For Ellen

“to live in this world

you must be able
to do three things
to love what is mortal;
to hold it

against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go”
Mary Oliver, New and Selected Poems, Vol. 1

As a parent, you are not supposed to have a favorite child, and since some of us physicians feel a strange but kindred protectiveness for our patients, likewise we feel guilty about having favorites.  But we always do. My favorite patient died last night.  On my last day of work, I gave her my email address and my cell phone number, so we could keep in touch.  She gave me a bright red stuffed teddy bear, so that I would always remember my “wild red headed woman from Texas.”  Except that she had no hair–she had grown and lost it so many times over the six years I treated her that even I lost count.  When I retired, I made sure that she had a follow up with one of my colleagues, who I trusted would give her his best opinion and effort in managing her care.  When he saw her in March, he told her there was nothing more he could do.  She signed on to hospice the following week.

She was diagnosed with a rare form of cancer of the uterus nine and a half years ago.  By the time I met her, in 2008, she had already developed lung metastases and had undergone several courses of chemotherapy, none of which had kept the metastases in check for very long.  After a trial of radiofrequency ablation which resulted in a pneumothorax and chest tube, she was referred to me for consideration of stereotactic radiosurgery.  We treated her lung lesions one by one, and one by one they faded into scar tissue.  She was happy and relatively without symptoms until eighteen months ago, when she began to recur in the lung, and brain, and soft tissues of her muscles.  She remained upbeat, larger than life, encouraging the radiation therapists to treat each new lesion as it occurred.  My entire staff looked forward to treating her every time she returned to the department.  We joked about awarding her “frequent flyer miles” and she laughed and her blue eyes sparkled. Her chocolate chip cookies were legendary, and she gave us the recipe, but they never turned out the way they did when she baked them.  We accused her of leaving out a secret ingredient and she protested vigorously.  She said she would never do that.

She traveled a lot in the last year of her life—to visit her children, to see a new grandchild being born.  Her last trip was to New Orleans with her husband, where she looked forward to eating beignets and listening to Dixieland jazz, even though her trip was interrupted by an emergency room visit for shortness of breath. When we parted at the end of February, we promised to keep in touch and get together for lunch or dinner but she had complications from her last course of therapy, or from the cancer itself, and when I heard from her by text and by email, the news was not good.  In her last email, she told me she had joined a gym, determined to try to regain some of her strength. She promised to call when she was feeling better.

She did call me, last weekend, to see if I could have lunch with her and her husband on Thursday.  I missed her call, but I knew I was busy that day, so I called her back to reschedule but she did not pick up the cell phone.  And so I was not surprised when I received the news today that she had passed away last night.  Not surprised, and yet astounded, that such a vital life force had left us.  My entire staff is bereft.

In his email to me and I am sure, countless others who knew and cared about her, her husband included two photographs of her.  In the first one, they are cutting their wedding cake—she in her beautiful white dress with her long flowing red hair and he, handsome in his tuxedo and moustache.  Over thirty years must have passed between the first photo and the second, where she stands alone, healthy, beaming, and holding a yellow rose.  After all, she was from Texas. As I looked at the pictures again this evening, it occurred to me that I knew that the ingredient she poured into those chocolate chip cookies but forgot to write down for the rest of us was love.  Simply and purely, love.

I’ll Take the Sexy Name

When it comes to radiation therapy products, the high tech companies really outdo themselves with names.  It seems to me that the higher the price tag on the item, the more thought goes into the label.  Varian, the largest manufacturer of linear accelerators, trumped its competition with the moniker on its latest linac, the “TrueBeam”.  What were all the other linacs–  “FalseBeams?”  Even the software gets a fancy name—I remember being in San Francisco a few years ago, sitting in a glass fronted restaurant when a city bus rolled by with the entire side painted with the Varian logo and the words “RapidArc” along with a letter from a child, in hand printed block letters, telling the mommy’s cancer to “be gone” now that she’s being treated with RapidArc.  RapidArc is just software that allows the linac to treat in a continuous 360 degree arc rather than making multiple stops along the way.  The technology speeds up the treatment, but in no way cures more mommies of cancer.

Nowhere does the name game get played out with more gusto than when it comes to anointing new stereotactic radiosurgery equipment.  This technical advance in radiation therapy originally allowed more precise targeting of very small tumors which were unfortunately located next to critical structures, particularly in the brain. Now it is used increasingly to treat lung cancers and metastases to liver and bone.  Roll down any big city freeway these days and you’re bound to see a billboard advertising Cyberknife (usually followed by exclamation points!!).  In a naming tour de force, the Cyberknife is made by a company called AccuRay—again, are the other companies “In-AccuRay?”  The name Cyberknife has made a big bang in the pantheon of medical terminology—with its connotations of cyborg and scalpel, both non radiation oncologists and patients alike imagine that the tumor explodes on impact, and disappears in a radioactive dust.  I am repeatedly amazed when I go to Tumor Boards and am asked, “Can’t you just Cyberknife it?”   Never in the history of radiation oncology has a new technology become a verb.  But when you think about it, if given a choice,would you rather be Cyberknifed, or would you rather go to BrainLab? Shades of Frankenstein!  Cyberknife wins hands down, despite the fact that BrainLab and Trilogy are competing, equally effective modalities for radiosurgery.

Radiation is radiation, my friends.  The technology is ONLY as good as the physician who decides to treat you in the first place, the dosimetrist who performs the calculations, the physicists who QA the plan, and the radiation therapists who aim that machine in the right direction.  So do yourselves a favor and don’t go chasing after the sexy names.  Ask about the credentials of your doctor and the physicist instead and you won’t go wrong.  But even so– my mind sometimes wanders back to my residency days when one of the Cobalt 60 units was called “The Eldorado.”   Now THAT was a name!