Thanks For Your Support

My husband likes to say, “No good deed goes unpunished.”  I don’t always agree, but sometimes you just can’t argue that concept.  One of my favorite patients, a forty nine year old woman who I treated for head and neck cancer a year ago is a good case in point. Head and neck cancer is on the rise, and is linked, like cervical cancer, to infection with human papilloma virus which is sexually transmitted.  Patients who are treated for this type of cancer have a very rough time.  Typically, curative treatment these days involves combining chemotherapy and radiation, reserving surgery for salvage in the case of an incomplete response or recurrence.  Patients have severe mucositis, inflammation of the oral cavity and the throat, and oftentimes require a feeding tube for nutrition. They lose their sense of taste, they are hoarse, their mouths are intolerably dry, and they are fatigued and miserable.  The good news, however, is that the majority of these patients are cured, even with advanced stage disease.  Many go on to be advocates for others just starting on their journeys.

It was with this in mind that my patient’s ear nose and throat doctor asked if she would mind speaking to a man of similar age and circumstance who had been recently diagnosed.  Of course she agreed.  She had been through the war, won the battle and wanted to help if she could.  She called him and they spoke at length about treatment side effects.  But something seemed a little “off.” Soon he was calling and texting her daily.  He wanted to meet her.  She politely declined, but she invited him to attend an event at our cancer center celebrating survivorship, and the role of complementary therapies.  He wanted more.  Soon his urgent text messages dominated her cell phone, culminating in the question, “So how did you get your HPV infection?  You must really like oral sex!”   She got a restraining order.

I saw another patient a week ago with breast cancer for an initial consultation.  She was very nervous, unduly so considering that her cancer was detected very early and she had completed her lumpectomy and sentinel node dissection.  The tumor was tiny, the nodes were negative and she was not going to need chemotherapy.  When I could not dispel her anxiety, she finally confessed that another breast cancer patient of mine had sent her a picture on her cell phone of her breast at the end of treatment, at the peak of her skin reaction.  This other patient had undergone chemotherapy first, which sensitizes the skin to radiation; she was large breasted which also increases the skin reaction; and she had refused to follow advice regarding her skin reaction.  She had an area of moist desquamation—peeling skin—in the inframammary fold.  She is now completely healed, with no permanent skin changes, but in the interim she deemed it important to frighten a new patient nearly to the point of refusing therapy.

Many years ago another head and neck cancer patient said to me, “When I found out I had cancer, I joined a club that I never wanted to be a member of.”  Support groups can be wonderful—many of my patients tell me they have met their best friends at group support meetings.  But always beware of people with hidden agendas.  When it comes to cancer support, there are far too many of these.

Don’t Let Me Talk You Into It

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?

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.

The Things They Put on Their Skin

When patients start their radiation therapy, one of the side effects that we tell them to look for is a skin reaction.  Depending on the area of the body treated, and the dose given, the skin reaction at the end of treatment ranges anywhere from a mild sunburned look all the way to what we call moist desquamation, where the skin literally sloughs off, yet ultimately heals without even a scar. My nurse spends a great deal of time educating patients about taking care of their skin.  The instructions are simple—do not get a sunburn on irradiated skin (breast and prostate cancer patients take note:  NO NUDE SUNBATHING!), do not use perfumes or deodorants on irradiated skin, do not use harsh soaps or detergents, and DO use a fragrance free product that helps the skin retain moisture.  The two tried and true products which have been on the market for over thirty years are Aquaphor ointment, and Eucerin cream (which, for the record, is just Aquaphor whipped like egg whites turning into meringue!)  When I was a resident, we had giant vats of the stuff stored in a back room and when a patient would start his treatment, my job was to go and get a sterile urine cup, and a sterile tongue depressor and scoop the ointment or cream out with the tongue depressor, fill the cup, put the top on and voila,  hand it to the patient. Simple, and very cheap.

