On The Road Again

On the road again
Goin’ places that I’ve never been
Seein’ things that I may never see again,
And I can’t wait to get on the road again.  Willie Nelson

 

If someone had told me even ten years ago that I would retire young and become an itinerant radiation oncologist I would have thought he had lost his mind.  As the career medical director of community based cancer centers, I was used to running the show.  And as the saying goes, I ran a “tight ship.”  Consultations were performed and documented in a timely fashion, day of the request if the situation was urgent, or within a few days if not.  The patients were given time to think about their treatment, but simulations could be done the same day as the consultation, or as soon as the patient agreed to treatment, and the new start times were never more than a week away. Patients were seen every week, or more frequently if needed.  I had the best team of radiation therapists, physicists, nurses and front office people that anyone could ever ask for.  But in early 2014, I like to say I retired.  But the truth is, I quit.

Articles about physician burnout are legion, and I have avoided adding to that literature in this blog. The truth of the matter is that we, as radiation oncologists, are a very privileged group.  We are privy to the most intimate details of our patients’ lives; we practice in a highly technical and ever changing environment which challenges us to be constant and consistent learners; our hours are regular and we are very well paid as a medical specialty.  And most importantly, we cure cancer.  What could be better?  But after thirty years in the field, I was tired.  2013 was a terrible year for me—in December of 2012 I lost a close friend, Catherine, and then my little dog Jack, and then in January my mother, and shortly after that my work partner Dr. William Spanos, the best colleague and friend a physician could ever hope for.  And in between, some very beloved patients who I had followed and treated for years.  I was done.

But a calling is a calling, and somehow, between the enchanted mountains of New Mexico and the healing hours spent on horseback and with my dogs, and the otherworldly sunsets and the pleasures of growing a vegetable garden, I needed to get back to doing what I do best—helping cancer patients.  So here I am, a “locum tenens” radiation oncologist, working for an agency, going where I am needed, for a few days, or a few weeks at a time.  On Sunday night I “saddled up” the old Suburban and headed to Las Cruces, NM to provide a little relief to the solo practitioner stationed there.

Today I saw an elderly woman who had just been diagnosed with locally advanced and metastatic lung cancer.  Despite the effects of her disease—weight loss, shortness of breath and pain—I could see that she had been and still is a beautiful woman.  I can’t cure her—no one can.  But I could promise her that I could make her breathing a little easier, and relieve the painful metastases in her lumbar spine. As I sat with the patient and her husband, I knew with certainty that I no longer had to be “in charge” or command my own practice.  I knew that I could help her.  And I knew, beyond question, that I had begun to love my profession again. For that I am very grateful.

