Gone With The Wind

I have forgot much, Cynara! gone with the wind,
Flung roses, roses riotously with the throng,
Dancing, to put thy pale, lost lilies out of mind,
But I was desolate and sick of an old passion,
Yea, all the time, because the dance was long:
I have been faithful to thee, Cynara! in my fashion.

Ernest Dowson

Having no artistic talent whatsoever myself, nonetheless I am fascinated by art, and especially by artists themselves.  My father has been both an artist and an avid collector since the ship he served on as a Navy dentist docked in Sicily, and the local artists were allowed to come aboard to sell their wares.  He still has paintings he bought in 1945 hanging on his walls.  As a teenager in Depression era Chicago, he took classes on Saturdays at the Chicago Art Institute and wanted to become a portrait artist when he grew up.   His father, my grandfather, told him to get real and learn a trade.  He chose dentistry, and only later, after going to medical school, discovered that as a plastic surgeon, he could both be a portrait artist and earn a living.

Many of my artist friends do not take commissions.  When asked why, they say that it is often very difficult, if not impossible, to reconcile their own interpretation of a subject with that of the person commissioning the work.  Fortunately for me however, some do, and I have been the appreciative beneficiary of portrait work by artists such as Stephanie Snell, Paul Doyle and Marilyn Terry.  What do these artists paint?  They paint my dogs of course.  My children and I would never be able to focus and sit still for our own portraits to be painted and besides, despite this age of “selfies”, we are far too self conscious.

A few years ago, a young man’s wife developed breast cancer at age 25.  He is a well-known video artist known as Daarken and he and his wife needed money to meet their medical expenses.  An on-line fund raising auction was conceived, with the theme stated as “Beautiful Grim.”  Beautiful, because despite his young wife’s diagnosis and treatment, she was and always will be beautiful– yet for some young women with breast cancer, the prognosis can be grim indeed.  His friends and fellow artists rallied to the cause, and many contributed original works to the auction.  I am a friend of Daarken’s sister, and I followed the auction with interest.  In particular there was one painting that I kept coming back to, that no one was bidding on.  It was a portrait of an African American woman, beautiful and naked, except for her long stockings which were peppermint striped, red and white. Her hair was a tangled wild mass of curls against her beautiful skin. When no one else bid, the portrait was mine.

Over the years I have become very friendly with the artist and his wife, who shall be unnamed because of the personal nature of this anecdote.   They visited our home this past summer, and we commissioned a work of art.  The assignment was intentionally vague—“just paint something you see in New Mexico that inspires you.”  A few weeks ago the painting arrived, a full 4’ X 4’ landscape entitled “Sombrillo Vista.”  It is as beautiful as I had hoped, and emblematic of the New Mexico I have come to love.

When I called to offer my sincere gratitude, the artist’s wife said, “You know, just after he finished your painting he received another commission—a most unusual one!  A man called and said he wanted a portrait painted of his ex-wife. He is still in love with her and wants an oil painting to remember her by.”  Apparently he had sent a few snapshots of his ex along with his request.  Always a romantic at heart, this struck me as both somewhat insane, but also a true romantic gesture.   I said, “Send me a phone pic of the work in progress.  I want to see the woman who inspired this act of unrequited love.”  She did.  The woman was indeed beautiful, and playful, and mysterious all at the same time.  I said, “Well if the ex-husband doesn’t like the portrait, let me know because I will buy it.”

Shortly after our conversation, a photo of the unfinished work was sent to the hopeful ex-husband.  He liked it a lot, but he felt that it was not quite there yet.  He had some advice for the artist– he said, “Just think—complex and Mona Lisa eyes with a dash of mischief and you’ll nail it!”  I laughed and said, “Now that should be simple.  You know, just be Leonardo da Vinci.” The finished portrait was unveiled to the good patron last week who promptly proclaimed, “It gave me goosebumps!”   The man likely needs a good therapist instead of a portrait of his ex.   But let us be clear:  he has been faithful to her, in his fashion.  And my artist friend, well—clearly, he NAILED it!

