Tag Archives: cancer

Gold

A woman in her 70’s came into my clinic last week. Her primary doc found a mass so she came to the hospital for a biopsy and passed out on the table so they scanned her head and found a mass there, too. She started radiation and then came to meet me in the outpatient clinic.

She had trouble expressing herself because she’d had a stroke two decades ago, but it didn’t interfere with her comprehension. She and her husband had found their rhythm – she mostly answered yes and no to questions, and for more complex answers she’d flick her gaze over to him and he’d supply the answer she couldn’t manage, and she’d confirm ‘yes.’

When I first meet a new patient I try to ease into the cancer discussion (usually to the consternation of my more time-pressured attendings) so one of the questions I asked her was how long she and her husband had been married. She said, ‘ten.’ He said, ‘No, you know that’s not right,’ and she looked to him for help. ‘You want me to tell him?’ he asked her and she nodded.

‘Fifty years, he told me, like he couldn’t conceive a finer achievement. They were 19 and 20 when they married and I’m not overstating the vibe between them, I felt like I was like watching The Notebook.

We reviewed her images and the details of her type of cancer and what the different treatment choices might be. I tend to repeat myself a lot during these conversations because nobody ever hears it all the first time through. When we were nearing the end of the visit, the patient’s husband asked, ‘so, could you tell us what stage of cancer this is?’

Which, shame on me, is a piece of information I had assumed they’d already been told. If there’s one thing that anyone who has ever known anyone with cancer knows, it’s that stage IV is the stage you don’t want, and I’d been carrying on the conversation without first gauging depth of their understanding.

I told them, and it was not what they had been expecting. They both broke into shocked tears, so I took a minute not to say anything and gave them space, which they took. Five decades together and it wasn’t difficult for them to find each other in that moment without my presence making a difference.

I’ve had to tell a few other people this type of news, and there was a difference this time. Most people deflate into themselves, and you can watch their world change by watching their face. Everything else in the room goes away, and their chin lowers to their chest and their shoulders sink inward and their world fills with noise and nothing else you say to them after that means anything.

This woman looked over to her husband, who still cried and his voice cracked when he tried to talk. In his mind, his response was both of their response because he was so used to filling in the gaps for her, now hindered by his inability to get out full sentences. She cried too, mostly silently, and watched him. The expression on her face was not what I typically see in this setting: her eyes were tearful and open and full and fixed on him, not threatened or frightened like most who have just received this type of news. She seemed almost wistful.

‘You’re sadder for him than you are for yourself, aren’t you?’ I asked. She nodded and cried more. They were so absorbed in each other, and so flattened by the news that I gently ended the visit and let them stay in the room until they chose to go. We didn’t make any decisions about treatments and didn’t talk any more about median survival or risks and benefits of chemotherapy.

Sometimes my job is to talk, but during this visit my job was to watch. To watch how fifty years of life together makes a terminally ill woman grieve for her partner rather than for herself because she knows how profound his loss will be. To watch and not to speak because I was in the presence of two people who had become what they were despite two decades of her being unable to generate a whole sentence, and who had found that in their case, words were generally not necessary.

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Cure

WhyNoCure

Sometimes I tell people I’m learning how to treat cancer, and their first question is ‘why haven’t we cured cancer yet?’

We will.  It’s coming.

In medicine we’re much better at treating infections than cancer, but it wasn’t always that way:

  • We didn’t know washing your hands before delivering a baby was safer for women until 1847.
  • The concept of a germ was proposed in 1870.
  • The first vaccine was made in 1879.
  • Penicillin didn’t show up until 1928.
  • The last fatal case of smallpox was reported in 1978, and smallpox was declared eradicated in 1979.
  • The AIDS epidemic began in 1981 when five previously healthy patients were diagnosed with Pneumocystis carinii pneumonia.
  • Now, HIV has changed from a deadly incurable disease to a chronic treatable infection thanks to anti-retroviral therapy.

When my grandparents’ grandparents were alive, we didn’t know that ‘germs’ existed.  Today we can prevent HIV from becoming AIDS.

The cure for cancer won’t be one discovery.  It won’t be one bold headline or a news broadcast.  Right now we’re in the phase of research that is like walking into a pitch-black room and feeling around until you find a light switch.  Practicing oncology is like standing at a wall of light switches and flipping the right ones (thankfully the scientists label them for us). Discoveries are made one light switch at a time, someday we’ll find the whole room is lit.

