How Old is Too Old?

Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

Dammit Janet

There is cancer.  And then there is CANCER.  The first refers to the ones we discover early, excise completely and move on—a tiny rent in the whole fabric of a life, easily mended or patched but never quite forgotten.  But the second, CANCER in capital letters—these are the ones that can never be discovered early enough, the ones that cause gaping holes in the hulls of unsinkable ships and the whole ocean falls in after the vessel goes under.  This kind kills, and kills so quickly that there are very few survivors left to mount the political assault necessary to raise millions for research and a cure.  These are the cancers that have no armies in pink T shirts walking or running for the Holy Grail.  Highest on my list of evil enemies these days is cancer of the pancreas.

In the early spring of 2011, my friend Janet Porter, President of the Scottish Deerhound Club of America, developed abdominal pain that she initially thought was gallstones or an upset stomach from food poisoning.  Her discomfort progressed rapidly and then, almost overnight she became jaundiced, with a yellow cast to the whites of her eyes, tea colored urine and light colored stools, because the blocked bile duct at the head of the pancreas cannot empty into the duodenum as usual, and the bile backs up into the blood stream and leaches into the skin.  She was diagnosed quickly, worked up well, and pronounced a good candidate for a Whipple procedure, one of the most difficult operations that a skilled surgeon can perform, involving removal of most of the pancreas, gall bladder and common bile duct with considerable rearrangement of the indoor plumbing. Janet was “lucky”.  Most patients diagnosed with cancer of the pancreas are inoperable and incurable from the minute they are diagnosed.  Janet was a smart cheerful optimistic person.  She underwent this difficult surgery, and then took months of chemotherapy and radiation, finishing late in 2011.  In the spring of 2012, she was able to attend the National Scottish Deerhound Specialty show which was held in Michigan. A week later she was told that the cancer had recurred in her liver and despite additional treatment she passed away on August 20.  She was 59 years old—we were born the same year. From the time she was diagnosed she lived every minute to the fullest—she saw her family, took care of her friends, and when it became clear that she was not going to survive she did what every good dog person does—she found homes for her beloved hounds.  I wrote something on the Deerhound List to try to describe her courage, and people liked what I wrote, but all I could think of, quite inappropriately, was title of that old song from The Rocky Horror Picture Show where Brad sings to Janet, in front of a cemetery—“Dammit Janet”.

Today in clinic I saw another patient with pancreatic cancer—this time a lovely woman who is 87 years old.  One of the best surgeons in the country had deemed her operable when she was diagnosed in May, but she hesitated, knowing that complications from such radical surgery could abruptly end her life, or at the least, affect the quality of her remaining days.  She was started on chemotherapy and did well initially, at least well enough to be considered for definitive radiation therapy, which is used when surgery is not desired or possible. Last week, a scan done for treatment planning showed that, like my friend Janet, the cancer had already spread to her liver.  Today I explained to her and five of her visibly distraught middle aged children that there would be no point to pursuing radiation therapy to the pancreas.  I said it would be like closing the barn door after the horse had gone.

Is an 87 year old dying of cancer less sad than a 59 year old?  How do you compare the life well lived for all those years which should have ended quietly, rewarded with a peaceful passing with the life that ended early, devastating friends and family?  Sitting in my exam room with that family today, I certainly could not say.  But tonight I am still thinking, damn it.  Janet.

How Do I Know This is Working?

This is the question I get asked the most:  “So Doc, how do I know that this is working?”  Sometimes my patients come to me with visible or palpable disease—something on the skin that they can see fading away, an enlarged lymph node in the neck that shrinks visibly during treatment, a lump or a bump that disappears, much to the gratification of both patient and doctor.  But most of the time, this is not the case.  Most of the time, the tumors are either deep inside, and not seen or felt, or the tumor has been removed, and we radiation oncologists are called in to do “clean up” work after the surgeon.  As disturbing as it might be to a patient, most of the time, we don’t actually know that “it”, meaning the radiation, is working.