It seems that there is now a cottage industry which provides skin care products for radiation therapy patients.  Many of the concoctions are “all natural” and as a result, some are very expensive.   A few are made by the big pharmaceutical companies and tout ingredients with chemical names that only a terrorist would recognize. One of the “natural” creams made locally contains aloe, lavender and calendula—it was light, smoothed on well, and was very popular with me and my patients until it came to my attention that it was made and marketed by a competing radiation oncology group. This seemed a bit devious and self-serving to me—make money off treating the cancer, then make more money off of selling skin care products.  I dropped it from our “line up” and went back to the old tried and true.

Despite getting very explicit written instructions at the beginning of treatment along with a few samples, I am always completely astounded by the variety of unprescribed substances that patients find themselves compelled to put on their skin.  Just in the last few months, I’ve had grown men who fought in wars extolling the virtues of jojoba oil, coconut oil, crisco and almond butter.  It makes me wonder if the discovery of the healing properties of these substances was actually a by-product of a different sort of usage!  And the women too get into the act—women who think nothing of spending four hundred dollars for a small vial of a wrinkle cream waltz in and tell me that they used rubbing alcohol on their skin reaction, or betadine, not to mention products from their spice rack including turmeric and cayenne pepper.  And these are the things they will admit to!

Let me tell you two little secrets.  First, there is NOTHING that will prevent a radiation skin reaction.  So don’t waste a lot of money trying.  And second, no matter how bad it gets, it will heal quickly.  Without a scar.  So use your Aquaphor, and please, try not to scratch!

The Purple Bathing Suit

“April is the cruelest month”  T.S. Eliot

Although I have spent my professional career battling cancer, cancer is not the cruelest disease.  Tonight I was looking through old photographs that my father had taken to a print shop to be scanned on to a disk.  He sent me a copy, but I had not had much time to look at the pictures.  When I finally did, last night, I was disappointed in the sloppy job that the print shop or camera shop had done—photos were scanned in upside down, backside forward, reversed, random and unlabeled.  There was no chronology or logic—it was just willy-nilly, get the job done.  And I am sure that they charged him a lot of money for that service.

Looking again tonight, there is joy and sadness in those old and out of order family photographs.  My sister smiles as she receives her diploma from Stanford.  My little brother, now long dead of a drug overdose, blue eyed and perfect as a three year old sitting next to my 5 year old pony-tailed self.  Me, in my favorite “car-coat” as my mother called it, felted and toggle tied and warm.  I remember that time it snowed in Houston—I was in first grade and I had pretended to be sick to stay home from school and then it snowed, beautiful white fluffy snow, and my Nana would not let me go outside to play because, of course, I was “sick”.  By the next day, the snow was gone.

Of all of those old pictures, there is one that jumps right off the screen at me.  It is a photograph of my mother, just graduated from college, in a purple skirted Jantzen bathing suit.  I know it is a Jantzen because I remember the logo from my childhood—a little diver with a swim cap covering her head, doing a swan dive into a pool, ubiquitously sewn onto every Jantzen suit of the 1950’s.  My mother is at the beach, sitting demurely on a beach towel that appears to be engulfed by a foamy wave which creeps just past her delicately crossed legs.  She is brunette, petite, beautiful and smiling.  She is 21, and her whole life is before her.  I like to think that my father, deeply in love, took that picture just before they married.

Sixty years later, my mother is a two time cancer survivor.  She was treated for breast cancer in 2001, and then for a disease of the blood, Waldenstrom’s macroglobulinemia, which involved her brain in 2005.  At that time she received chemotherapy directly into her central nervous system.  Five years later, in 2010, she began to lose her memory, and her will to walk, and to speak, and to eat.  Now, in 2012, she has advanced dementia.  She does not recognize me or my sister, and my father dutifully visits her at least every other day in her nursing home, where she receives excellent care, completely dependent on others for her survival.  Because her nurses are so attentive, she has not had a life threatening pneumonia or urinary infection or infected bed sore which would cause her demise.  And so, we wait.

