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.

7 thoughts on “What Comes Next?

  1. Thank you for this extremely. Timely. Post. Serendipity struck her brass bell when google reader brought me first to you during this “not again-outta bed with hip pain-wish I were sleeping instead” experience during these wee hours of the wolf.
    So I forwarded the link to my sister of another mother who just finished her battle; I think she will get something and perhaps you will gain another subscriber. Have a good Sunday.

  2. This is often discussed in the Women’s Cancer Support group that I facilitate. While going through treatment they are DOING something to get rid of the cancer. When that period ends, they many times feels helpless, which leads to fear & anxiety. I’ve seen that women who are in a support group with others going through the same thing, but in different stages, realize this is coming & are not as fearful or surprised by their feelings. There’s nothing like talking with another who has been through the same thing. It’s never the same just talking to family & friends. Thanks for bringing this into the public conscience.

  3. I am looking at my last six sessions of radiology for breast cancer. I’ve already done the chemo and the bilateral mastectomy. I actually had to sit out these last two weeks because of the amazing and intense reaction my poor skin has had so far. But I see the end coming soon.

    So I have already experienced some of what you right about and it is amazingly accurate. I have never really been the center of so much attention in my life. It was very easy to focus on all the activity and new people in my life and overlook the underlying reason. Lately I have been at 6s and 7s trying to put perspective back on my every day life and no matter how often I would tell people that I want normal back, it was quite sobering when I realized that my normal is not going to come back.

    I had never been sick in my life. There was nothing that I came down with that a couple of days in bed, lots of liquids, some ibuprofen and maybe a hot toddy couldn’t take care of. What a wake-up jolt.

    And then, it all falls away. The doctors that were so much a part of my life, their nurses and staff, now I have to give them my last name when I call. That is the way it should be but I am struggling with what to do next.

    No matter what, I know how grateful I am for having the doctors and the treatments and the nurses helping me but I will never be normal again.

  4. Thank you so much for this article. The post treatment depression walloped me. I tried therapy, but it did not help. Finally, my radiation oncologist suggested a support group. The group helped, but the best emotional healer for me was simply the passage of time. You validated my feelings and I am grateful.

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