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.

Father’s Day

My father finds it hard to believe that he has a sixty one year old daughter.  I find it hard to believe I have a nearly ninety year old father.  I almost didn’t, which is story behind the scarcity of Crab Diaries blogs in the last two months.  If cats have nine lives, Dad must have ten or eleven.  The ninth life flashed before my eyes on April twentieth.

I have a “spiel” for the side effects and late effects of radiation therapy for every disease site. One of the late effects of radiation for abdominal malignancies is the risk of a small bowel obstruction months to years after the treatment.  My little speech goes something like this:  “Every patient who has ever had abdominal surgery, even for benign disease, is at risk for a bowel obstruction at some point later in their lives.  Scar tissue forms adhesions which restrict the bowel—if you’ve had cancer surgery, or an appendectomy, or even, like me, a C-section or two or three—you are at risk.  Radiation increases that risk, but if you recognize the symptoms early, and get treatment, there is a high likelihood that you can avoid surgery.  So if you ever have a period where you are experiencing abdominal distention, and realize that you are not passing gas, and start to feel nauseated, get thee to an emergency room for quick diagnosis and treatment.”

Apparently Dad didn’t get the memo.  In 2004, my mother called me late one evening to report that Dad had been in a car accident.  After running a red light, he was broadsided and found himself in the passenger seat when he should have been driving.  No, he was not wearing a seat belt.  He was taken to the emergency room of the hospital where he practiced, and was found to have a pelvic fracture, but he was “fine” and not to worry.  At his insistence, his colleague, the Chief of Plastic Surgery was called in and pronounced him fit to leave the hospital.  At four am, I got a second call from Mom, asking me “What does it mean that he got up to leave to go home and promptly fainted.”  It meant a ruptured spleen and I told her so.  A few hours and a splenectomy later, all was well– until April.

Dad woke up feeling a little queasy on a Friday after a lovely trip to Phoenix a few days earlier.  The feeling persisted and overnight the symptoms progressed, but being the stoic and ever in denial physician that he is, he knew that the food poisoning or virus would soon be over and he would be back to normal.  But when he described his symptoms to his primary care doctor nearly 30 hours later, she sent him to the nearest emergency room.  By the time I was able to get back to San Diego, he had perforated his obstructed bowel and was headed into surgery, two years after his second open heart surgery and one year after hip replacement, two months shy of his ninetieth birthday.  Surgeons are different from normal people.  At a time when I would have had my arm out for a shot of morphine and hospice, he said simply, “Let’s go for it.”   Six and a half hours later, minus eighteen inches of small bowel, he was brought to the ICU where I was asked, as his next of kin and medical power of attorney, what his code status was.  You know the answer. Despite all of my previous prejudices against family members who refused to acknowledge the obvious—that 90 year olds have to die sometime, he was a “full code.”

Dad is back home now in his own apartment, feeling a bit tired but generally speaking no worse for the wear.  Despite the fact that my sister and I were at his bedside continuously for a month, when he returned home, he sent a long email to all of his friends describing his ordeal and thanking his girlfriend Evelyne for her devotion to his care.  His daughters were cc’d on the email.  After a serious bout of righteous indignation, I reminded myself that patients NEVER remember their time in the intensive care unit, and that is a VERY good thing.  The entire family will be headed to California in ten days for his big 90 birthday, and we couldn’t be more thrilled.

Happy Father’s Day, Dad, and we sincerely hope there will be many more.  Your loving daughter—M.

Two Hundred and Nine Short Essays Later

 

Here I am in Boston, on the eve of my very first writer’s conference, feeling a bit like an imposter.  After all, the extent of my writing so far has been this blog, apart from thousands of histories, physical exams and treatment plans over the last thirty-nine years since starting medical school.  It occurred to me that someone might actually want to know what it is that I write about.  And then it occurred to me that I had never actually thought about it.  So I did, and this is what I came up with.

 

WHAT I WRITE ABOUT:

Cancer                                                                                                                           Radiation Therapy                                                                                                                 Dogs                                                                                                                                   Cats                                                                                                                                     Horses                                                                                                                                   Being a mother                                                                                                                         My kids                                                                                                                                 Travel                                                                                                                                    My father                                                                                                                               My mother                                                                                                                             Being a doctor                                                                                                                         Life

