Archives of The Cheerful Oncologist, Volume 2

[Editor’s Note: I know that y’all figured out the meaning behind that last little story (being such highly intelligent not to mention attractive readers), but just for the heck of it here is the C.O.’s explanation. Now git, cawse I’m fixin’ to go dreckly to supper!]

Once upon a time there was a woman who delivered her first child as a teenager. Fortunately this was not a hindrance to her entering a life blessed by marriage, family and work. The woman was well liked by her co-workers and customers, but based on the frequent visits she made to doctors, life seemed to be only tolerable for her - no more. She complained frequently of various ailments and by the time middle age appeared her medicine cabinet was brimming with attempted solutions. Somewhere between the ages of 55 and 65, when millions of Americans are most vulnerable to finding themselves without health insurance, her luck ran out. Just as her coverage lapsed she was diagnosed with metastatic cancer. Her physicians ignored her uninsured status and gave her the best treatment available for her malignancy anyway. They also reflected a little on her past, as physicians are wont to do, and perhaps cast a cold eye on life, on death as they chronicled her lifestyle choices over time. The listing was a dour one, not likely to bring accolades to the individual who boasted of it to their doctor, to wit:

She smoked cigarettes for 40 years.

She was morbidly overweight, and sans-souci about it.

She developed diabetes, but didn’t put much faith into controlling her blood sugar level.

Her cholesterol and triglyceride levels went through the roof, but no repairs were made in case of rain.

One by one her major joints eroded into unrecognizable junctions reminding the doctors of rock formations jutting out against the sky of the old West.

No eyebrows were raised when her list of medications showed that narcotics and benzodiazepines were frequent companions on her journey toward old age.

Despite this her doctors mapped out a plan to improve her breathing, to put her tumor into remission, to protect her from high blood sugars - to help her live her life. They were determined to make something good happen.

The cancer was determined, too, and it had the advantage over the doctors - not just guile, not just sedulousness, not just cruelty.

It held illimitable dominion over all.

When the tumor finally began to break her body down, she revolted against her caregivers. No one knew for sure how much of her behavior was due to the side-effects of morphine versus her personality, but in the end she accused them all of neglecting her. Her last few weeks were galling, a discordant symphony of antagonism that boiled away pity and, having fired all of her previous physicians, left her in the hands of strangers.

One Saturday a hand turned the pages of the local newspaper while the other held a quiet mug of coffee. A name was read out loud and a sudden wave of memories spilled over the table, bringing the morning to a halt. Only the silent ticking of the clock inside the mind was heard, until the pages rustled and once more the earth resumed its ancient voyage.

[Editor’s Note: We’re pretty sure that the following allegory describes a health-related topic, but given the esoteric workings of the inner sanctum of his cranium, even we aren’t certain what the C. O. is up to. Look for an interpretation soon.]

The beginning of this magnificent journey was a thing of beauty. Within a minute after liftoff the cheering crowd turned silent as a thousand necks craned to follow the path of the orange torch rapidly shrinking against the backdrop of pale sky. Inside the spaceship the astronauts were confident, enthusiastic and more than motivated to guide their ship safely to its destination. The explorers performed their duties with precision and vigilance, constantly alert for any signs of malfunction. The future beamed radiant in their eyes even as the cloak of space dimmed the light from Earth to blackness.

Just as a lonely college student brightens when a voice from home is on the line, the astronauts were comforted by the reassuring patter from Mission Control. As the distance between the spacecraft and Earth stretched to a number only dreamt of before, the crew kept a proud vigil on the status of their ship. The cramped quarters hummed with the sounds of activity as they performed instrument checks, computer queries and other maintenance. The darkness of space surrounded the viewing ports like an eternal night as the voyagers sailed into the far corners of the great dome hanging over the heads of lovers and stargazers back home.

It was two months into the voyage when Mission Control sent out the first warning. Some new calculations on fuel consumption needed to be made, but had not been done. When asked about this the ship’s captain was heard to reply, “I know, I know. We need to do it. We’ll get to it.” Soon after this an irregularity in the climate control was found and another message sent to the crew. No reply was heard for three hours, until the chief engineer radioed to say that they would “get on this” as soon as possible. The log book at Mission Control began to fill with incidents of sloppy maintenance, unsuccessful repairs and overt negligence. The flight directors urged the crew to pay attention to the ship and not forget their mission.

Looking back now, I guess it was a mistake to broadcast the astronauts’ final hours. Mission Control made the decision to go live when the crisis hit, and perhaps NASA thought that the drama would be good publicity for the program. What shocked the nation was not that the ship was in trouble. After reading the reports put out by NASA we all knew she was in bad shape, but we were unable to figure out why the crew couldn’t make the necessary repairs. It wasn’t until the ship’s captain got on television did we realize the sickening truth.

“Why is this our problem?” he screamed. His voice was jarring but strangely muted, as if smothered by an unseen pillow. The television commentator kept breaking in with breathless updates on the rapidly declining oxygen level in the cockpit. The captain kept ranting, stopping every few seconds to catch his breath. No other voices were heard from within. His accusations rattled speakers all across the country.