I never got along very well with my mother, but despite that I wish fervently that she could be herself again, older and wiser, waiting out the tide in her purple Jantzen bathing suit. Cancer is not the cruelest disease—dementia is.   I am waiting to see which shoe will drop for me.


At one of the boarding and training stables where I took riding lessons, there was a custom passed down through generations of instructors and eager children.  If a horse managed to unseat a young rider, the slightly bruised and dirty little victim was allowed to pull a few strands of said horse’s tail.  The instructor would braid the strands–black, or white, or grey or red—into a thin plait and secure the ends with rubber bands.  This small symbol of failure was sent home with the child with the pronouncement  “You cannot be a REAL rider until you’ve fallen off THREE times!”   Three braids of horse hair pinned to a bulletin board and a rider you shall be.

As a fourth year medical student, I eagerly embarked upon my “subinternship”, a make-or- break rotation for aspiring doctors where the student was expected to function as an intern on the admitting team, which consisted of two or three interns, a junior or senior resident, and an attending physician.  Each “Sub-I” took new patients admitted from the ER  in rotation with the real interns, and we were supposed to perform a history and physical, order appropriate tests, come up with a differential diagnosis and present the results to the attending physician on rounds the next morning.  My first “admit” was an elderly woman, massively obese, who had been found at home alone on the floor, in an altered state of consciousness.  After an EKG in the ER showed she had not had a heart attack, she was sent up to the floor to be evaluated. No one had been able to draw her blood in the emergency room—they could not find a vein and since she was stable, they sent her on up.  I was well trained in the art of blood letting, yet after two hours of poking and prodding various sites where veins were known to hide, I reported to my senior that I had not been able to coax out a single milliliter.  He said, “Well, go on home then, we’ll get the IV team to do it when they come around to start her IV.”  I arrived the next morning for rounds and terrible news.  At 2 am, my very first patient had had a cardiac arrest, and in fact she had died when the “code” team could not rescusitate her.  But, oh, they had gotten blood out of her then.  Her potassium level was 7.5, incompatible with life.  She had been in kidney failure and we had not known it.  The blood test which had not been done the evening before might have saved her life.

As a senior medical resident, in charge of such an admitting team, I rounded daily with the interns, dispensing sage advice on each patient on our floor.  Three days in a row we rounded on a lady with late stage breast cancer, in the hospital receiving chemotherapy, then given in the hospital due to significant side effects which in those days had few remedies.  Three days in a row, she had complained of leg weakness, which we attributed to the debilitating effects of her chemotherapy.  Of course she was weak, she had CANCER and was getting CHEMOTHERAPY.  On the fourth day, she was to be discharged home.  As we rounded, her complaint of leg weakness had changed.  She said, “I cannot move my legs.”  Indeed, she could not move her legs.  On our watch, she had suffered a spinal cord compression from metastatic breast cancer to her spine and was paralyzed.  Spinal cord compression is one of the most dreaded complications of cancer.  Unless detected in the early stages of weakness and numbness, it is nearly always irreversible.  Almost unbelievably, as an inpatient attended daily by a multitude of students, interns, residents and senior physicians, this woman walked into the hospital and left in a wheelchair, never to walk again.

