That was how I began my visit with my 82-year-old patient.
She had been on my mind even before I had discovered that metastatic disease had been found in the bones in her cervical spine. That was the origin of her complaints of pain down her left arm and across her shoulder. This wasn’t new. Two years earlier, she had gone to hospital with similar pain.
That time, investigations had resulted in a diagnosis of acute coronary syndrome. In other words, a heart attack. She received a stent promptly, and within two days was back in my office for a follow-up visit. Cardiac care, at least in Canada’s cities, seems to be timely, efficient and effective.
But something kept niggling at me about my patient. I’d diagnosed her breast cancer five years earlier. She is one of the many women I look after who constantly remind me that breast cancer is a disease of older women because its incidence rises as you age.
Today in Canada, women between 50 and 70 are advised to have a mammogram. But after 70, they aren’t. Why? Because after 70, they’re far more likely to die of heart attack or stroke than breast cancer. Yet women over 70 still face the possibility of this diagnosis with the same trepidation and fear that any cancer diagnosis carries. Women over 70 don’t live with the daily notion that a heart attack or a stoke could profoundly change their lives but they do shrink from the probability that a cancer would do just that.
At any rate, my patient’s lump wasn’t picked up on a mammogram; she discovered it herself.
She didn’t rush in to see me, so the diagnosis of breast cancer was pretty much a sure thing by the time I felt it and referred her on. It began with a lumpectomy, followed by radiation. Then what I call the chemo for old women quickly ensued. You take tamoxifen, a pill a day for five years, with no nausea or hair loss.
That was five years ago. Two years later, there was an increase in the mass that was the scar and it occasioned many a consultation, another biopsy, more consultations.
But when she began to complain once again of pain in her left shoulder and arm and it didn’t respond to physiotherapy, I feared the breast cancer had spread. I didn’t say anything to her but ordered an X-ray of her cervical spine. The X-ray was clear aside from some mild degenerative disc disease.
I stopped short of pursuing a diagnosis because in hindsight I think it was my own avoidance of what was ahead for this octogenarian. So my apology was necessary because had I even ordered an X-ray to include the upper thoracic spine, the spread of her cancer would be clear, and my job then would have been to tell her the cancer was back.
Does it matter who gives the bad news?
I think so. As hard as it is for patients to hear – and many don’t hear much beyond the first sentence – I believe it is the familiar office setting with a doctor you know, rather than hearing the bad news from the oncologist, that will provide the best base for everything that’s to come.
This was brought home a few weeks later with another 70-year-old patient. She had just retired when she was met with a breast cancer diagnosis on her screening mammography.
We set up all the follow-up investigations by phone so that her next visit with me was in fact for a preoperative check. And that was the first time we’d ever talked about her diagnosis. A week later, the following letter with a poem arrived in my mail. It was her reflection on being “a woman on the moon.” It came not from the breast cancer diagnosis but rather from her new station in life as a retiree. Retirement had unsettled her profoundly. The last time she felt this way was when she had voluntarily left the life of a nun some 40 years earlier.
“Practical adaptation was easy,” she wrote me, “but seeing myself as secular and sexual were not.” I didn’t meet her for a number of years after that time, so I can attest that her transition into secular life was smooth and highly successful.
But her realization that she was once again having to rediscover a new identity gave her some comfort as she faced this new trial.
She is a highly articulate and published author, and her note also introduced me to her poetry, which went like this:
Let Me Compare You to an MRI
I’m taken to a room,
Fastened, slid into a barren tunnel, sealed.
It shouts at me
Works over the breast with ferocious intensity.
Each second timed.
It’s over, noises stop
The fasteners spring open
Silence is all I hear.
We meet in your office
You listen to my words, confusion,
You wait, listen.
Pinpoint with MRI accuracy
Pain. Help me. Heal.
Her poem doesn’t just remind us that we all receive life-and-death sentences via machines these days. It is also a nudge that the longer I care for these patients, the more vulnerable I am in avoiding giving them bad news, shelving probability in favour of familiar continuity.
Yet both these women have taken the measure of the challenge ahead for themselves. They shoulder the news and bear it with grace and self-assurance that they will come through.
In the bargain, they will bear my sometime flagging spirits in their wake as well.