling fine and had no other symptoms, he waited. And waited. Until July when he suddenly became short of breath, especially when lying down. He heard himself wheezing in that position. He was finally referred to an ear, nose and throat specialist who recognized the signs and symptoms of advanced laryngeal cancer and performed a tracheostomy to save his airway, and his life.

When we are young, and in medical school, we are taught an old saying: “When you hear hoofbeats, don’t think of zebras.” In other words, when a patient comes in with a cough, your first line in the differential diagnosis is infection or asthma, not lung cancer. Most breast lumps in young women are cysts, or fibroadenomas, not breast cancer. And when a patient comes in with hoarseness, it’s likely laryngitis, not cancer of the vocal cords, causing airway obstruction and requiring an emergency trach. As a radiation oncologist, I see things a little differently, as in “through a glass, darkly.” When I hear hoofbeats, it’s nearly always a zebra, not a horse. When a patient shows up in my office for a consultation, they’ve already been diagnosed with cancer, many times after being misdiagnosed for months or years with bronchitis, or laryngitis, or cysts, or hemorrhoids. Today my patient was the fourth patient I have seen in as many years whose laryngeal cancer was misdiagnosed as a benign process, ultimately resulting in the need for an emergency tracheostomy. This is because you cannot see laryngeal cancer with a wooden tongue depressor and a flashlight. The Norman Rockwell image of the doctor with the bright light above the exam table, shining into the mirror strapped on to his head, which in turn reflects light on the tiny mirror held to the back of the throat—those are images from the past. Primary care doctors simply do not have the fiberoptic equipment necessary to do a good laryngeal exam today. It’s expensive, and used infrequently. But there is no excuse for not referring a patient with persistent hoarseness to a qualified ENT doctor. It could mean the difference between life and death, or life without a voice, which is no small disability.

As I was completing my internal medicine residency, before I decided to become a radiation oncologist, I had a brief notion to take the LSAT’s and apply to Harvard Law School. Back in those days there were only five or so MD-JD’s in the country, and there was definitely a need for people who had a foot in both corners. In the end, I decided that I didn’t want to give up patient care, as interesting as I found the law, due process, presumed innocence—the whole lot. I opted out and continued my pursuit of medicine. Thirty years later, it occurs to me that I didn’t have the experience or the knowledge back then to have made a good attorney. But now, knowing what I know about the consequences of missing a diagnosis of cancer, I’d make a helluva good malpractice lawyer for the plaintiff. In the words of Marlon Brando, “I coulda been a contender.”

Like a Freight Train

Posted on November 8, 2012 by miranda

Sometimes, you can see cancer coming. What I mean is that when we sign up for that mammogram, or that PSA blood test, there has to be some tiny little part of us that says, “Ok, this time it’s my turn. This time I’m the one who’s going to get the call.” Sometimes the cancer sneaks up on us—that nagging little cough that makes us want to—suddenly and belatedly—quit smoking. Or that little bit of blood in the stool that we’d rather think is a hemorrhoid, or that lump in the neck that doesn’t go away even when our doctor treats us for the strep throat that we know we don’t have. But sometimes, as it happened to my patients yesterday, that cancer hits us like a freight train. Just flattens us and leaves us in fragments, speechless in surprise and terror. And when that train hits, we know in an instant that life will never be the same again.

I had two of the freight train kind of patients yesterday. The first was a man in his 70’s, previously healthy, an avid stamp collector. One day in August, he suddenly had difficulty finding his words. A CT scan done without contrast dye showed no stroke or bleed in his brain, and he was sent home from the emergency room. His wife persisted with the primary care doctor—“My husband is just not right!” she said, and last month an MRI was ordered which revealed a large ugly looking brain tumor, and the patient was taken to surgery. The pathology returned as glioblastoma multiforme, the most aggressive type of brain cancer. He was seen in outpatient oncology clinic by a young neuro-oncologist, just out of his training. By the time the patient came to me, every shred of hope was gone. The man, still having difficulty with his speech, told me that the doctor said that at most, he would live a year, if he chose treatment, a few months if he did not. He said that the doctor told him that the tumor would spread like a spider web over his brain, and that he would lose all function. The patient cried when he told me this.