In Praise of Angelina

I have always been one of Angelina Jolie’s biggest fans.  The Academy of Motion Picture Arts and Sciences saw fit to reward her 1999 performance in “Girl Interrupted” with an Oscar, but I wasn’t well and truly smitten until the second Lara Croft Tombraider movie was released in 2003.  In that film, Jolie, who performs her own stunts, is seen galloping on a dark horse while spinning a heavy shotgun from side to side to shoot alternating targets.  And she is riding SIDESADDLE.  If you don’t believe this, have a look here:  https://www.youtube.com/watch?v=tz1lCcs9tac  In the Lara Croft movies, she is the epitome of a strong, athletic, intelligent and self assured woman.  It may not seem like much, but I granted Miss Jolie a high honor indeed—in 2004 I named a dark, agile and fast deerhound puppy after her, the soon to be champion Caerwicce’s Lady Croft, aka “Angelina”.

 

In the years that followed the Lara Croft movies, Angelina Jolie went on to surprise her public in more ways than one.  The girl who initially achieved notoriety for wearing a vial of her second husband Billy Bob Thornton’s blood gained a different type of fame when she adopted a Cambodian child, and subsequently became a respected ambassador for the United Nations.  She has become well known for her humanitarian efforts, devoting as much time to improving the lives of refugee children as she does to her own career.  Recently, she has added the titles of author, director, and Mrs. Brad Pitt to an already impressive resume.

 

But perhaps the biggest surprise of all came two years ago, when she went public in the New York Times with the revelation that she is positive for the breast cancer gene BRCA1. In a moving statement, she wrote of her difficult decision, at age 37, to undergo bilateral prophylactic mastectomies and reconstructive surgeries in the hope of staving off the cancers that took her mother, her grandmother and her aunt.  She was clear and concise, reasonable and dispassionate in her account.   Not only did she raise awareness of the heritable form of breast cancer, she gave courage to all women facing the challenge of a mastectomy.  If one of the worlds most beautiful and sexy women could undergo such surgery in the glare of the celebrity spotlight and come out looking stronger and even more beautiful, so could some of the rest of us.

 

Today she has done it again.  In a New York Times article entitled “Diary of a Surgery” (http://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html?ref=opinion&_r=0 ), she reveals that she has recently undergone removal of her ovaries and fallopian tubes to prevent ovarian cancer, the disease that killed her mother.  She describes precisely the terror she felt when informed that some recent blood tests were equivocal, the dreadful anticipation of the results of a PET/CT scan and the realization that now, at age 39, she has entered menopause.  But she also describes the relief she felt once she had made a decision to go ahead with the preventive surgery: “I know my children will never have to say, ‘Mom died of ovarian cancer’.”

There’s bravery and then there’s true courage and grit.  It’s one thing to perform gymnastics while swinging from the rafters of the Croft estate, or to shoot a rifle off the back of a galloping horse.  It’s quite another to write clearly and objectively the story of being diagnosed with a genetic mutation, and of the careful informed decisions she made to minimize her risks, while at the same time admitting that her decisions were not necessarily the right ones for everyone.  As Angelina says, “Knowledge is power.”  We owe her thanks for sharing hers with us.

 

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.

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.

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!

The Way I See It

When it comes to surgery for cancer, having a “positive margin” is a bad thing.  It means that when the surgeon said he “got it all,” even though he meant it with all of his heart, likely he didn’t.  For a woman undergoing a lumpectomy for breast cancer, that positive margin means a re-excision of the lumpectomy site or alternatively, a mastectomy.  For a woman who has just had a mastectomy, it means that she will likely be seeing me.

I saw a new breast cancer patient on Thursday, a very attractive woman in her early fifties.  She had undergone a mastectomy last March, and had a tissue expander placed at the time to facilitate a later reconstruction with a silicone implant.  The final pathology showed positive lymph nodes on her sentinel node biopsy, and a positive margin where the tumor was close to the chest wall.  She required chemotherapy because of her lymph node involvement, and radiation to her chest wall for the tumor cells that may have been left behind.  She finished her chemotherapy without any difficulty in June.  But instead of coming to me at that time, she elected to complete her reconstruction first.

The first time her expander was replaced with a permanent implant, in August, there were complications which resulted in a failed reconstruction. The plastic surgeon elected to take her back to surgery in November, and replace the implant, and transfer fat cells from her inner thighs to make the reconstructed breast rounder and more perfect.  When the patient saw me on Thursday, she was still not entirely happy with the result, and was looking forward to having additional fat transplanted in the upper inner quadrant.  She guided my hand to the area and said, “See?  The tissue is so THIN right there.”  I stared at her reconstruction in amazement.  It was one of the best I had ever seen.