In the emergency room, a macho mystique presides.  Again, to quote Samuel Shem in “The House of God”, the goal is to “buff and turf”:  Tune ‘em up and get ‘em out!   This somewhat testosterone fueled mentality results in an unstated reluctance to admit patients to the hospital—no senior medical resident in charge of an emergency room wants to be seen as a “wuss” by his or her peers presiding over the floors—the fewer the number of patients admitted, especially at night, the more sleep your fellow residents and interns can get, and the more they will thank you in the morning.  Each patient in the emergency room is triaged by the nurses first, and the senior residents last, nowadays with the blessing of the attending physician, but back then we were on our own in the wee hours.  One night during my senior internal medicine residency, a young healthy man in his early 30’s came into the ER, complaining of chest pain.  He was a budding young chef at an up and coming local restaurant.  He was slightly overweight, a condition which was exacerbated by his chosen profession.  To remedy this problem, he had decided to start jogging.  Earlier that day, he had gone for a three mile run.  During his run, he began to have chest pain, substernal chest pain radiating down his left arm.  The pain had subsided when he stopped, but he came to the ER to be checked out, you know, just in case.  His heart rate and rhythm were normal.  His EKG was normal.  The blood tests which we now do routinely to rule out cardiac muscle damage were in their infancy, and took 8 hours to run.  He had no family history of heart disease.  He had no heart murmur.  He was only 33, for goodness sake!  There was NO way this man could be having a heart attack. No way.  I sent him home.  But, just in case, I scheduled him for a stress test to be done a few days hence.  At 8 am, my 24 hour shift was up, and home I went.  Twenty four hours later, I returned.  In the conference room, the attending was rounding with the interns and residents.  He took report on the previous night’s admissions.  One of those admissions was a 33 year old chef who had returned to the ER less than a day after I had discharged him, clutching his chest in pain and fear, having a massive heart attack.  He was admitted to the ICU. He survived.

Perhaps it is the same with physicians as it is with children taking riding lessons—you cannot be a REAL doctor until you have made three mistakes that you will never forget.  Doctors hate making mistakes, and hate admitting them even more.  This is the reason for the conferences which take place at every teaching hospital in the country called “M and M’s”, which stands for Morbidity and Mortality.  It is where physicians, young and old,  stand up and say, “This is what happened and this is what I learned and that is why I will never let it happen again.”  Rarely do they say, “This is what happened and it was my fault and I am truly sorry.”  When I was in training, the conventional wisdom to avoid malpractice liability was to call Risk Management but to NEVER admit you were at fault.  That was for the insurers and the courts to decide.

That has changed now, for the better.  Now we are counseled that it is better to admit one’s mistakes, and to apologize.  I have my three braids of horsehair pinned to my brain, and to my heart.  And there are probably more.  I am sorry.  Truly sorry.

Cancer is a Word, Not a Sentence

I am the one who doesn’t like to fast forward during the commercials.  While others get up from the couch for a bathroom break, to grab a beer, take a phone call, or interrupt our programming to discuss the new season of whichever show we happen to be watching, I sit riveted to the screen. I wax nostalgic over the Hallmark ads, drool over the car and jewelry ads (especially those romantic proposals involving large diamond rings where every kiss begins with Kay’s), and weep copiously during the Kodak moments (Yes, I “turned around” and they were gone.).  I hear the Christmas harness bells of the Budweiser Clydesdales in my sleep. And I am faithful to my products, in my fashion.  To me, Chevy will always be “like a rock”, and CocaCola will always be “the real thing.” I love a good advertisement—always have and always will.

So it should come as no surprise that I am fascinated by the advertising slogans and campaigns which come and go in cancer—cancer awareness, cancer screening, cancer treatment, cancer support.  These ads and slogans  and symbols have become part of the national consciousness:  who can forget the television ad of the wasted old woman (or was it a veteran?) in a wheelchair, smoking a cigarette through a tracheostomy hole?  The “Anti-Marlboro” man creators may not have stopped kids from smoking, but you certainly can’t fault them on a shock value scale.  Pink ribbons and yellow wristbands have become part of our collective cancer symbolism.  See a pink ribbon, think breast cancer. See a yellow wristband, think Livestrong/Lance Armstrong.  Knee jerk, empathize, feel the pain, and above all, send the money.  It is desperately needed.

But to me, the best ads and slogans are the ones that involve a little humor, combined with a little humility and self deprecation.  I was watching the National Finals Rodeo on television last year and noticed that all the cowboys, including the bull riders ( the toughest of the tough though not necessarily the smartest of the smart) were wearing pink.  Each, to a man, had on a pink shirt, or a pink bandanna, even pink hats and gloves.  Kudos to Wrangler Jeans for their sponsorship, and their Tough Enough to Wear Pink campaign for breast cancer.  In a similar vein, some of the funniest T shirts I’ve ever seen during the Susan B. Komen Races for the Cure have been worn by men, including “Don’t Let Cancer Steal Second Base”, not to mention the one with an antlered stag on the front proclaiming  “Save the Racks!”.  And then there is my husband’s personal favorite:  “Save a Life, Grope your Wife!”