The second patient was a very fit man in his early sixties, a retired school teacher who had surfed and been a life guard all his life. In July, he had a surfing accident (his wife said, “Can you believe it? He surfed some of the greatest waves in the world and he wiped out in two feet of water here at home.”) He broke his collarbone in three places, which required surgery to repair. His pain got worse however, and he started to have back pain. Spine films showed a compression fracture, also thought to be related to the accident. As this tan, fit, athletic man began to seek more and more narcotics for his pain, an MRI of the spine was obtained, which showed the bones to be brittle and riddled with tumors. Yesterday the biopsy of his sacroiliac area came back positive for multiple myeloma, a disease of plasma cells in the bone marrow which destroys the bones that cultivate it. In an instant, this nice couple’s dreams of a happy retirement were shattered.

When we first moved to the West Coast, I was offered two very different jobs. In one practice, I was to be the person that rotated through six different outpatient facilities, covering the regular doctor’s vacations. I would see the patients for consultation, and perhaps treatment planning, but would never see them through their treatment or in follow up. The other job was a hospital based practice where I would be the director of the department and have longitudinal care of the patients. I chose the second, of course, because being the linear task oriented person that I am, I could not conceive of not seeing each patient through from start to finish to follow up.

I see things differently now, twenty years later. I have a calling in life. I want to be there when that freight train hits. I know I can put the pieces back together, and I know that when that shattered patient leaves my office, for the first time in hours, or days, he will be able to notice the sun shining in our Southern California sky, and taste a faint flavor of salt on the warm breeze flowing from the Pacific. In turn, I will have the deep satisfaction of knowing that I did something good that particular day. And that, actually, is quite enough.

Rethinking heroism

Posted on November 5, 2012 by miranda

For Elly

I have mentioned in previous essays here that I do not treat pediatric patients–that I learned that I don’t have the temperament for it–but I never said why. The meeting in Boston brought back a flood of memories from the early days of my career, and it is time to revisit some of them. Every year my professional organization honors one or two or three of its own, for exceptional lifelong service. This year, Dr. Robert Cassady was one of the honorees. During my residency, he was the Chairman of the Department of Radiation Oncology at Boston Children’s Hospital and I had the good fortune to rotate on his service. He taught me a lot about compassion, and how to approach difficult problems. But one lesson I failed to learn was how to mask my feelings for the good of the patient, and the family.

In 1985, I was asked to see a two year old boy with Stage IV neuroblastoma. This is a malignant tumor which develops from nerve tissue, occurring in infants and children. Most neuroblastomas begin in the abdomen, in the adrenal glands or next to the spinal cord, or in the chest. The disease is most commonly diagnosed before age 5, and the incidence is 1 in 100,000. In most cases, the tumor has already spread when it is first diagnosed. The little boy that I was asked to see had failed numerous rounds of chemotherapy and radiation. There was nothing more that we could do. Somehow, I found myself in the uncomfortable position of telling his young mother that her firstborn child was going to die. She started to cry. And then I started to cry and I could not stop. When Dr. Cassady offered me a job at Boston Children’s a few months later, I declined.

At the meeting, I had time to reconnect with an old friend who had been one of my very first residents. She is an exceptional physician who has had more than her share of tragedies in her own life. Her husband, who was a prominent child psychiatrist, died young leaving her as a single parent with three children including a fifteen month old boy who will never know or remember his father. She has spent her career in New Orleans, and after getting through the nightmare of losing her husband, she had to deal with Hurricane Katrina in 2005, which flooded her department, depriving her of a job, and which completely unhinged her eldest daughter during the formative years of high school. The family was displaced to Florida, their futures uncertain. My friend recovered from these challenges and losses with incredible courage and dignity.

I sat with my friend at dinner last Monday night, as the winds and rain of Hurricane Sandy raged outside our hotel. Her family is doing well now, and to my complete surprise, since she made her own career treating gynecological cancers, she told me that she has become the pre-eminent pediatric radiation oncologist in the great rebuilt and revitalized city of New Orleans. She told me that she loves it—taking care of kids with cancer. I was incredulous—I asked her how she could stand it. She told me that with what she herself has been through, she feels that she can truly help other mothers and children in crisis. The triumphs, in her mind, significantly outweigh the tragedies. She is a “glass half full” kind of person. She is my new hero.

