Thursday, January 13, 2005

Do You Want the Good News or the Bad News?

Let's face it - the job of an oncologist could be interpreted by one viewing it through a jaundiced eye as an exercise in futility, especially if this opinion is based on the unusually brief life span of Uncle Joe after he was taken under the caring wings in the summer of '89. True, our triumphs have been modest for many decades but we feel there is no reason for pessimism.

"Oh, really?" sneers the skeptic. "Show me what percentage of patients with metastatic cancer are being cured today."

"Vescere bracis meis!" cries the cancer specialist. Our modern treatments, based more and more on blocking esoteric messengers lurking throughout the cancer cell's command and control center, have produced many encouraging results. Newer treatments have fewer side effects; supportive care has improved tremendously; more and more oncologists are walking into the exam room with the following pronouncement on their lips:

"I've got good news for you!"

Oncologists, long condemned to waddle about in the lowest caste of medical society, are beginning to swagger with a new-found confidence in the efficacy of our weapons. Many of the old nostrums have been replaced with combinations of chemotherapy and targeted therapy agents that are more effective in either shrinking the tumor or simply stopping it from growing. In either case life is prolonged as the disease becomes a chronic condition, to be treated when necessary - so there, you cynics!

What's not to like about this new paradigm?

Am I brimming with vainglorious delight, or what?

I guess I can't hide it any longer.

You see, my pride in the improvement of cancer care is still a hollow one. To illustrate this let me tell you what happened in the office today. I saw a patient of mine with metastatic colon cancer who had just completed his first treatment with a new, highly active combination of chemotherapy and biological therapy. As he jumped up on the examining table he said "I think my lump is smaller, Doc."

This was unlikely to be true. The patient had a bulky midline abdominal mass that protruded from his belly like one of the unfortunates slated for an early death in the movie Alien. Such a huge tumor would typically require at least eight weeks of treatment before I would even dare to check for any reduction in size. Nevertheless, as he lay there and exposed his belly I could see his assessment was right even before palpating the area. The mass, just two weeks after the first treatment, was about half its original size.

With a smile I performed the sacred rite reserved for those who wear the vestments of the Order of Anti-Mitosis-and-Angiogenesis: "I saith unto you my son - I bear tidings of good news."

Yes, I gave him the good news and he and his family rejoiced in this evidence of an early remission. As he walked away I thought about the many months of improving health that lie ahead for him now that it was clear he was responding to treatment: relief of pain, a good appetite, return of vim and vigor - even prolongation of life. As he walked away from me I gave thanks for his reversal of fortune.

As he walked further down the hall, I became aware of a grotesque transformation. I could see his withered frame lying in a curtained room, and could hear soft sobs shattering the quiet. I felt the knotted twig of a bony hand in mine.

This vision of things to come is the bane of the oncologist. I knew all too well that his treatment for colon cancer was not curative no matter how upbeat the news was today, and was haunted by the grief that awaited this man. I delivered hope to a patient whose life was already marked for sacrifice. Because of the continuing limitations of modern treatment, I could not give out the best news of all. As I stood there I felt like a sideshow barker, touting the latest potion to the crowds...not believing a word I said.

This is just one of the many paradoxes the oncologist muses on as he or she goes about the day, assembling a plan to defeat an intelligent enemy, and preparing to play the role of a messenger of hope in a drama that for many cannot be rewritten - no matter how ill-fated the ending.


At 11:36 PM, Blogger mrlmd said...

I have to say that your blog is one of the best medical blogs I have seen. Your insight, compassion, humanity, humor and just plain skillful and entertaining writing make it a realy joy to read. Have you done writing in any other format? You could base a book on a few of the posts here.

Thanks for another great one, Matt

At 2:50 AM, Blogger Me said...

Dear Dr Hildreth,

first of all, let me thank you for your well-written and thoughtful as well as thought-generating blog! It's interesting and insightful to read the views of 'the other side' (I've got incurable metastatic cancer myself, so read your blog from a patient's point of view).

Having said that, I'd like to comment on this post. My first thoughts was that neither Medicine nor Man are perfect, sad but true. There can never be a hundred percent cure rate nor a zero death rate. But that's more of a generalized viewpoint. Once you've realized the above, truly taken it in, with the thundering implications it has for patients as well as doctors, I think concepts like 'hope' and 'good news' can take on a new meaning. It certainly has for me. Although the process of realization is hard and ongoing.

There is always hope for the things you pointed out: pain relief, vim, vigor, quality of life; even hope for more time, for accomplishments of things, for acceptation. Don't undervalue that!

You write that This vision of things to come is the bane of the oncologist -- surely not of the oncologist alone. Patients have their visions too. Yet both patient and doctor can /re/adjust their visions and envision other things, even hope as described above, as well.

And you must know that, too: I delivered hope to a patient whose life was already marked for sacrifice. Isn't that a great gift in itself? Must everything be black and white, cure or kill? When you go on to say As I stood there I felt like a sideshow barker, touting the latest potion to the crowds...not believing a word I said it saddens me. I -- and surely many patients with me, even those considered incurable -- will believe you. When you readjust your sights and acknowledge that life isn't perfect, your words become perfectly true.

So I guess the point of what I'm saying is, don't let the ideals get in the way of the doable, the here-and-now achievements. Please go on as a messenger of hope, regardless of the outcome, as you yourself write. Don't detract from the value of the good you are doing.

Again, thanks for your blog -- regards,

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