I’m old enough to know that life is not black or white, right or wrong, on or off.  But still, as an optimist,  I  am a person who likes absolutes—I have always believed that if you play by the rules, you deserve to win.  I dot all of my  “I’s” and I cross my “T’s”.  I was the kid who NEVER colored outside the lines in my coloring book, and now that I am a grown up, everything should be in place:  my patients will attest to the fact that I am likely to rearrange the furniture in the consultation room if the cleaning people have set anything off kilter. I don’t see this as obsessive-compulsive—I see it as maintaining order in a disordered world.  I like to see justice served, the plates cleared off after dinner, and I do not eat dessert first.   In my linear world, the beginning is the consultation, the ending is the cure. The daily radiation treatments are the means to that end.  Why should my patients expect less?

So what do I tell my patients who ask tentatively, half way through treatment,  “Is it working?” when they have the invisible tumors, the ones deep inside, or the ones where the surgeon took most of it and we’re seeking out and destroying those microscopic stragglers?  One of my teachers once said, meaning to be humorous,  “Radiation works best when there is no disease!” Even the patients with the palpable masses that melted away—how can we be sure that every last malignant cell is gone?   At the end of treatment, my patients want to be told that their disease has been vanquished and will never come back.  Some doctors will oblige.  They will say  “We got it all”.  Or they say, “You are cancer free.”  This is despite the fact that there is not a single diagnostic test on the planet that can support that claim.

We oncologists prefer to use the word “remission.”  Or “complete response.”  As in, “You are in remission.”  Or “You have had a complete clinical and radiographic  response to treatment.”   We would love to say, “Your cancer is cured,”  because that is ever so much more satisfying than stating the truth, which is that we do not and cannot know for sure.   Sometimes, somethings, some days—you just have to take it on faith and try to move on.  Even if you are not a believer.

Here is what I tell my patients. I tell them that first the side effects will fade from their bodies and their memories.  And then  there will come a day when they will actually miss the camaraderie and support that they got from their chemotherapy and radiation teams. I tell them that the sun will rise and the sun will set, and they will bravely put one foot in front of the other.  And one day, before they know it, they will wake up and stretch and smile and they will have forgotten, just in that moment,  that they ever had cancer.  And that’s when they will know, it worked.

TANSTAAFL, or There Ain’t No Such Thing as a Free Lunch!

Robert Heinlein got it right.  In “The Moon is A Harsh Mistress”, sometime in the future, we colonize the moon.   But we don’t send our best and brightest, we send our criminals, our misfits, our dregs of society.  They eke out a hard living in this future penal colony:  their language becomes muted, shortened;  their luxuries are in short supply.  They learn lessons about survival early and often and they become a tough, spare people whose motto is “There ain’t no such thing as a free lunch!”

It is a great misfortune that this axiom is true in cancer treatment as well.  Sometimes patients come to me too late.  They have been seeking the path to a cure elsewhere, and in this part of the country elsewhere is many times across the border, where all manner of crooks and quacks (and as my Yiddish speaking grandmother would say, “SHEISTERS!”) have set up shop to convince patients with dread diseases that THEY alone have the cure. The first wave of so called “alternative” cancer treatments came in the 80’s with laetrile, distilled from the pits of apricots and peaches.  This was followed by a whole load of so-called “cleansers”, some of which involved putting some pretty disgusting substances into orifices that should have been on the giving and not the receiving end of the body (coffee ground enemas, anybody? Anybody?)  From the macrobiotic diet, to the wheat grass cures, to the more expensive and extremely dangerous Insulin Potentiation Therapy which killed Coretta Scott King, patients come in droves to line up for any “cure” but standard of care curative treatment. Scott King, Martin Luther King’s widow,  died a miserable death at the Clinico Santo Tomas, which was not legally licensed to perform surgery, take X-rays, run a laboratory, or dispense drugs from a pharmacy, all of which it was doing until an investigation after her death shut them down.  Patients will go to great expense and travel extraordinary distances from their homes to line the pockets of snake oil salesman.

Why do they do this?  They do this because they are so frightened of conventional surgery, chemotherapy and radiation, that they will do ANYTHING to avoid the purported side effects of such treatment.  I say “purported” because the reality of standard cancer treatments is often times far less toxic than what lies in the imagination.  Friends and relatives are often less than helpful, even though they are usually well meaning.  Trust me, there is no vitamin you can take, or juice you can drink, or special berry that you can put where the sun doesn’t shine that will cure you. Conventional treatments have side effects, but they also CURE cancer.