But yes, there was a problem.  It was not a problem that she had concerned herself with.  The problem was that it was nine months after her mastectomy, and that no one had pointed out to her that a local recurrence of her breast cancer, for which she was certainly at high risk, is a harbinger of metastatic disease and death.  In other words, she had failed to grasp the fact that it was her cancer, and not her breast reconstruction, that she needed to pay attention to.  It took me the better part of an hour and a half to convince her that she should proceed with radiation BEFORE her plastic surgeon achieved the perfection that she sought, and BEFORE her cancer recurred, if it has not already.

I understand the importance of breast reconstruction, and of feeling whole, and feminine again.  But I also understand the evil nature of “the beast.”  I may be a curmudgeon, but I want my ladies to comprehend that it’s not about the boob and the plastic surgeon isn’t going to tell you that—that’s MY job.  First and foremost, pure and simple, it’s about getting rid of the cancer. That’s the only priority.  It’s just the way I see it.

When Life Gives You Lemons

When I was about ten years old, swimming on a Texas swim team, I remember hearing that the child of one of the local coaches had been diagnosed with leukemia.  The idea of a kid dying of an untreatable disease was so foreign to me that I am sure that I have blocked out most of the details.  I do know that the child died, and it didn’t take very long.  In the fifty years since, the landscape of childhood cancer has changed dramatically for the better.  Today, most children diagnosed with acute lymphocytic leukemia—the most common type—survive.  But in the past, we oncologists significantly underestimated the cost of that survival.

For the last six months, I have been taking care of one of the earliest survivors of childhood leukemia.  In her late forties now, she was treated with life-saving combination chemotherapy when she was six years old.  A couple of years later, she relapsed with leukemic cells in her brain and spinal cord, and received cranio-spinal irradiation—radiation therapy to her entire brain and spinal cord, a toxic treatment associated with short stature due to reduced growth of the spine, lowered IQ, and a depressed immune system.  Again she survived, and grew up to be a teacher of disabled children—the ultimate in “giving back.”

In 2005, she was diagnosed with breast cancer, likely a consequence of the radiation exposure she had as a child.  She underwent a mastectomy, and then did well until last fall when she noted a lump in the medial aspect of her breast reconstruction.  A staging work up revealed a benign appearing brain tumor which, again, was likely a late effect of her brain irradiation.  Since she had no symptoms from her brain tumor, her medical oncologist forged ahead with chemotherapy for the breast cancer, followed by removal of her reconstructed breast and its residual cancer, followed by radiation to her chest wall and lymph nodes given by me.  All of this she bore without question, without complaint.

I saw her in follow up on Friday and she was doing well, but she knew she needed to undergo more testing for an enlarged and nodular thyroid—possibly a thyroid cancer, also radiation induced.  She also needed to have a follow up MRI for her brain tumor, to be sure that it is not growing rapidly.  She was matter of fact about the inconvenience, not to mention the anxiety, of having multiple additional tests and procedures over the next few weeks and months.

I am continuously amazed by her grace and equanimity.  I said to her, “You are my hero.  How do you just keep going, day after day, month after month, year after year, dealing with cancer, one cancer after another?”  She said, “When I was a child, dying was NOT an option.  My parents never even mentioned the possibility, so I was never afraid.  I just did what I had to do.  Now it’s the same thing—I know that this is the price I have paid for the wonderful life I have led.  I just keep putting one foot in front of the other, one day at a time.  I know that I will be okay.”

Here’s the thing about oncology folks:  It puts everything else into perspective.  If this brave woman can take the lemons life has given her and make lemonade, so can you and I.   This is the crux of the matter; this is what has kept me going in this field for over thirty years.  If this woman considers herself lucky, so should we all.