After spending a few days in her company, I have been rethinking pediatric radiation oncology. Maybe, it just takes a little bit of life’s hard knocks to be able to be helpful when the unthinkable occurs. Maybe you just have to be older, to learn that it is indeed possible to “ride on through it .” And maybe, just maybe, we are ALL capable of a lot more than we think we are.

The Things His Father Taught Him

Posted on October 31, 2012 by miranda

If you had asked me before today, I would have told you that I was beyond being inspired by cancer stories. There are so many of them, and I have tried to share the ones that have been most meaningful to me with you. But today was different. Today, Teddy Kennedy Jr. gave the keynote address at ASTRO. For those of you who don’t remember, Teddy Kennedy Jr was twelve years old in 1973, when he was diagnosed with osteosarcoma—bone cancer that was widely considered fatal at the time. Teddy is now Edward, and he is an all grown up cancer survivor who has dedicated his life to health care law. He told endearingly funny jokes and family vignettes as an introduction—he said that in turn of the last century Boston, his grandmother used to go to his great grandfather’s political speeches because back then Irish Catholics couldn’t become doctors or lawyers so they went into politics, and seeing how they were quite “prolific in their ability to multiply” (his words), they succeeded in getting elected. His grandmother was quite adamant that the children and grandchildren not waste their hard earned political clout—they had to DO something with their lives.

Edward Kennedy Jr told us all what it was like to have his father tell him that the doctors were going to remove “part” of his leg. When he asked what part, assuming that it would be the raised red lump on his calf, his father told him that it would be “all of it”—the lower leg beneath the knee. And that when the surgery was over, he would be getting an experimental chemotherapy regimen of high dose methotrexate at the Jimmy Fund, the part of the Dana Farber Cancer Institute in Boston where they treat children. As he put it, this was at an age where having a pimple was a disaster, and having a bald head was unthinkable. He talked about how, as a Kennedy only a few years after the assassination of both his uncle John and his uncle Bobby, he was expected to keep up a façade of being brave. He spoke of what it was like to have people tell him that they “felt sorry for him”. And about how, after the operation, the doctors would come in with their entourages of medical students and residents, and look at his stump, but not at him. And he talked about how his father, Edward Kennedy Sr told him that the biggest obstacles he would face would be the ones he created for himself. His leg was amputated in November. He was skiing again by March. His father died in 2009 of a malignant brain tumor. By then, he was called “the Lion” of the United States Senate.

The last part of Edward Juniors talk was about survivorship. He reminded us that it is okay to be sad and to feel loss when diagnosed with cancer, and of the importance of aftercare for psychosocial and emotional issues. He talked about the fact that when a person with cancer leaves my care, and the care of the surgeon and the medical oncologist, that person becomes a person with a pre-existing illness. He spoke about Obamacare, and what this legislation has done for people with cancer. He called it a godsend. Insurance companies can NO LONGER deny a cancer patient coverage because of their pre-existing condition. They cannot drop that person, or charge outrageous sums. They cannot deny that person access to potentially life saving clinical trials. He spoke of the birth of his daughter eighteen years ago, and how that event was the culmination of everything he thought would never happen to him and how grateful he feels, to this day, to the physicians who treated him.

One in four of us will get cancer. And many of us will die from it. Do we want to be cancer victims? Or cancer survivors? Do we want to help those less medically fortunate than ourselves, or not? It is time to decide.

Table for One

Posted on October 26, 2012 by miranda

We’ve been very busy lately, and so it was 6:30 this evening before the last patient was escorted to the linear accelerator to be treated. She had had a compression fracture of a lumbar vertebra last week due to metastatic breast cancer, and had been in excruciating pain despite a procedure called a vertebroplasty, where cement had been injected into the crumbling bone to shore it up. When that gave her no relief, and her doctors were concerned about impending spinal cord compression, she was referred to me. Despite the already packed schedule, what could we do except get her planned and treated as an add on at the end of the day? The alternative of paralysis was not an option. I grumbled to myself all the way down to the vault—my feet were aching and I was tired. As I walked into the shielded “maze”, I heard my radiation therapists cheerfully assisting the woman onto the treatment table as if she were the first patient of the day.

