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!