Respectful Insolence

The monster returns

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgWhile I am on vacation, I’m reprinting a number of “Classic Insolence” posts to keep the blog active while I’m gone. (It also has the salutory effect of allowing me to move some of my favorite posts from the old blog over to the new blog, and I’m guessing that quite a few of my readers have probably never seen many of these old posts.) These will appear at least twice a day while I’m gone (and that will probably leave some leftover for Christmas vacation, even). Enjoy, and please feel free to comment. I will be checking in from time to time when I have Internet access to see if the reaction to these old posts here on ScienceBlogs is any different from what it was when they originally appeared, and, blogging addict that I am, I’ll probably even put up fresh material once or twice.

I’m bummed.

It began a few weeks ago. After getting back from vacation, I was sitting in my office, not in the least bit please to be back, arduously climbing the pile of reports and journals that had accumulated on my desk like a mini-Mount Everest that required me to be Sir Edmund Hillary, my mind wandering during the drudgery, wondering how on earth my partners, who, not having to run a lab, are much busier than I am clinically, can deal with what surely must much bigger piles of paper and many more clinic dictations and operative notes than I. Of course, they don’t have to deal with massive grant applications, but I can’t figure out if that balances things out or not. In any case, I was nearing the end of the pile when I came across a dictation from Radiation Oncology about a patient of mine. I was just going to glance at it and leave it for later, assuming that it was just a clinic note about the patient’s standard adjuvant therapy, when I remembered something. I had operated on this patient a while ago (I’ll call her Mrs. X). Her adjuvant therapy was over. She shouldn’t be seeing a radiation oncologist anymore

I read the note.

Ah, shit! I thought, as I slumped back into my chair.

Mrs. X had shown up in my office last year complaining of a large mass under her harm. On examination, she had a 5 cm mass that was either in the axilla or the axillary tail of her breast and appeared to be fixed to the chest wall, making it inoperable, stage IIIB. Once again, I marveled at the power of denial. Surely this thing had been palpable for a long time. Surely she must have been aware of it. Finally it must have gotten so large that she had to seek attention. By this time, she surely knew what it was, at least at a subconscious level. I knew she knew. Yet the ritual dance went on nonetheless, in which I did a core needle biopsy of the mass, pretending that there was a chance that it was something other than what we both knew that it was.

Not surprisingly, it was. Breast cancer. It wasn’t clear if it was an involved axillary lymph node or if this was the primary. It actually didn’t really matter much which it was. Because her tumor was not operable, after proving the diagnosis, I ended up referring her to a medical oncologist for neoadjuvant chemotherapy to try to shrink the tumor to the point where it could be surgically removed. I strongly suspected that she probably had metastatic disease, but all of her studies showed no evidence of disease outside of that mass, although an MRI did confirm what my physical exam showed, that the mass was infiltrating the chest wall. So she went to my favorite medical oncologist, who gave her six cycles of chemotherapy over several months.

When she came back, she was changed. Yes, the mass had melted to a fraction of its prior diameter and become unstuck from the chest wall. Indeed, it was so small that I was concerned that it might disappear and not be easily found at the time of surgery. But she had lost her hair and her cheeks were sunken. But she was still potentially curable, even if the odds weren’t that hot. So I operated on her. Not surprisingly, there was residual tumor left, but less than we expected. She then underwent radiation. I hadn’t seen her in a while, but the last time I did she was doing fine.

But, always, lurking beneath the surface, was the monster, like a shark circling the survivor of a shipwreck. And I knew there was a high probability that the monster would return. If Mrs. X acknowledged how much at risk she was, she didn’t show it. I knew I had told her. Knowing her medical oncologist, I’m sure he too had told her and that he probably had even put a percentage risk on her odds of recurrence in five years. Stage IIIB is about as high a stage of breast cancer that still has a reasonable chance of “cure,” but the chance isn’t that great.

And now, several months later, I learned that the monster had indeed returned.

According to the note, about a month and a half before, she had noticed headaches and dizziness that became persistent. She saw her oncologist, and a CT scan of her head revealed brain metastases. She was hospitalized and underwent an urgent course of steroids and whole brain radiation therapy. Her condition improved. But her prognosis was grim.

The other day, I was reminded of her again by the confluence of two things. First, a relative of hers showed up in my clinic with a breast complaint. Fortunately, it didn’t appear to be anything to be concerned about. However, she informed me that Mrs. X had been recently hospitalized because of leptomeningeal involvement with tumor and was receiving intrathecal chemotherapy. Unfortunately, involvement of the meninges with tumor portends mean survival of only four weeks without treatment and only six months even with aggressive treatment. Then, as if to drive home to me the triumph of her cancer, waiting for me on my desk the next day was another note from her radiation oncologist describing her neurologic deficits (mainly leg weakness, but, fortunately, no bowel or bladder complaints) and the plan for her to receive intrathecal chemotherapy and then radiation to the lower spinal cord. This lovely woman who is only in her 50’s and had been looking forward to watching grandchildren grow up was dying, and there was nothing that could be done stop it.

Doctors are supposed to keep a certain distance from their patients. It’s necessary in order to try to remain objective and not to let personal feelings interfere with our clinical judgment. At least that’s the story, and we generally stick to it, whether it’s always true or not. Some specialities try that objectivity more than others, because of a close bond that becomes inevitable. Medical oncology, for example, is such a specialty, because it often involves prolonged courses of treatment and followup for several years for a condition that, like a monster under the water, can return when you least expect it to do your patient in. Medical oncologists, however, unfortunately have more experience dealing with death up close and personal. They have more experience telling a patient that there is no longer any chance of cure, that the best medicine can offer is to try to ease their symptoms as they deteriorate. Surgical oncologists rarely have to do that, the exception being surgeons who deal with particularly nasty malignancies like pancreatic cancer. Frequently, patients are sent to them to be evaluated for surgery. If the surgeon deems a patient’s tumor resectable, they have a chance (albeit small) of living five more years. If the surgeon deems the tumor inoperable, that’s it.

Also, for surgeons it tends to be a bit different. We tend not see the patient as many times or for as long a period of time. There are differences, of course, depending upon what tumors we specialize in (surgeons specializing in GI malignancies, for example, can forge relationships with patients as long lasting and as strong as those of any medical oncologist), but for the most part it’s true. We are used to appearing like the cavalry, to rush the patient off to surgery, vanquish the evil tumor by ripping it out and contemptuously dropping it triumphantly into a bucket, and save the patient’s life. Then, after the patient recovers, we discharge him or her into the care of the medical oncologist and then only occasionally see the patient again. Occasionally, we have the patient with early stage breast cancer who unexpectedly recurs metastatic disease and are shocked (or even go into denialourselves), but such cases tend to be anomalies. It’s hard not to occasionally fall into the trap of thinking that all the tumors we successfully remove will behave like early stage, favorable tumors. Even in a case like Mrs. X, whose tumor was locally advanced and had only a modest chance of ultimate cure, when we successfully remove the tumor with negative surgical margins, we still think that we have “cured” the patient. We have to. Surgery is the primary tool we have to offer, and to have to admit that it offers only a small chance of cure to such patients is hateful to us, even though in the deepest recesses of our minds we know the true odds. But deep down, we know that, despite the apparent admission of defeat from the tumor as it shrinks in response to the onslaught of chemicals administered, that cancer is a clever and persistent foe that can all too often weather everything we can send at it, hunkering down in microscopic deposits in the bone, the brain, the liver, the lung, or elsewhere, waiting for a chance to return.

This post originally appeared on October 12, 2005 on the old blog.