Once a week, on Mondays, I see all of my patients on treatment. Each patient is escorted from the linac to an exam room by one of the therapists. There is never a Monday where at least one of the patients, and many times all of them, comment about what a great “crew” I have treating down there at the machine. I smile, nod, and say “That’s because I hired them!” I am lying. I did put that team together, but the truth is that radiation therapists everywhere have much in common. They stand on their feet all day, helping patients who are sometimes tearful, sometimes anxious, sometimes immobilized by pain or fear. Between each patient who is honestly grateful for their services, they deal with those demanding a schedule change daily, those who are chronically late, those who are chronically early, and those who will only be treated by a (woman) (man) (person with blue eyes) (whatever—you name it). They risk injury all the time, lifting and assisting patients who cannot do for themselves. They smile, and they are pleasant and they care, leaving their own problems at home to be kind all day, every day, for their entire careers. This is a profession, and believe me they are professionals, that selects for genuinely nice people. It’s a hard job, both physically and emotionally and if you do not have the temperament for it, you do not last long.

There is one radiation therapist that I worked with longer than any other, for nearly nine years. I changed jobs in 2004, but George is still there. An exceptionally tall man at six foot five, his size alone inspired confidence in the patients. Despite the fact that I always explained the treatment to them ahead of time, little old ladies would get two or three days into treatment, and say, “George, tell me again what the side effects of treatment are going to be.” He would reply, without missing a beat, “You will have an irresistible urge to BAKE!” And bake they did, cookies and brownies, and cakes and cinnamon rolls to make very sure that their special guy did not go hungry during a long treatment day. I remember the very first time I followed a patient into the treatment room at that place. The linear accelerator, imposing in its immensity was ready; the treatment table, which we call the “couch” was covered with a clean white sheet. George stood by the set up smiling, one arm outstretched, gesturing like a maître d’ at a fine restaurant. When he said, “Table for one?” the patient collapsed into giggles.

Nothing kills cancer like kindness and a good sense of humor.

Perspective

Posted on October 24, 2012 by miranda

When I was young and foolish, or very smart depending on your perspective, I married a man who is five and a half years older than me. When my husband was my age (and never trust a woman who will tell you her age, but between you and me I am 58), he started to say something quite often whenever he would get annoyed. He would say, “I’m too old for this!” This would irritate me no end because I thought that I would never be too old for ANYTHING, and if I was I would never admit it so freely. I would reply, “If I ever start saying that, just take me out behind the barn and shoot me!” Now that I am exactly the age that he was when he started to say it, I find myself saying it too. Luckily for me, he hasn’t gunned me down yet! Our tolerance for little annoyances seems to lessen as we age. In other words, we become a lot more like our least favorite parent.

There is another curious phenomenon I have noticed. I had to put one of my all-time favorite dogs to sleep in July. He was old, for a deerhound male and he had lived a wonderful life as the “patriarch”, the alpha dog and the undisputed best puppy raiser ever in our household. As it turned out, we had to do the deed on our thirty second wedding anniversary, July 13. This year, fittingly, that day was a Friday and I didn’t much feel like celebrating after that. I am always sad when we have to put a dog or a horse down—it’s natural to feel that way. But I am finding that the older I get, the harder I am taking each loss. I’ve thought about it and I think the reason why is that I am staring my own mortality in the face when I watch another beloved pet die. When you’re a kid, you just don’t see how these things could be applicable to you. When you’re older, you think you should get used to it, but the funny thing is, you just never do.

When I started in radiation oncology, most of my patients were older than me, in fact, a lot older. Now each day I realize that many of them are younger than I am and that is a sobering thought. In college, one of my favorite quotes was from Andrew Marvell’s “To His Coy Mistress” –“But at my back I always hear Time’s winged chariot hurrying near.” I know what it means now. It’s why I stay up late; it’s why I am writing. The company No Fear updated Marvell’s sentiment on a T shirt that I wore until it wore out after too many washings. On the front it said, “It’s not the pace of life that concerns me. It’s the sudden stop at the end.”

Nothing like taking care of cancer patients to give you a little perspective.

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Category Archives: Philosophy of cancer