Four years ago I travelled to Kansas to pick up a Ford E150 van being sold by the son-in-law and daughter of a friend out there.  Said son-in-law and daughter were artists, who had spent several summers touring with Ozzy Osbourne and his Ozzfest tour, running the souvenir/concession stands.  Not being a huge Ozzy fan, yet tooling across country on Interstate 40 with an Ozzfest bumper sticker on my well used van, I decided it was time for some research.  I was surprised to discover that Sharon, his wife, had been diagnosed with colon cancer while still in her 40’s, and had undergone successful treatment.  I was even more surprised to see how much money she had donated to Cedars Sinai Hospital in Los Angeles, to develop a whole center for excellence in the treatment of colo-rectal cancer.  But what surprised and delighted me the most  was to see Sharon’s own take on advertising for cancer awareness—quite possibly the best slogan ever:


Top that one if you can!

If Wishes Were Horses

For Missy

Is there any woman alive who can’t recite the old nursery rhyme “If wishes were horses,then beggars would ride”?  The line is etched into the memory of every little girl who ever wanted a pony, but its true lineage dates back to James Carmichael’s Proverbs of Scots circa 1628 when the original read  “and if wishes were horses, then pure (poor) men wald ride.”  In my post entitled “Nana”, I recounted my short though blissful riding career at age 10, ended prematurely by the illness of my grandmother.  During a brief college fling with a polo player (yes, he had a string of polo ponies and yes, his name was Julian, and yes, his family were Hungarian emigres of questionable political  heritage), I was treated to a ride at breakneck speed that started with an innocent giddyup and very nearly ended in my demise.  Ultimately I decided that I would prefer life and limbs intact and gave up on Julian and his horses that handled like Ferraris, but without brakes.

Twenty years went by– medical school, two residencies and three children later—I found myself as the Radiation Oncology director of a community cancer center equidistant between Cape Cod and Providence RI.  One day, I saw a young woman in her early thirties who had been diagnosed with breast cancer.  She had elected to have a  lumpectomy and radiation, and when I saw her for the first time she had just completed her adjuvant chemotherapy.  I noticed two things about her immediately—the first was that despite her hair loss and other effects of her chemotherapy, she was beautiful, athletic, confident and in control of her body, her life and her situation.  The second thing I noticed was her bracelet.  It was perfect—a golden circle made of beautifully worked horses heads, eyes alert, nostrils flared, ears forward, manes flying, the horses of my dreams .  There was no way that I was going to ignore that bracelet. But first things first—the cancer.  We spoke about radiation, the risks, the benefits, the course of treatment, the side effects.  She told me her biggest concern was her little girl who was only three years old—she wanted to make absolutely SURE that I knew that she was going to make it, because she could not bear the thought of her daughter growing up without her.  I told her I understood perfectly, and I did.

At the end of our session, I could restrain my curiosity no longer.  I asked her about the bracelet.  She told me she had always loved horses, and that she had grown up riding on the Cape. The bracelet was a gift from her husband, as was her horse, Percy.  She told me she rode that horse every day, rain or shine, stopping only briefly for her breast cancer surgery, and continuing on right through her chemotherapy.  She said, “He keeps me sane”.  She asked me if I rode horses.   I said, “No, but I always wanted to—I just never had the money when I was a teenager, and as I got older, with career and kids, I just never had the time.”  She looked me in the eye—and said to me, “Well the time is now.  You never know what is going to happen.  You could end up like me, with breast cancer or something worse, when you least expect it.  If you’re ever going to do it, you should start NOW.”