WHAT I AM TRYING TO SAY ABOUT LIFE

Cancer patients inspire me and motivate me                                                                       I’d like to explain a few things about cancer                                                                         I’d like to explain a few things about radiation therapy                                                     Cancer is evil and is not selective and makes me sad                                                 Cancer patients can be funny and they also make me laugh                                   Sometimes people do really stupid things when it comes to cancer treatment         Sometimes simple people can be heroes                                                                         Dogs are good therapy for me, my cancer patients, and my kids                                     Ditto on cats                                                                                                                       Horses are beautiful, liberating, dangerous and always expensive                                     You can be a mother AND a doctor and it’s going to be very hard                                     Your kids will forgive your shortcomings                                                                            Your kids will make fun of you                                                                                           Your kids will be successful if you EXPECT them to be and don’t harass them              Travel is enlightening and sometimes difficult and sometimes funny                                    My surgeon father is both an inspiration and a source of extreme annoyance                       My mother had a hard life and a hard death, despite appearances                               There’s always someone worse off than you                                                                   There’s always something to hope for

 

WHAT I AM TRYING TO SAY ABOUT BEING A DOCTOR AND ABOUT MEDICINE

Examine your patients—it’s important                                                                               Think for yourself and follow your gut instinct                                                                Beware of templates.  They tempt us to cheat                                                                     The Rules of the House of God still apply                                                                      Doctors make mistakes.                                                                                                       Be very selective about who you hire and set a good example for them                             Be the captain of the ship                                                                                                     Try not to whine, even if you fail                                                                             Communicate with your referring doctors and with your patients                                     Take the time and make the time                                                                                         Learn to speak slowly and clearly in layman’s terms                                                           Try not to say no, and never say “never”                                                                             DO NOT DROP THE BALL when dealing with cancer patients                                           And finally, answer your goddamned phone calls

Did I leave anything out?

The Glass Is Half Full

A couple of weeks ago my nurse came to me with a request for a consultation.  Since our schedule has been packed full lately, she’s been asking me where I can squeeze patients in.  She said, “I’m not sure about this one—he says you treated him twenty years ago and he wants to see you.  But there is no new pathology so I don’t know how urgent it is.”  I looked at the consult request and did not remember the patient but there were several handwritten jottings on the cover sheet from the referring physician that listed phone numbers and beside them, “no answer at this number X 3,” and “Dr. Fielding hasn’t worked here since 2004.”  Apparently some effort was made to track me down, since I have changed jobs a few times in the last twenty years. I said, “Well get the latest information on the patient and put him in the open emergency slot a week from Friday.”

So Friday came yesterday and this patient was scheduled at one o’clock.  I like to review the charts before I see new patients, so I picked up the chart during a hurried lunch and read through it with a growing sense of recognition, and no small amount of dread. The man had been treated for advanced head and neck cancer back in 1994.  He had presented with cancer on the lateral aspect of his tongue, which was excised by his surgeon.  Six months later, he recurred both on the tongue, on the soft palate, and in his neck, with a large tumor wrapped around his jugular vein.  His surgeon tried, even sacrificing the large vein, but he could not resect all of the cancer and the patient was referred to me for post-operative radiation therapy.  Given that the man was only fifty one years old, his medical oncologist made the decision to give him chemotherapy along with the radiation, a decision which was considered quite radical at the time.  Treatments for head and neck cancer back then were crude by today’s standards, and fraught with complications, and this man had had all of them.

By 2000, he could no longer swallow, and his esophagus had to be dilated.  This happened again in 2008, and another procedure provided relief.  His saliva never fully returned after treatment, and so in 2012, plagued with tooth decay, he began a series of extractions, augmented by hyperbaric oxygen therapy to prevent osteoradionecrosis of his mandible.  Unfortunately this did not work, and he ended up having a portion of his jawbone removed.  A year ago, he began to have a new issue—when he tried to swallow the food was going down “the wrong way” and causing him to choke, resulting in several episodes of aspiration pneumonia.  It was becoming hard for him to go out socially, and enjoy a meal with friends and family. His carotid and vertebral arteries were narrowed, putting him at risk for stroke. Multiple recent studies showed no evidence of recurrence of his cancer, but there was scar tissue in the back of the throat which prevented the epiglottis from closing over the trachea when he swallowed.  These were the things I read in his chart before I saw him, and I anticipated that our session together would be an angry one.

Tall, older and thinner than I had last seen him, the patient greeted me with a huge hug.  His wife smiled warmly.  As we sat and talked in our sunny consultation room, he described his current difficulties and told me that his surgeon had referred him back to me for electrical stimulation therapy of the throat muscles, which might help his aspiration.  Our institution has an entire department for the rehabilitation of head and neck cancer patients.  I groped for the right words to say to this man who had suffered through complications which are rare by today’s standards of care.  I apologized profusely, and explained that now we have better ways of shielding normal tissues to spare patients the terrible late effects of treatment.  I told him I would be happy to put in a referral to our swallowing and speech rehabilitation specialists.  He looked at me in surprise, and said, “Doc, I didn’t come here for that.  Dr. M (the surgeon) already put in the referral. When I found out you work here, I came to say thank you.  I was fifty one when I was told that my chances of survival were 10 per cent.  Now I’m seventy one years old.”  He squeezed his wife’s hand and said, “We’ve traveled the world together.  We’ve seen our grandkids graduate high school.  We’re going on a cruise to San Francisco next week.  Yeah, I’ve had my problems but we’re still having fun!”

