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.

Denial Is Not a River in Egypt

If you desire healing,
let yourself fall ill
let yourself fall ill.”
Rumi

Yesterday I saw a patient—an 80 year old woman with metastatic cancer involving her bones.  She had near complete replacement of her twelfth thoracic vertebra by tumor, and also significant destruction of her fourth and fifth lumbar vertebrae, demonstrated by PET-CT scan and bone scan.  She had so much pain in her legs that it was difficult to walk.  In attempting to discertain whether her pain was coming from her thoracic or her lumbar spine, I asked her a series of questions.  The only answers I got were that she had slipped while getting into the bathtub a few weeks ago and that her pain was in her left ankle and her right thigh, both of which had been X-rayed and were normal.  Questioning her about her bowel and bladder function was also unrevealing—sure, she had problems with both, but that was because of the radiation she received in 2009.  It would seem as though her cancer was causing her no pain at all, yet that was why her medical oncologist had asked for a stat referral.  After 30 minutes of discussing her bathtub mishap, her daughter had had enough.  She nudged her mother and said, “Mom, you KNOW that is not why we are here.”

My eighty seven year old father has been similarly reluctant to attribute his recent symptoms to his failing aortic valve.  Despite being told last summer that he had aortic stenosis, he asserted to his cardiologist that he had no chest pain, only a little shortness of breath with exertion.  He was able to walk downhill the eight tenths of a mile to his tennis club, but walking back up had become more difficult.  In December, he was still playing doubles tennis despite the fact that he had squeezing chest pressure which occurred with exercise, and was relieved by rest.  His cardiologist believed him—that his symptoms were pulmonary rather than cardiac.  The pulmonary doctor from Denver was summoned, and the lung consultation was exhaustive.  The conclusion was that my father had nothing wrong with his lungs.  My father, who by the way is a physician himself, could not admit that his symptoms were classic angina pectoris, and were worsening to the point where he was having them with minimal exertion. For the last two months he has insisted to every doctor who has interviewed him, “I have no chest PAIN, only a little squeezing pressure when I exercise.”  The result has been undiagnosed congestive heart failure which would have killed him, if he had not contracted an upper respiratory infection which landed him in the hospital and led to the real diagnosis.

I admire the stoics, the non-complainers.  I am not one of them.  When I have an ache or a pain, the entire world knows about it.  But there should be a limit to stoicism and that limit should be where the patient who is in denial is doing himself harm.  On Monday, my patient will undergo a CT simulation for radiation treatment of her thoracic and lumbar vertebrae before she suffers from a spinal cord compression and paralysis from her cancer.  On Tuesday my father will have his aortic valve replaced.  May they both emerge from their ordeals physically and mentally intact.  And may their doctors, including myself, learn to diagnose and treat these patients before they do themselves irreversible damage.