That was it—my wake up call from a patient who was smart enough to see what I had missed and game enough to point it out to her physician—that the only time and the best time one is ever guaranteed is right now, right here.  The following weekend, I got my 8 year old daughter out of bed, made a beeline to the girls boarding school riding stable near our suburban home, and signed us both up for riding lessons. My 5 year old son followed in breeches, knee straps and short stirrups, and my 2 year old– ever the cowboy—well, when he turned three and got his helmet, he loped Old Ellie around Far West Farm much to the shock and dismay of the other boarders, to see such a small boy piloting such a huge animal, completely on his own.

Twenty one years have passed since I saw and treated that patient.  I left the practice to move out west in 1993.  But every year, at Christmas, I get a card from her wishing me well, and thanking me.  Always included in the card are photographs of her, usually on her horse, though Percy is long gone, and also photographs of her daughter, now grown and a beautiful young woman in her own right.  And there is always a gift, a little something “horsey” chosen specially for me– a picture frame, a Christmas ornament, a beautiful box of stationery, a silk scarf—with ” clouds of white stallions with bright fiery eyes”. Every year, without fail, there is that renewal of our friendship, and a reminder of what is important in life.

As for the horses themselves– Rosie, Lucky, Veronica, Harmony, Sissy, Romeo, Truffles, Oscar, Shorty, Besty, Norman and good old Dash—they’ve served my family well over a period of twenty years, carrying us over miles of trails, and through both adolescent and midlife crises. They are the best therapists—they listen without comment or criticism, and they never mind when you cry into their thick strong necks. Winston Churchill said  “No hour of life is wasted that is spent in the saddle.”  But I still think that J.D.Salinger said it best in The Catcher in the Rye:

“I’d rather have a goddam horse.  A horse is at least HUMAN, for God’s sake.”

Who Wants to be First?

After much preparation, we opened our new radiation therapy department in September 2008.  Many many elements and “players” had to come together to produce a new state of the art community cancer center.  No detail was overlooked– the existing space had to be renovated  to create a more “zen-like” work flow and feel; the front office staff  had to be selected whose faces and voices would materialize as the “first impression” that our new patients would form as they entered a “brave new world”. My nurse had to be hired, who would play a critical role in the education and management of the patients.  Radiation therapists were recruited who would see the patients daily for up to eight weeks of treatment, directing the beams with the utmost precision while acting as “parents”, confidants, psychiatrists, social workers and otherwise infinite sources of knowledge, gossip and entertainment.  The physics staff– the dosimetrist who does the actual treatment planning and the medical physicist, ultimately responsible for the function of the machines and the safety of the patient—were chosen first, because in order to get a new radiation therapy department going, the linear accelerator must first be installed, and then “commissioned”.

A Linac is a very complex piece of equipment, housed in its own “vault”, a lead shielded room in the department.  Long ago, and far away, for precisely 24 hours before my written board exam, I could tell you EXACTLY how one works.  Now when a patient (and it is nearly ALWAYS an engineer!) asks me, “How does that thing produce radiation?”, I take his arm, and escort him to the office of my physicist who will gladly  explain everything (and I do mean EVERYTHING) to the patient.  Usually the patient emerges an hour later, with eyes slightly glazed over, and I am never asked another question.  And when it comes to explaining, and commissioning a linear accelerator, my physicist is simply the best.

The process of commissioning takes up to six weeks.  The company provides the “specs” of how the machine is supposed to perform, however we don’t just take the manufacturer’s word for it and plug it in and run with it.  After all, this is radiation, dangerous stuff if applied incorrectly.  The physicist uses his equipment to measure the output of the beam, at every different energy, at every different depth, for every different radiation field size.  Internal shields and beam adjustors and compensators are put through rigorous use to try to find faults. Computer connections are tested; video systems are monitored, and no stone is left unturned.  It is an arduous process, producing reams of data. At the end, when all is said and done, the machine must produce beams of sufficient strength, and fields of precise shape, or there will be no “acceptance”, and back it goes to the manufacturer.