Some folks are just “the glass is half full” kind of people.  Having always thought of myself as one of them, I’m surprised it took me a whole consultation to recognize that in my patient. Taking care of cancer patients has always been a good way to remind myself that my own life is not so bad.  Lesson learned, again.

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!

Another Thanksgiving

Every year when the time changes and the days get shorter and the nights longer, I start to feel it.   By the time that the halls are decked with boughs of holly, now shortly before Thanksgiving, the season of airport delays, of frantic last minute shopping, of eating and drinking too much and then doing it again has begun, and with it, for many, the season of sadness.  At a time when festivities and noise are ramping up in the outside world, the Cancer Center becomes curiously still and quiet.

No one wants to get chemotherapy and radiation for Christmas.  It is far easier to ignore that lump or bump or missed mammogram than it is to schedule one more thing—a doctor’s appointment—when there are trips to take, family to visit and cookies to bake. And for those who have been recently diagnosed, it is rare that the treatment can’t wait a few weeks, just until “after the holidays.”  Although the “C” word strikes terror into our hearts, most of the time cancer truly is not an emergency.  This time of year, lunch breaks actually appear on my schedule, and the therapists cheerfully ring me up promptly at five to check the localization films for the day.

It isn’t hard to squeeze a new patient in this time of year, but when I get asked to do so, there is a very good chance that that patient is a little bit sicker, a little bit more symptomatic, a little bit more urgent and oftentimes a little bit younger than the average patient that I see though out the rest of the year.  Especially if that patient is hospitalized. Every year, there is someone—a husband, a wife, a child, a brother—who won’t be home for the holidays.

And so tomorrow, when you raise your glass around the Thanksgiving table, and give thanks for all of the blessings you have, do not forget to give thanks for your good health and that of your family, if you are lucky enough to have it.  And send out a prayer, or a positive thought, or an email or card to those who have not been so lucky.   It will mean the world to them.   Nobody wants cancer for Christmas.

The Gift of the Magi

When I was young, one of my favorite stories was O. Henry’s “The Gift of the Magi.”  Originally published in 1905, the short story became standard fare in public school reading classes and I doubt that there are any of you out there who have not read it.  But just in case– the story is about a young couple, poor and deeply in love.  At Christmas, they have no money to buy each other gifts.  She cuts off her long golden hair, her prized possession, to buy him a watch chain for his own treasure, the pocket watch his grandfather left him.  He sells the watch to buy ornamental combs for her beautiful tresses.  In a classic example of cosmic irony, the two are bereft of everything except their enduring love for one another.

Yesterday, an eighty five year old man was crying in my office.  A month ago, he completed a grueling seven weeks of treatment for head and neck cancer. Otherwise healthy, he endured the side effects of treatment with great equanimity—the loss of taste, the sore throat, the dry mouth, the hoarseness, the skin reaction, the fatigue and the weight loss associated with treatment.  His reward is great—he is free of disease and very likely to remain so.  He drove himself to every treatment, clearly motivated to complete his therapy despite his advanced age.  I never had to cajole him into continuing and finishing the treatment—he was clear that he was doing this for his wife of sixty three years, and for his family.  He wanted more time, and more healthy time with them.

When I saw him in follow up, I asked him how his post treatment time had been.  Many times for radiation therapy patients, the week or weeks following treatment are even more difficult than the treatments themselves—the side effects may worsen before they improve.  So I was not surprised when he said, “It’s been TERRIBLE.”  I patted his arm and said, “Tell me about it.”  He replied, “Right after I finished, my wife was hospitalized and now she is in kidney failure.  She started dialysis on Wednesday.”  Somewhat surprised that an eighty five year old woman would choose to go on dialysis, I asked him, “Do they expect her kidney function to improve?”  He said, “No, the doctors said there is no chance of improvement.  The hospital doctor said that under no circumstances would he recommend dialysis for her.  But the kidney doctor said it was her choice—to have dialysis and live, or to be made comfortable and die.  She chose to live, for me.”  And then he wept.

We can all be cynics or pragmatists if we choose.  We can talk about the escalating cost of healthcare, and the wisdom or folly of treating eighty five year olds with intensity modulated radiation therapy and daily image guidance and their wives with hemodialysis.  But what I saw yesterday was an affirmation of enduring love, in two elderly people, who gave one another a gift not unlike “The Gift of the Magi”—the gift of sacrificing self to continue to live.  It’s hard to be cynical about that.

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!

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.