Another Dog, Same Breed, As Soon as Possible

“Hark to Beaumont. Softly, Beaumont, mon amy. Oyez à Beaumont the valiant. Swef, le douce Beaumont, swef, swef.” Beaumont licked his hand but could not wag his tail.”  T.H. White, “The Once and Future King”.
               For the past couple of years, my life has been pretty easy.  I spent last summer putting in a vegetable garden, and making improvements in the landscaping around my home.  In September I went back to work after a somewhat abbreviated bout of retirement, but just part time covering other radiation oncologists’ practices.  My two Scottish Deerhound sisters, Queen and Quicksilver were then approaching 7 years old, and were long past the destructive behavior so characteristic of the giant breeds in their youth. My little mixed breed rescue Yoda had never been a problem.
             On December 19, 2015 I upended my quiet comfortable life by getting a new puppy, a ten week old borzoi named Pibb.  Two weeks later, I compounded the chaos by acquiring a “brother” for him to play with, an eighteen week old Scottish deerhound puppy named Cole.  Despite a few misgivings and knowing full well what I was getting myself into, I went ahead with what I knew deep in my heart was a preemptive strike. Queen had been limping off and on, and despite my denial I knew that the proverbial “other shoe” had dropped.  Her chronic lameness worsened suddenly a few weeks ago and like her dam before her, she was diagnosed with osteosarcoma, a bone cancer common in her breed.
                  As a radiation oncologist for adults with cancer, my day to day ethical challenges are few. I do my very best to be sure that my patients understand their diseases, and the side effects, risks and benefits of treatment. As a devastated dog owner, the decision making process is not so simple. The tell tale X-rays resulted in a consultation with a board certified veterinary oncologist, where my husband and I sat and listened to our options. Amputation and chemotherapy, the standard of care, would give Queen a median survival of 9 months.  Untreated the disease progresses rapidly, often times resulting in a pathologic fracture. Pain control is also a problem, and pain can often be ameliorated by radiation therapy–my own specialty. Except in the rarest of cases, the disease is incurable because metastases are present, whether they can be detected or not.  All treatment is palliative.
               As we sat with the veterinary oncologist two weeks ago, contemplating our options, I remembered my friend and vet oncologist Dr. Greg Ogilvie saying, “The dog doesn’t look in the mirror and say, ‘Oh, I only have three legs.’ The dog only knows that the pain is gone.”  And we were told that dogs tolerate chemotherapy exceptionally well, much better than human beings.  So we sat and nodded and thought that perhaps our initial instinct, which was to provide comfort care only, might be wrong.  Who knows better than a cancer doctor how important it is to provide and maintain hope?  And so we wavered.
                 In her incomparable essay “Oyez a Beaumont”, Vicki Hearne describes what it was like to lose her Airedale Gunner when he fractured his pelvis from prostate cancer.  As a dog trainer, her advice to clients has never wavered:  ”Another dog, same breed, as soon as possible.”  And then she admits to us, that it was ten years between the death of Gunner and the purchase of a new Airedale pup.  She says, with feigned indifference as our hearts break, “That was as soon as I could get to it,what with one thing or another.”  I got to it a little sooner.
               Deerhounds are homebodies, and our Queen particularly so.  Carsick since puppyhood, trips are stressful for her, and the risk of fracture even getting such a large dog in and out of the car is significant. Outside the veterinary specialty hospital, in the cold light of day, we lifted her into the car and she fell immediately into a sound sleep because she knew she was going home-home to her sister, her humans, and even those pesky puppies. We knew then that home is where she will be for what remains of her life.  We love her and this, more than anything, is what we owe her.

The Curbside Consultation

Recently a friend of my husband’s in San Diego had a mammogram which showed some suspicious microcalcifications in her right breast.  She underwent a stereotactic biopsy which revealed ductal carcinoma in situ, the earliest form of breast cancer also known as Stage 0 breast cancer.  This type of cancer is non-invasive and does not metastasize, however, if untreated it can progress or recur as a more serious type of breast cancer, so at the very least excision of the abnormal area is indicated, and in some cases radiation and/or mastectomy are necessary.  My husband asked if I would speak to her regarding her breast cancer, and somewhat reluctantly I said yes.

 

Why reluctantly, you might ask.  Isn’t that the nice thing to do?  I said to my husband, “I think it’s a mistake to do consultations over the phone.  I have no access to the mammograms or pathology report, and I cannot examine her.  These things are important to have and do to give someone an informed opinion about her case.”  He said, “But can’t you just talk to her a little bit and recommend a surgeon, and maybe give her a bit of information about radiation therapy?”  I agreed to do it.  A few days later we connected by phone.

 

Having practiced in San Diego for twenty one years, and having a major interest in breast cancer, I know every surgeon in San Diego and Riverside counties who specializes in breast cancer.  Likewise, every radiation oncologist and medical oncologist.  I am a virtual referral encyclopedia—tell me where you live and I will tell you where to go.   In this case I recommended the surgeon whom I would choose to operate on ME, if I had breast cancer.  Same thing for radiation oncology.  I did this for my husband’s friend, and we discussed her case at length.  Because of her relatively young age, excision alone was a bad choice, so we discussed the pros and cons of excision plus radiation versus simple mastectomy with or without reconstruction.  At the end of the conversation she thanked me, and then mentioned that there were actually TWO areas in the breast that were biopsied and were positive, and they were not particularly close together.

 

That little fact, which I would have known if I had had her pathology report and her mammograms in front of me, changes everything.  If a woman has multifocal disease, there is a good probability that she may be better off removing the breast.   I backtracked and covered that point, but I worried that I had made an anxiety provoking situation much worse by confusing a new breast cancer patient.  In the end, she sought the care of an excellent breast cancer surgeon, and I know she will be fine.  But I have the lingering feeling that in trying to do the nice thing, I did the wrong thing.

