Daniel Menaker

Onconversations XI

Friday, September 30, 2011

CLEARLY BRILLIANT THOUGH QUITE YOUNG RADIOLOGIST:  After you talk with me today, you’ll have an appointment with Dr. ______ [a surgeon] next week, to discuss the possibility of conventional surgery, a pneumonectomy, to remove the remainder of your left lung. Then the Tumor Board will meet and we will form a consensus about how we think we should proceed.
ME: [ I immediately think of an in-denial knock-knock joke: Knock, knock. Who’s there? Tumor Board. Tumor Board who? The plane is full but Tumor Board anyway.]
ME:  Is it your opinion that this disease could possibly be managed with SBRT? [Stereotactic Body Radiosurgery –http://radonc.ucla.edu/body.cfm?id=61 –in which highly concentrated and focused beams of radiation are blasted at tumors inside the lungs. Radiologists generally reserve this procedure for single nodules and/or for people who can’t have conventional surgery. I have three lesions, two of which are close together, one more distant.]
RADIOLOGIST: Your case is extremely unusual. We don’t know. The two nodules that are close together might be treated in one course of radiation therapy, and then we would use another course for the other one. But I have to emphasize that we don’t have enough history or statistics to judge SBRT’s long-term results against conventional surgery when both are feasible, and so surgery usually remains the treatment of choice for people who are physically able to have it.
ME: It sounds to me like you think that these radiology treatments may eventually prove to be as effective as surgery.
RADIOLOGIST: There are some early indications that that might be the case, but it really is too soon to tell. We just don’t have enough data yet. Also, if the rest of the lung is removed, we can examine and analyze the lesions more closely, to see what we have been dealing with.
ME: Why am I thinking that you might like to try SBRT on me just for the fun of it, sort of?  Just to see. Have you treated anyone else with this kind of early, recurrent disease with SBRT who might have been able to have surgery?
RADIOLOGIST: There is one other patient who is somewhat comparable whom I’m treating now. It’s too early to judge the results.
ME: If the rest of the lung is removed, then, well, there’s no chance to retain that amount of pulmonary capacity, right? You can’t put it back in there.
RADIOLOGIST: Of course not.
ME: You have to understand that I am pretty frightened of the Complete Montgomery of a pulmonectomy.
RADIOLOGIST: Montgomery?
ME: The Full Monty.
RADIOLOGIST (chuckles): Of course.
ME: And  SBRT wouldn’t preclude a later pneumonectomy, if it proved necessary, right?
RADIOLOGIST: Actually, it might well, because of scarring and other side effects of the radiation.
ME (gloomily): Oh.
RADIOLOGIST: Dr _______ is a wonderful surgeon. And a wise one. I think we all think your prospects are actually quite good, no matter what course we follow.

It occurs to me after this conversation to dwell on the word “consensus.”  Serious illness brings out the obsessiveness in many of us, especially those who are used to overthinking things in general. But how can this situation, in which the experts themselves appear somewhat uncertain about how to proceed, be overthought? Anyway: “consensus”: All well and good, but what if someone on the Tumor Board disagrees vehemently with this consensus? Will I ever know that? And if not, why not?

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Onconversations X

Monday, September 19, 2011

(At lunch, with a fellow-cancer-patient friend–osteosarcoma in his leg–who has had chemotherapy and very complex surgery in which, more or less, the doctors threw his femur, tibia and fibula up in the air, discarded one of the bones, the sarconomic one, and repositioned and vascularized the other two)

ME:  So I will probably have surgery during the fall, but I’m still hoping to put it off until after the holidays.
FRIEND:  Do you know what the “census” means?
ME: Well, I mean, yes–like the U.S. census?
FRIEND: Like that but having to do with hospitals and surgery and the holidays. It might be helpful for you in making your decision.
ME: Well, then, no–I guess I don’t know.
FRIEND: Well, think about it. My surgery wasn’t elective, but I could choose when I had it, within a window of a month or so. So why did I choose the third week in December?
ME: I don’t know–you’re Jewish and you don’t care about Christmas?
FRIEND: Nope.  It’s because of the hospital census.  Almost everyone who can put surgery off until after the holidays does, and the hospital fills up and the staff in general is really busy. But a week or two before the holidays has much less traffic–they can pay better attention to you.
ME: Never thought of that, but it makes complete sense.
FRIEND: So take that into consideration.
ME: I definitely will. Also  I do worry a little about getting older and frailer as time passes. Just about to turn seventy. [I just did.]
FRIEND: Did I tell you about my mother-in-law’s brother?
ME: I don’t think so.
FRIEND: He’s eighty-three and was recently diagnosed with lung cancer and they have a chance to remove the lung and basically cure him or give him a good, long remission. But he was in bad shape generally–beyond even his age– and they judged that he couldn’t have withstood the operation. So they gave him an exercise regime to help build him up, and it worked–he got himself into much better shape. The trouble is that right near the end, as he was walking maybe a little too vigorously the mile or so that was part of the program, he fell down and broke his leg. They had to set it and he is now on bed rest and is losing all the gains he made.
ME: I hate to say it, but  eighty-three–this doesn’t sound like a promising situation.
FRIEND (gloomily): No, it isn’t.

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