Friday, December 29, 2006
Memorable Patients: part seven
I first met her when I consulted on her hospitalized son, who'd been in and out several times with transient abdominal pain. He'd already been through various tests and consultations, each time improving before a diagnosis was established. When I was asked to see him he was once again on the mend, but I concluded that he likely had the uncommon condition of recurrent appendicitis, and proposed surgery. Taking out his appendix, which I did shortly thereafter, permanently cured him, and the pathologist confirmed the diagnosis. Mrs. Davidson told me she knew God had sent me to them, and thanked me prayerfully. As her son recovered, she prayed with him as well.
When next we met a few years later, she was the patient, having discovered a lump in her breast. With a fine-needle aspiration I confirmed the diagnosis of cancer, and before long we were together in the operating room. Based on my physical exam, I expected to find some lymph nodes containing tumor; but when I got into her axilla, I was surprised -- sickened, really -- by how many. There's a clear correlation between failure to cure and the number of lymph nodes under the arm. Whether removing those nodes is therapeutic or merely diagnostic is a matter of disagreement: in other words, does removing them improve prognosis in any way other than telling us what we're up against? Regardless of further therapy, is it good to remove all the nodes you can? I think so, until clearly shown to be otherwise. When the cancer has marched its way all through the axilla, the odds are very strong that it's gone beyond as well; but in the absence of proof of spread outside the axilla, it's still theoretically possible that removing all the tumor in the breast and under the arm will be curative. Theoretically. That's what I did for Mrs. Davidson, and of the fifty or so lymph nodes found in the tissues I dissected out, thirty-two had tumor in them. I think that's the record, in my practice. Her risk of relapse somewhere in her body was dauntingly high.
At each stage of the game, Mrs. Davidson prayed, and her faith seemed to carry her. The lump would be OK, she felt, and when it wasn't she knew God would be with her. But when she got the news about the lymph nodes, and the implication for cure, and when she heard the recommendation of her oncologist, she fell apart.
Not far down the road from my area of practice, there was an on-going study of women with advanced breast cancer: removing and preserving bone-marrow stem cells, giving massive doses of chemotherapy and radiation -- enough permanently to kill the production capabilities of the marrow -- followed by returning to the patient her saved marrow cells to regrow her blood-making ability. It was tough stuff, taking the women to the brink in a most literal sense, suitable -- if at all -- only for those with very poor prospects. (The therapy has fallen into disrepute, in a pretty messy set of circumstances featuring another patient of mine who'd come to me with widespread recurrence.) With cancer all over the body, it was a desperate "hail Mary" of a treatment. In a situation like Mrs. Davidson's, it made more sense, at least from some points of view: take a woman with a very high statistical chance of having cancer somewhere, but undetectable, in her body, throw the therapeutic book at her on the theory that the best chance to cure lay in getting those cells when they were at their fewest in number. (Which is also part of the rationale of removing all the involved nodes.) That's what her oncologist recommended, and I concurred.
For Mrs. Davidson, it was hell on earth. Unable to eat, nauseated, dependent entirely on intravenous feedings, bleeding what little blood she had, fighting infections -- she was as miserable as it gets. Per protocol, she remained hospitalized for the entire treatment and well after the stem-cell reinfusion. Her husband, who worked at a coffee shop I frequented, told me on many occasions that she'd said she wanted to die, that she'd begged them to stop treatment. He wouldn't let her; he wanted her around. But she sank deeper and deeper into depression; how could God do this to her, she asked, after everything she'd done for God?
Her anger and depression outlasted her therapy. After her release from the hospital, I saw her fairly regularly, even though she'd healed her surgery: she just wanted to come in and ventilate. As hard as it was for her, it was frustrating for me: surgeons like to fix things, and I had little to offer except an ear. Seeing her continuing to lose weight, to descend into darkness, I finally suggested anti-depressants, which she accepted with a "why-bother" shrug. In the periods between visits, which eventually tapered off, I frequently saw her husband at the coffee-shop. He was nearing the end of his rope as well. She remained despondent, he said, despite the passage of time with no sign of cancer.
I've generally observed that when people have deep religious faith of any sort, in most cases it helps them cope with bad news: "God's will." Despite her attitude when I cared for her son, in Mrs. Davidson's own crisis it seems to have done the opposite. Funny thing is it's over fifteen years since all this happened, and she's doing great. Her depression is long gone, she's active, and there's not been any evidence of disease since her operation. In our relationship, I never initiated discussion of her faith, and I don't know where it ended up in her life. In medicine, nothing is 100%. She seems to have beaten very long odds. How? Maybe I actually got to her at the moment before any distant spread, and my operation cured her. Maybe the hyper-intense therapy did exactly what it was intended to do. Maybe she'll recur still, and we just bought her some time. Or maybe....