 

Think of this when you stop your doctor friend on the street to ask about a friend or relative who has recently been diagnosed with cancer.  Curbside consultations do no one any favors.  If you or a friend or relative need an opinion, get an INFORMED opinion—present to the consulting physician with your history, your radiology, your lab work, your pathology and your body to be examined.  Then, and only then, you will be assured that the recommendations that you receive are the ones you should truly follow.  It could save your life.

When Cancer Comes To Call

A patient story tonight, from Jackie:

 

It was one of those days.  I had been to the gynecologist the week prior because I somehow knew the sporadic bleeding which I had experienced was NOT a simple Urinary Tract Infection for which I had been treated three times.  My doctor did the scrapings and biopsies and had me run down the hall for an ultrasound.  I’d had lots of ultrasounds during my pregnancies – especially with my twins -  but this one wasn’t fun.  There was no cute baby to smile at.  This time it was a transvaginal ultrasound which involved the insertion of a rather large tube into “that place” to look at the uterus.  “My what a big wand you have” I joked with the sonographer.  She didn’t smile.  That’s when I got a bit nervous.

Of course my doctor put a positive spin on everything – prior to the biopsy results.  He said it was probably just an over thickening of the uterus, Hyperplasia.  So I decided to wait until there was something solid to review and went on about my life.  I had a dental appointment a few days later.  My dentist announced I needed a root canal immediately and sent me to a nearby Oral Surgeon.  As I was pulling up to the Oral Surgeon’s office my cell phone rang.  It was my gynecologist.  “Well, there is a malignancy….”.  The words hung in the air.  We had a brief conversation – darn, I thought – I had researched  Hyperplasia thoroughly and knew all the right questions to ask.  I felt like I had studied for a test and then the test changed.   He said I needed to contact a special Gynecological Oncology surgeon and that his office would tell me what’s next.  So I called and left a message with that doctor but said I couldn’t talk for a couple of hours because I was just about to go in to have a root canal.  One thing I will say about those specialists’ offices; they run like a well oiled machine.  As I walked back to my car 2 hours later there was a message on my cell phone.  It was Jay, the Office Manager for the Gynecological surgeon I needed to see.  He was calling to schedule my appointment.  He paused and said “Good luck with the root canal. Sounds like you are having a great day”.   And so it went.

My life was forever changed.  May brought the diagnosis.   June brought the scheduling of the hysterectomy.  July 1 was the surgery.  July 10 came the pathology report.  Not what we had hoped for– the “once and done” hysterectomy revealed some naughty cells lurking within the uterus that have a tendency to “jump” into other areas.  Chemo or Radiation? My case was submitted to the Austin Gynecological Oncology Tumor Board for review as recommended by my Surgeon.  I was overwhelmed.  I didn’t know what I didn’t know.  As is often the case when you do get the “C” diagnosis; you are thrown into a blender of emotions but when the dust settles the appetite for knowledge takes over.  And so it was decided that radiation was the protocol. After I healed from surgery, radiation began.

So here’s the thing:  it wasn’t that horrible.  For anyone who has been through tough times, worked hard and experienced inconvenience or sadness – you are mentally strong and prepared for this challenge.  It is definitely a Mind Game.  I decided to fight and endure and not to whine and whimper.  For 6 weeks my life revolved around daily visits to the Oncology Center.  The treatment wasn’t bad.  The hardest part was drinking 40 ounces of water prior to treatment.  The side effects clicked in about 3 weeks in; lower GI issues.  But oh well, diarrhea is not the end of the world.  My pubic hair fell out which I found fascinating. I met wonderful friends in the waiting room.  The therapists and nurses and doctors were wonderful.  My neighbors and family rallied and emotions ran high.  Food and flowers poured in.   My sweet neighbor who had just finished two years of breast cancer diagnosis, surgery, chemo, radiation, reconstruction – I was at her door daily for her battle.  Now, she was at mine.  Life sifts down to the basics of priorities: Faith and Family and Friends.