So it was with great excitement and anticipation that we finally were ready to treat our first patient.  She was a lovely elderly woman with breast cancer, diminutive in size but full of personality!  She wore a royal blue boucle suit to her first treatment, replete with a silver flower brooch that she had made herself in her eldercare silversmithing class. She took tiny steps on her kitten heels down the ramp leading inside the vault.  Her hair and make up were perfect.  She was composed and polite to the staff.  She beamed at me.  As directed by the therapists, she changed into her gown.  They positioned her on the table, five feet off the ground.  They set the machine to its assigned position.  Everything was ready, so I pronounced, in my most important special occasion voice:  “Mrs. B, you are about to be the very first, number one patient EVER to be treated in this department on this machine.”

There was a moment of silence, and then Mrs. B EXPLODED into action, causing all of us, the therapists and me, to take a step backwards in surprise then forwards in alarm since she was at a height which could practically guarantee not only orthopedic but also neurosurgical injuries, should she fall.  She sat bolt upright and began to climb off the table, all the while exclaiming:  “The first?  THE FIRST??!!!  You never told me that I was the FIRST!   YOU GET ME DOWN FROM HERE AND EXPERIMENT ON SOMEONE ELSE FIRST!  I am not your guinea pig!  I’m going home RIGHT NOW!”

Okay…..would anyone else like to be first?


September 11, 2001 was supposed to be a very good day.  It was my mother’s seventieth birthday, and she and my father were scheduled to fly from their home in Colorado to New York City to celebrate with my sister, who lived on West 72nd Street, a few blocks from the famous Museum of Natural History, where dioramas of early man invite young and old visitors to step into prehistoric times.  As my parents opened the trunk of their sedan to start to load their suitcases, their next door neighbor came running outside, to tell them, “You’re not going ANYWHERE!  The World Trade Towers have been struck by airplanes!.”  In utter disbelief, they went back inside and turned on the television, to discover that America’s worst nightmare, a terrorist attack on our own soil had come to pass.

Because my mother did not get to go to New York to celebrate her birthday with champagne and a Broadway musical, she stayed home and scheduled her overdue mammogram.  Shockingly, because she had not palpated a lump, the mammogram showed a small tumor in the upper outer quadrant of her left breast. The biopsy was positive for invasive ductal cancer, and she had a lumpectomy and axillary node dissection, followed by radiation therapy.  The cancer was Stage I.  Eleven years later, she is cured.  Perhaps it is just a coincidence that she “remembered” to schedule her mammogram the day after 9/11 but I don’t think so.  I think that sitting at home, watching human beings falling from buildings and wives crying over lost husbands, and firefighters standing helplessly as the buildings themselves collapsed, their brethren inside, gave my mother a tiny premonition, a chilly little reminder that we are all mortal, and that we should never forget it and always take care.

On the day before the eleventh anniversary of 9/11,  there was finally fall out from that day that was eagerly welcomed by many:  The James Zadroga 9/11 Health and Compensation Act was expanded to include compensation for 58 different types of cancers potentially caused by exposure to toxic fumes and chemicals, exposures which were particularly intense for first responders and survivors at the scene, but which also affected the search and rescue volunteers and the clean up crews.  The Zadroga Act, passed by Congress in December 2010, and signed by President Barack Obama in January 2011, was named after a New York City Police Officer who died at age 34 of lung disease attributed to working around toxins at Ground Zero. New York Mayor Michael Bloomberg lauded the additional coverage, stating “Tomorrow we will remember those we lost to the 9/11 terrorist attacks and also those who bravely responded during and after the tragedy.”

I have not been to Ground Zero since the attack.  But I have dreamed of that place many times since that day.  In my dream, there is a stairway that rises naked from the ashes, and reaches the clouds where it disappears.  At the bottom of the stairway, there is a policemen, standing feet apart, one hand to his mouth where he blows a whistle whose noise pierces the dust and smoke, the other hand pointing the way OUT for the survivors.  Coming down the stairs, there are two men descending very slowly, because they are between them carrying a tiny elderly woman in her wheelchair. And just above them, on their way up, their faces lined with determination, are two firemen in full gear, hurrying skyward with no hesitation whatsoever.