Mama’s Gonna Sing You a Lullaby

I have had patients and their families do strange things during a consultation.   Patients taking notes and recording what the doctor says are pretty commonplace these days, as are answering a cell phone and arguing with a spouse over what really happened while giving a history.  Some patients go to great lengths to disconnect from the process, filing their nails, or flipping through a magazine.   I’ve watched babies’ diapers being changed, snacks being eaten and business conducted by text messaging.  I have probably encouraged this informality—I have a consultation room furnished with a comfortable couch and chairs, with soft lighting.  I think it’s nice for patients to meet their doctor and nurse for the first time with their clothes on, as if they were home in the family room.  I thought I had seen everything, but I learned yesterday that I had not, because yesterday, for the first time in my career, a patient fell asleep during our initial consultation.

 

Now I am not saying that I give the most interesting speeches on the planet about the risks, benefits, alternatives to and side effects of radiation therapy.  In fact—a little confession here—I have given the spiels about the various treatments of prostate cancer and breast cancer so many times, that occasionally, just rarely, after an afternoon meal during the dog days of summer I have found myself drifting off mid-sentence and righting myself with a jerk.  Not very subtle, I know, but forgivable, especially during the early sleepless nights of motherhood combined with career.  No one has ever actually complained that I fell asleep during the consultation, so I suspect that my heavy nodding head and half closed eyes were taken as  Yoda like signs of wisdom and empathy rather than tactless boredom.  At least I hope so!

 

So yesterday was a watershed moment in my lifetime of treating cancer patients.  A middle aged woman, otherwise in excellent health, had been given the diagnosis of breast cancer after a routine screening mammogram.  She underwent a lumpectomy and was found to have ductal carcinoma in situ, the earliest detectable form of breast cancer, Stage 0.  She was referred to me for consideration of postoperative radiation therapy, and was seeing me for the first time with her husband accompanying her.  She was lucky—her cancer was detected so early that the likelihood of relapse was low, no matter what treatment she chose.  As I launched into my time worn discussion of her good prognosis, and the finer points of radiation therapy, she suddenly interrupted me, saying, “I just got back in the pool and swam for the first time since my surgery.  I love to swim.  It’s great exercise, but now I am really tired. Do you mind if I lie down on the couch here?”  There are many reasons why I am not a psychiatrist (see three previous essays on the subject for reference!) but generally speaking, I am okay with couches.  I said, “Sure!” and continued to talk.  As I neared the topic of CAT scan based treatment planning, to avoid treating her heart and left lung, I noticed that her eyes were closed.  A few minutes later, a slight snore escaped her lips. Her husband sat at rapt attention, but my patient was out like a light!

 

I am choosing to take this as a sign that she was very, very comfortable with me.  But in the meantime, I think it might be time to spruce up my dog and pony show, for sure!

Denial Redux

Today I saw a new breast cancer patient in clinic.  She was a lovely lady of 64, who had retired last year from her job as a special education teacher.  Her medical history had been unremarkable until last November when she began to gain weight inexplicably.  She was also short of breath, but did not want to seek medical attention during the busy holiday season.  When she finally did see her primary care doctor in January, she had gained seventy pounds.  Her primary took one look at her bulging neck veins and swollen ankles and called an ambulance to take her to the hospital–she was in florid congestive heart failure.  She refused the ambulance, saying that she was fine, and that she needed to go home and take care of a few things, but that she would get to the hospital shortly on her own.  And so she did.

When she was being examined in the emergency room, the resident noticed a very large breast lump on her left side.  He asked her, “How long has THIS been here?”  She was vague in her response–it may have been “a few months” or it may have been “a few years”. It wasn’t hurting her, and she had other things to worry about–namely her 70 pound weight gain.   Mammograms and ultrasound while she was an inpatient led to a biopsy which showed malignancy.  Cardiac echo showed both coronary disease and cardiomyopathy.  She was treated with multiple cardiac medications and began to diurese, and her heart function improved dramatically, especially after a stent was placed in her left anterior descending coronary artery.   Finally she was able to go to surgery to remove the breast mass, and today she showed up for her consultation looking very chipper indeed–a slender 134 pounds down from 206, breathing normally, with no ankle edema.  The breast cancer turned out to be stage I, and she will receive radiation therapy in the next few weeks.

When I walked into the consultation room, I introduced myself and asked her to say her name, which was somewhat difficult to pronounce.  She laughed and said, “Just call me Cleopatra, because I am the Queen of Denial!”  Fortunately, I think she is going to be just fine.