Fire and Ice

“Some say the world will end in fire, some say in ice…..”     Robert Frost

Sometimes there is a very fine line between doing too much, and not doing enough.   I have been thinking about this lately as I watch patients go through radiation therapy.  It’s not  just the acute side effects that worry me with radiation, it’s the late effects also.  One only needs to have known a few patients who were treated for Hodgkin’s Disease in the 1970’s, with now archaic radiation therapy techniques, to realize the havoc that can be wreaked  later, in the form of breast cancer, coronary artery disease and other secondary malignancies.  And yet I always counsel patients who need the treatment to take it, because as hard as it is to say this, the cancer that the patient already has is far more likely to kill him than the theoretical risk of something bad happening 25 years down the line.  For some reason, patients have a hard time understanding this concept.

When it comes to an individual patient, the radiation dose is sometimes the issue.  Most cancers have a clear dose-response curve, where the higher the dose, the more likely the tumor will be obliterated– up to a point, and that point varies from individual to individual and from tumor to tumor. At the highest doses, the complication rate starts to rise, and some complications can be quite severe indeed.  So one of my duties is knowing when to stop, when enough is enough.

When I was a young doctor, just out of residency, the first year of practice was the hardest. One of my very first patients was a 50 year old Polaroid executive with a very advanced form of nasopharyngeal cancer.  I had the sudden and startling knowledge that I alone was responsible for curing this man—in those days chemotherapy and surgery played no role in treating this type of cancer.  It was terrifying to have that responsibility, even though I had been well trained.    I asked one of my mentor/ teachers about the total dose that he would use.  He gave me a rather conservative number, stating grandly that “A tumor recurrence is an Act of God, but a complication is YOUR fault”. I went with the conservative approach; the patient was cured, and seven years later I named my third child after him.

Many years later, I was chatting with a colleague and we were talking about philosophies of treatment.  I drew myself up, and in my most senior, most pompous and most commanding voice I said:  “A tumor recurrence is an Act of God, but a complication is YOUR fault!”  He laughed.  I had ten years experience on him and he actually laughed at me.  And he replied, “Well, my own mentor always said to me, the WORST complication is a tumor recurrence!”

Are you, my readers, fire or ice people?  I’ve discovered through the years, that “cooling it down a bit” has served me well.  But then again, I’ve never been a risk taker.  Not with my life, and not with others.