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Optimism

Don S. Dizon, MD, FACP

03 Jul 2013 3:06 PM

Maybe I should’ve noticed how she looked… “She” was a new patient, Louise*, and she had been diagnosed with stage IV cervical cancer. Only in her 40s, the diagnosis had hit her extremely hard. At her first meeting, she wanted the “truth,” and I had told her what I felt to be most relevant--that her cancer had spread, that it was not curable, and someday it would probably kill her. However, she was not dying now, and we could certainly treat her cancer, which could help her thrive, keep the disease in check--and perhaps even place her into a remission. While a remission was not the same thing as cure, remission was a reasonable and realistic objective.

She had come back to clinic after our initial meeting with hair shorn and a new sense of mission as she exclaimed-- “Let’s do this, I'm ready.” She decided to embark on chemotherapy and did well with her first three treatments, from which she experienced minimal side effects. Although she lost her hair, she took even that in stride--and discovered a passion for scarves along the way. “I may not go back to long hair; heck, I might stay with my Sinead O’Connor look!” We both laughed.

However, at her fourth visit, she was more reserved, almost sad. “I think it’s this weather; I always feel lousy when it rains continuously. And this cancer isn’t helping."

“Well, on the positive side,” I had told her, “I am pretty optimistic that things are going well. I can’t feel your tumor anymore and your symptoms are gone, suggesting treatment is really working. I think that’s terrific news.”

She looked me in the eyes as I talked and when I finished, she replied, “Explain what you mean by optimistic?"

"I agree that treatment is working, and I am grateful for that. But, by optimistic, do you mean that I could be cured, or that I’m fine for now? Should I be less scared that I might die in a couple of years or can I go into remission and be fine until I'm 90, all because of this optimistic treatment regimen? I need you to explain to me exactly why you are optimistic.”

It is not often that questions of long-term outcomes arise during active treatment, especially when treatment is working. For an instance, I was confused about how to respond. Had I not been truthful with her? Had I unknowingly confused her with my talk of “optimism” and her “responding to therapy”? After all, our first conversation had been about how her metastatic disease was incurable and potentially fatal. 

As an oncologist, I often ask my patients to live for today (in the words of Robin Williams’ character in Dead Poets Society^--“carpe diem”). I've come to realize that my emphasis in "today" influences my assessments, evaluations, and how I communicate with my patients. When treatment works, I feel like I am doing something worthwhile--helping someone in the journey with cancer, and I am happy for them. When it is not, I adopt more emotional restraint as we think through prognosis, treatment, and endpoints together.

However, while this approach works for me, it may not work for some of my own patients, especially  those who find living with cancer a far more complicated existential dilemma--even more so in the context of advanced disease. As Louise helped me see, living for today might be good advice, but thoughts about the  future are never far away. 

Ultimately, oncologists are here to treat cancer, including our continual assessments of treatments, their toxicity and whether or not they are helping. However, we can never forget the person living with cancer. Indeed, meeting the psychosocial needs of patients is part of a comprehensive treatment approach. Taking the time to explain what is happening now in light of what we anticipate for the future is important. I guess in the end, seeing the trees is just fine, but our patients never lose sight of the forest, which remains an ever present reality, and perhaps, far more important.

DSD

*Name and characteristics changed to preserve privacy.
^Thanks to V.S. Schulz (@portefeuillefun) for pointing me to the correct Robin Williams film!

Comments

Number of Comments: 8
Lucio Nobile

Friday, July 05, 2013 11:43 PM

Thank you for sharing your story with us and for your insightful observation. Fear of death often arises at cancer diagnosis. Our patients develop their own coping mechanism to some degree independently of what we are doing, but I believe we can do something to facilitate that process; be mindful. There are three main fears related to the fear of death: fear of loneliness, fear of pain and fear of the unknown. Over the course of time, I noticed that most of my patients that are long term survivor of metastatic cancer overcome most of those fears, part due to our frequent f/u's which provide a positive and reassuring bond (we are there for them) and part to the fact that as time goes by, they realize they are still alive when they were expected to not survive. I am often surprised to realize that most of the time in our follow-up my patients are quite happy despite their diagnosis. I am sure that this happens to many other oncologist:it is the healing power of our profession. If we can't heal the body often we are successful in healing the fear of dying. 
Don S. Dizon, MD, FACP

Saturday, July 06, 2013 6:56 AM

Lucio: I appreciate your post and also your own insights on this matter. Of the three fears you cite, I think the hardest is the fear of the unknown, particularly for the one just diagnosed with cancer (and their families no less). Perhaps you are on to something- helping patients realize that living with cancer is indeed a possibility is something we can do that is both psychologically and emotionally helpful. Through our visits and our conversations with patients, which should extend beyond just the diagnostics and therapeutics of malignancy to include getting to know our patients as people, we can acclimate them to a new reality, that, even with the fear of unknown not addressed well, helps people. It is truly the healing power of our profession (in your words) and reflects the art of medicine too.
DD
Nancy Stordahl

Saturday, July 06, 2013 3:35 PM

This is a terrific piece, so real and so honest. It's no surprise that these are such important qualities in a trusted oncologist as well. 

"However, we can never forget the person living with cancer." Such a simple and yet profound statement.

Thank you for writing this. 
Don S. Dizon, MD, FACP

Sunday, July 07, 2013 9:55 AM

Dear Nancy, what a wonderful complement. I truly appreciate that you took the time to read this and comment. DSD
Susan Zager

Sunday, July 07, 2013 2:13 PM

This is such a beutiful piece. I really appreciate how much you truly care about your patients and that you are always aware that when someone is faced with "incurable cancer", you tune in to focusing your energies to the needs of the patient livivng with the cancer. I am especially touched as I have been with loved ones and their oncologists and witnessed different approaches. Your words and approach (as well as titling this "Optimism") are so helpful and very appreciated. It is so moving to know that as an oncologist you really understand and can work together as a team with your patients. This itruly is "the healing power of your profession."
Don S. Dizon, MD, FACP

Sunday, July 07, 2013 5:42 PM

Dear Susan, Thank you for posting; I am fortunate to have mentors and colleagues in my own professional life whom I have admired and sought to emulate. But, perhaps my greatest teachers, and those for any physician, are their own patients- all of whom approach their own disease in distinctly individual ways. I am humbled by the lessons I learn each day from individual people, whom I am honored not only to meet, but also privilveged to take care of. Best to you, DSD
Rhon Laurente

Monday, July 15, 2013 4:43 PM

Hi Don,

This email is definitley long over due... I truly enjoy your blogs and actually looking forward to reading them.  We have a close family member that is battling pancreatic cancer.  Reading your "insights" are very inspirational and uplifting. Your positive messages bring hope to all of us.

Rhonele    
Don S. Dizon, MD, FACP

Monday, July 15, 2013 8:00 PM

Dear Rhonele, Thanks for the complement, truly. I will keep you and your family in my prayers! D

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Don S. Dizon, MD, FACP