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.