We’ve made great progress in the 30 years that I’ve been a radiation oncologist by reducing normal tissue doses, increasing shielding ability, shaping more precise radiation beams, and my medical oncology colleagues have done the same, with targeted disease specific drugs rather than the old “shot gun” approach.  But if you think that it is possible to cure cancer without risk, side effects and yes, even potential harm, think again.

In cancer, in life:  There Ain’t No Such Thing as a Free Lunch!

Blame it on the radiation!

“Blame It On The Bossa Nova”

(Barry Mann and Cynthia Weil)

 

I was at a dance when he caught my eye Standin’ all alone lookin’ sad and shy
We began to dance, swaying’ to and fro
And soon I knew I’d never let him go

Blame it on the bossa nova with its magic spell
Blame it on the bossa nova that he did so well
Oh, it all began with just one little dance
But then it ended up a big romance
Blame it on the bossa nova
The dance of love

(Now was it the moon?)
No, no, the bossa nova
(Or the stars above?)
No, no, the bossa nova
(Now was it the tune?)
Yeah, yeah, the bossa nova
(The dance of love)

Now I’m glad to say I’m his bride to be
And we’re gonna raise a family
And when our kids ask how it came about
I’m gonna say to them without a doubt

Blame it on the bossa nova with its magic spell
Blame it on the bossa nova that he did so well
Oh, it all began with just one little dance
But then it ended up a big romance
Blame it on the bossa nova
The dance of love

(Now was it the moon?)
No, no, the bossa nova
(Or the stars above?)
No, no, the bossa nova
(Now was it the tune? )
Yeah, yeah, the bossa nova
(The dance of love)(Now was it the moon?)
No, no, the bossa nova
(Or the stars above ?)

No, no, the bossa nova  (Fade)

What drives me really crazy is that if a patient has radiation, everything BAD that happens to them for the rest of their lives MUST be due to the radiation.  And it’s not just the patients that think that’s true.  It’s their referring physicians, the emergency room physicians they see in five years when they have their diverticulitis, their hair dressers, their dentists….the  list goes on and ON.

Here is my own version of this song:  you can Karaoke it but you’ll have to provide the music!

I was going for my cleaning and the dentist caught my eye.

She said, your gums are bad and your mouth is really dry.

She began to use that instrument that scrapes and makes you bleed.

I didn’t have the courage to tell her t’was my prostate got those seeds!

Blame it on the radiation!  With the killing rays.

Blame it on the radiation!  T’will be the end of days.

Oh it all began, with the big “C” word

But it ended up—Let me tell you life’s absurd!

Blame it on the radiation!   I’m in nuclear distress!

Was it my heart? (No, no, the radiation!)

I’m falling apart (Yes, yes, the radiation!)

Was it my brain? (No, no, the radiation!)

Am I insane?  (Yes, yes, the radiation!)

The rays of DOOM!

Now, I’m glad to say, that I am cured.

And I’m gonna write my blog, and make my feelings heard.

But when my friends ask how it came about,

I will be the first to shout:

It’s the acai berries, the magic mushrooms, have no doubt!

But any complications—well,

Blame it on the RADIATION!

The rays of DOOM!

 

My latest case was a man who has a very curable prostate cancer.  He’s a sweet guy, but lives alone and maybe his hygiene isn’t perfect but he tries.  On the day of his treatment planning, we photographed the area to be treated—it’s routine to do so.  My therapists noticed he had a very ugly rash on his anterior abdomen.  When he started his radiation treatments a week later, the rash was worse. I do not have the ability to look for fungal or bacterial infections in my outpatient clinic.  So I sent him back to his primary care physician for the appropriate studies to be done to determine the best treatment for this rash.

The primary care doc told the patient that his skin rash was DEFINITELY a radiation reaction. Would I send a patient with a radiation reaction back to his primary care doctor for management?  NO, I WOULD NOT! I would manage it myself, of course. This patient had only had one or two treatments.   I sent the primary care doctor the photographs from the treatment planning session with a note saying that this was not a radiation reaction—he had this rash BEFORE he had radiaton.  So far, I have not heard back from him.  But the steroids are working…..

Blame it on the radiation!  A song I know very well. Apologies to Mann and Weil!