We’ll keep pushing things forward and one day we’ll notice that the word ‘cancer’ no longer strikes fear in us the way it does today. Cancer may become a chronic, suppressible disease like HIV has.  Maybe we’ll find better ways to find it early before it’s too advanced.  The days of toxic chemotherapy will be gone, and things like cancer vaccines , cancer-selective antibodies, drugs that target cancer-specific gene mutations, and drugs that cut off cancer’s blood supply will take its place.

But that’s only part of it.

Look at how people phrase this question, ‘when will we cure cancer?’ The we who will cure cancer are not doctors or scientists or drug companies or governments.  The people who will cure cancer are the patients.

Thank you if you have ever participated in a clinical trial.  Your contribution to cancer research is more valuable than any discovery that has ever made by a lab scientist or physician.

Thank you if you have ever accepted the care of a medical student, resident, fellow, or nursing student in an academic hospital.  You are the most important teachers we have.

Thank you if you are currently trusting us to treat your cancer, or if you trusted us to treat someone you loved.  This is not an honor we take lightly.

Thank you for your help.

Because of you, someday we will look back with incredulity and say ‘can you believe there was a time when young people died of cancer?’ and the fear we now feel when we say its name will be gone.

Breathe

We’re born into our bodies, and we take that for granted.

Our first job is to take a breath, something we’ll hopefully do many millions of times and never think about.  That first breath changes everything:  our blood starts to flow through our heart and lungs in a different way and for the first time we taste a new world.

Before we’re born, all our needs are met via an artery and a vein.  It’s how we get our oxygen, our nutrients, our means of fighting infection.  When that connection is lost,  we start to depend our own body to notify us when we need something.  If we’re fortunate, there’s someone nearby to respond, to feed us, to clean us.

Sometimes that need is simply to be held, a combination of touch and movement and hearing a larger heart beating, and we learn to assemble those things into love.  Messages from our body, delivered to our brain and becoming the most important emotion we’ll ever experience.  A reassurance that what we need will continue to arrive, that we will be able to grow and thrive and remain.

Anyone who attempts to distill these things down to science, to a cascade of synaptic firing and neurotransmitter release can never have held their own child during the moments of those that first breath, that first cry, after making it through all that pain and fear and blood and  felt the flood of relief carried on that mighty shriek. The first of hundreds of millions of breaths to come.  Much more than physiology and catalytic enzymes.

Our bodies – astoundingly complex assemblies whose chemistry we’ve only begun to understand, physical substance that is driven and maintained by emotions that become so intertwined as our bodies and minds develop, that we cease to understand them as distinct things.  We discourse about the physical self and the emotional self as if they’re separate, but they’re not.  Each is made of the other.  They are undissectable.

When we’re young, our bodies are our deliverance.  Uncontainable energy, flexible and cartilaginous and healable.  Limited only by the height of the countertop and too many syllables.  Sometimes our bodies report pain, but it’s usually the byproduct of growth spurt or exertion.  Sometimes it’s a bone knitting back together or a scar forming.

As we age, we calcify.  Our thoughts and legs less prone to frenzy and sometimes harder to compel.  We creak and pop and sometimes forget.

Sometimes we discover a new character of pain.

I had a patient who was diagnosed with stage IV lung cancer, found when she came to the hospital for weakness in her legs.  It was in her lungs, her bones, her spine, her brain.

The body she had come to trust, to recognize as herself, the place she depended on, now an enemy. Now she was confined in a small space with a fast, destructive thing whose motives were unknowable.  Her cancer all but ignored our medicines, and her back pain and headaches became the landscape on which all other things were placed.  Nothing was just one thing anymore.  Hunger and eating both meant pain.  Eventually her ribs hurt so much that the previously effortless act of taking a breath was restricted as if tied by wire:  the memory of deep lungs unable to be satisfied by her short, stabbing attempts.  Her physical home, invaded and traitorous.  Her mind, however, remained without self-pity or resentment.

My colleagues in Palliative Care were able to give her the only thing she needed then:  a reprieve from the relentless transformation of her physiology into the source of her greatest pain.  She passed away comfortably in her home attended by hospice nurses.

She and others have taught me that there’s a part of us that’s unafflictable.

There’s a thing in us that cannot suffer disease, or degenerate, or know pain.  Objectively, I don’t know what a spirit or a soul truly are, but I can say with some hope that I don’t think our bodies are our limit.  When our physical self transforms into something malevolent, we remain something else: a thing that is capable of dignity and strength even when our ability to raise our head is taken away.   This thing opens our eyes when we first join the world, and squeezes our lungs to project that first high-pitched roar in the delivery room.

It’s the thing that drives our first breath.
It remains after our last.