I finished my radiation on September 15 and got to Ring the Bell which is special to all cancer patients because it means YOU ARE DONE.   My sweet family and a few friends showed up.  Tears flowed.  My husband pushed through the group to shake the hand of my Radiation Oncologist and choked “Thank you for helping my wife”.  I was ready to start my new healthy life.

Check-ups will continue for a few years and I will see both my Surgeon and Radiation Oncologist often. That’s okay.  My Surgeon is cute (I think he is almost the same age as my oldest son) and my Radiation Oncologist is an incredible mother of four who never seems hurried or distracted and makes me feel like I am THE most important patient in her practice.  I feel so blessed to have been in such capable hands.

I feel wonderful.   Celebrating my December birthday was more special this year.  Welcoming the New Year signaled almost a palpable relief to make a fresh start.  I take nothing for granted and try hard to live in the moment.  Ever the planner, this has been my most challenging goal.

For Christmas this year my daughter gave me a beautiful silver charm.  On the front it says “Faith”.  She told me to turn it over.  On the back was engraved 9-15-2014.  My final day of radiation.  It has been the most horrible of years, but it has been the most wonderful of years.  When Cancer comes to call you rise up and fight the good fight.  And then, you go on.

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.

I am Passionate About…

A few days ago I decided that since I have been officially retired for two months, it was time to change my profile on the LinkedIn social network.  After all, the purpose of that network is to link business and professional people to potential opportunities and ideas.  I needed to let contacts know that I am no longer with the University where I practiced for the last seven years, while at the same time, just labeling myself “retired” seemed far too final.  LinkedIn, as it turns out, has a “prompt” on each member’s profile page which encourages us to say succinctly what we’re all about.  The prompt is “I am passionate about…”  It took a few moments for my brain to dispel romantic visions of the great love stories of all time–Catherine and Heathcliff?  Zhivago and Lara? Scarlett and Rhett?  The realization dawned on me that what LinkedIn was alluding to was professional and not physical.

What I am passionate about, and remain so despite the significant burn out that led to early retirement, is community based cancer care.  Contrary to what I believed during my residency, when I referred to patients being admitted by LMD’s (local medical doctors) from St. Elsewhere, over the course of a long career I have come to believe that most cancer patients are served best by being treated in their own communities.  Certainly there will always be patients whose presentations, diseases and complications merit immediate referral to a tertiary care center, however most patients with typical presentations of common cancers are also people who have jobs, who have children and/or elderly parents to care for, who have concerns about the financial burdens of treatment, and for many elderly patients concerns about transportation to and from treatment.  Our job, as community based cancer specialists, is to make sure that the treatment being provided measures up to the standards of care and safety that we have learned from our colleagues in major academic practices.  In communities with limited resources, this can be challenging.

For physicians and community leaders interested in creating a community cancer center the key ingredients are simple. First, you need a mission.  Decide what the goals of your center will be and write them down.  Create a statement.  An example could be:  “Our mission is to deliver medically and technologically advanced cancer care to residents of this community in a supportive environment close to home.”  These goals will be your guiding light as you proceed.  Second, you need a building.  Although many of the functions of a tertiary cancer center can be spread out into the community, we are not yet at a point where we can deliver “virtual cancer treatment.” Many pre-existing buildings can be modified to accommodate chemotherapy and even radiation therapy, at a fraction of the cost of new construction. Third, you need equipment.  Specifically, in order to deliver radiation therapy you need a multipurpose linear accelerator, capable of delivering highly focused stereotactic radiation as well as standard of care intensity modulated radiation therapy and superficial electron therapy for skin cancers.  Although it makes a good PR campaign to have the latest “sexy” name in equipment, much of this highly specialized equipment is not designed for a general practice. You will need infusion equipment and likely some laboratory equipment.    Fourth, you need highly trained and certified personnel to administer chemotherapy and radiation therapy, and particularly in the case of radiation, to insure quality. Fifth, it is my opinion that community cancer centers benefit greatly from affiliation with university practices in terms of access to clinical trials, to tumor boards, to advanced pathological diagnosis and to the expertise of specialists in each disease site.  Finally, and perhaps most importantly, you need the support of the community. To paraphrase Hillary Rodham Clinton who said, “It takes a village to raise a child”, I would say that it takes the dedication of a community to create a successful cancer center.

