Archives of The Cheerful Oncologist, Volume 2

Gang aft agley,
An’lea’e us nought but grief an’ pain,
For promis’d joy!

Last night, wrapped in a dark, wispy heat left over from one of those egg-frying-on-sidewalk summer days, I spent a quiet hour or two out on the screen porch trying to absorb some cast-iron tome written to better one’s education. I believe it was on page 342 when I suddenly stood up and cried out “Enough!” My furry faithful companion, who was in her usual spot on the chair next to me, gave me a look like a bull trying to be milked. I quickly reassured her that my mental status was immaculate and we both hitched up our shorts and wandered inside to watch a bit of television before retiring. The first program I came upon was a highlight show from a previous Super Bowl in which my beloved St. Louis Rams lost as time expired.

I watched the program with about as much glee as Charles I felt when espying the lumberjack assigned to fell the royal tree. How painfully obvious it was to me that numerous strategic and tactical errors were made during the game that clearly cost us the championship. While my loyal consort drifted over to her favorite spot I grabbed the remote and began violently channel-surfing, only to stop on a World War II documentary on Operation Market-Garden. The narrator did a fine job chronicling the mistakes made by the Allies that probably cost us control of Berlin. Should we have poured more men and materiel into that attack or abandoned it completely? Should the Rams have blitzed on every play during that last Patriot drive? Should Monty have blitzed on September 17, 1944 instead of using one narrow road to the bridges?

It’s easy to find fault when using the proverbial retrospectoscope to examine tough decisions from the past that led to bitter outcomes. It’s daunting to make these choices in the here and now and then wait for the reports to come in with messages of either victory or despair. If one is overly cautious the enemy may survive long enough to become invincible; on the contrary if the troops are sent in recklessly they may fall like prairie grass before the scythe before critical adjustments can be made.

I picked up my snoozing sidekick and carried her with me upstairs, ostensibly to hit the hay. Something about those shows stuck in my mind though, and as lay beneath the sheets I realized that forming a treatment plan to kill cancer is sometimes like forming a battle plan. Patients present with life-or-death problems and doctors, like head coaches or pistol-packing generals, must devise a strategy to remove the invader without injuring the star quarterback, or destroying the village. The difficulty in creating a treatment plan is that doctors are never completely certain that their patients will survive the toxicity of chemotherapy, let alone achieve a response.

My dilemma therefore is this: do I go with the standard dose and schedule each time I start someone on treatment, as patients who are enrolled in clinical trials receive, or should I take into consideration mitigating factors such as age, prior radiation therapy or performance status? If I modify the plan because I’m afraid the patient will get sick I could be accused of giving “Friday night chemotherapy”, which is tailored to be just enough of a dose to not cause any symptoms that could lead to a phone call during some important weekend function.

I guess this is what they call the art of medicine. My sleepy thoughts that night ended with visions of head coaches pacing the sidelines…of generals standing before a large map studded with pins representing hundreds of souls. In both scenarios as in the world of cancer treatment decisions are made with the best possible intelligence available, using the most favorable of plans. Thankfully that is reassuring - up until the point when the snap is taken, when the first bullet whistles past the ear, when the patient leaves the office full of chemotherapy. From that point on:

…The game’s afoot:
Follow your spirit, and upon this charge
Cry ‘God for Harry, England, and Saint George!’

Hmm….I must already be dreaming….