The future of cancer treatment, indeed of medicine in general, is unclear however we must not lose sight of the fact that patients are more than their cancer diagnosis, their chemotherapy recipe or their radiation dose prescription.  We need to keep them in their jobs, with their families, functioning as normally as possible under difficult circumstances, throughout their treatment and afterwards.  My own experience has shown that this is achievable in a personalized setting in the patient’s community.  That is what I am passionate about.

This piece is condensed from a longer talk I gave in Jamaica in October 2013.  For the full transcript feel free to email me and I will send it on.

Heisenberg and Your Prostate

Uncertainty Principle:  A principle in quantum mechanics holding that increasing the accuracy of measurement of one observable quantity increases the uncertainty with which another conjugate quantity may be known.

Perhaps it is because I just got back from Albuquerque, a city which has become like a second home to me, that I have Heisenberg on my mind. For the one or two of you out there who are not “Breaking Bad” fans, “Heisenberg” is the name that mild mannered chemistry teacher Walter White assumes when he decides to manufacture pharmaceutical quality methamphetamine after being diagnosed with Stage III lung cancer. His motivation is to be able to leave his pregnant wife and son affected by cerebral palsy a little cash when he dies.  The evolution of Walter from upstanding high school teacher to ruthless drug lord unfolds over six seasons where moral ambiguity is the coin of the realm—in uncertainty principle terms, the more single mindedly he pursues his meth business, the fuzzier his personal ethics become.

Recently I have begun to think of the dilemma of PSA testing and the diagnosis and progression of prostate cancer in terms of the Heisenberg uncertainty principle.  Nowhere is this more apparent than in the case of men who have a rising PSA level post prostatectomy.  For many men faced with the choice of surgery versus radiation therapy, the selection revolves around the perception of certainty.  In medical school we are given the mantra, “To cut is to cure!”   Many patients choose surgery because of that perception—the ability of the surgeon after the procedure to say, “We got it all” and the satisfying thud of that post op PSA falling to zero.  Life is as it should be, the offending organ is gone, and the PSA is the definitive proof of cure.  In my own career I have pointed out countless times that if a man wants it black and white, cut and dried as it were, he may be more satisfied with the surgical option, since the slow fall in the PSA level post radiation therapy, with its attendant subtle blips and variations can be maddening to the patient, his family, and of course the attending physician.

But what of the patient whose PSA post prostatectomy does not fall to an undetectable level?  Or the patient whose PSA becomes unmeasurable, but months or years later starts to rise again?  On the one hand, our ability to measure serum PSA levels as a proxy for prostate cancer still lurking in the body has improved to the point of being able to measure values as small as hundredths of a nanogram per milliliter of blood.  We call this the supersensitive PSA assay and we accept this as proof that the cancer is there, somewhere, waiting to recur.  But what this supersensitive test cannot tell us is exactly WHERE those cancer cells are.  Neither bone scan, nor CAT scan, nor Prostascint imaging nor ultrasound is likely to give us the answer.  So what do we do?  As radiation oncologists we offer the patient the best we have, treatment to the “prostate bed”—the area where the prostate used to be—and sometimes the adjacent lymph nodes.  We know statistically that over a period of years, large groups of patients who were treated for their rising PSA with radiation do better than those who were not, but sadly this tells us nothing about the individual patient.  And the individual must decide for himself whether to take the leap of faith, and the side effects of one treatment compounded with another, that the cancer cells are still localized and that the radiation will kill them.

As a clinician treating patients with rising PSA’s post prostatectomy, I wait with bated breath for the first PSA after radiation to the prostate bed.  The patient is equally anxious—that stark simple but highly precise number is the measure by which we judge success or failure of the treatment.  But in focusing on the PSA, we often forget the obvious—that a number, even a highly precise number, is just that and nothing more.  What the patient will die from, and when, remains uncertain.  If I can help my patients remember that, and go and live their life with zest and satisfaction, then I have done them a real service.

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.