“If you would have known what you were doing this wouldn’t have happened!”

“We were in trouble months ago! Why did you let it go so long? Why didn’t you do something about it?”

“It’s your responsibility to keep this ship going, not ours!”

I remember finally jumping up and turning off the set. It was late, and according to the paper the new moon was slumbering somewhere far out of sight. I stepped outside into the shivering nothingness of the winter night and wandered just far enough into the back yard to clear the silhouettes of the oak trees overhead and see the bejeweled sky. Somewhere out there, in the ineffable sorrow of a universe filled with an abundant emptiness, a tragedy was taking place. Its cause was clear, as clear to me as the call of a whip-poor-will in the branches nearby. He sang bitterly that night and I slept with unease, listening to his mocking requiem until the first grays of morning finally drove him back into the deep, black forest.

Where there is great love there are always miracles.
-Willa Cather

[Editor’s note: the following is a transcript of a true conversation between our narrator, a provider (formerly known as “physician”) and a caregiver (formerly known as “loved one”). All names have been changed to protect the innocent.]

Jolly Oncologist: Hello - is this Mrs. Therese R. Green?

Female Voice: No, this is her niece, Claire Annette. Would you like to speak to her?

J.O.: Yes, Please.

2nd Female Voice: Hello?

J.O.: Mrs. Green? This is Doctor Howard Fine Howard from the hospital. I wanted to give you an update about your brother.

Mrs. Green: Yes?

Dr. H.F.H.: Well, as you know he’s been on artificial life support for several days due to his cancer and pneumonia. Today he seems to have taken a turn for the worse - his blood pressure has fallen to the point where he now is on medicine to artificially keep it above the danger level, and I’m not certain how much longer he can keep fighting this.

Mrs. G.: He’s a fighter all right, and he told me he wants to fight this cancer and beat it.

Dr. HFH the J.O.: The problem is that I can’t treat his cancer with him so critically ill, and without any treatment he has no chance to shrink his tumor. My feeling is that his time left is very short due to his lung damage and now his low blood pressure.

[Editor’s note: the phrase “time left is very short” is a euphemism for more official medical phrases for dying, such as “circling the drain,” “vulture precautions,” “PBBB - pine box by bedside,” etc. It appears that the Jolly Onc is trying to prepare the family for the inevitable. Let’s pick up the conversation.]

J.O.: I recommend that we don’t perform any further “heroic measures” or life support treatments such as CPR or electrical shocks if his heart should stop.

Mrs. G.: What do you mean? Why do you think his heart is going to stop?

J.O.: I think he is at great risk of dying, Mrs. Green, and if that happens, performing CPR will not bring him back to life after his death.

Mrs. G.: That’s what they said about me two years ago! I was in Intensive Care and the doctors had given up on me, but I made it through. I had Hodgkin’s disease but now it’s in remission. We Greens are tough - my brother is not going to give up.

J.O.: I understand, and hope he does improve, but if he should die while in the ICU I recommend that we let him go in peace and not perform CPR or give him electrical shocks. It would only increase his suffering in my opinion.

Mrs. G.: Well, I want you to know that I’m not going to die, and neither is my brother. Miracles do happen, you know.

[Editor’s note: Obviously the patient does not have a living will, or this phone call would be irrelevant. Go ahead and say it - “You’re a genius, Mr. Editor.”]

J.O.: This is where we disagree, ma’am, for I know that I’m going to die someday. I pray for a miracle for your brother, but my feeling is that we mortals can only do so much. I also believe that miracles can happen, but that they don’t always occur prior to death. I thank you for your time and will be happy to speak to you again.

Mrs. G: Thank you. Bye. (hangs up)

J.O. (sotto voce): Mundis vult decipi, ergo decipiatur… (stares at the telephone for several seconds, then walks off to make himself a cup of white tea).

Quidquid id est, timeo Danaos et dona ferentes.
(”Whatever this may be, I fear the Greeks even when they’re bringing gifts.”)
-The Aeneid, Book II

Following a diet consisting mainly of fruits, vegetables, olive oil, fish, beans, nuts, pasta and breads (known as the Mediterranean Diet) seems to not only reduce the risk of developing heart disease, hypertension, diabetes and certain types of cancer, but also Alzheimer’s disease.

In a study published in the Annals of Neurology, 2,258 individuals without baseline dementia “were prospectively evaluated every 18 months for an average of four years. The primary outcome was the rate of decline in cognition as assessed at each study visit…During the course of the study 262 individuals were diagnosed with Alzheimer’s disease.”

262 persons out of 2,258 developed dementia? Let’s hope that isn’t the national rate, otherwise we had better start reading the classics now before it’s too late.

“Adherence to the diet remained the main predictor [for avoiding dementia] even after adjustment for cohort, age, sex, ethnicity, education… [etc.].

The hypothesis is that the the monounsaturated fatty acid found in olive oil, the omega-3 fatty acids found in fish and the antioxidants contained within fruits and vegetables all contribute to a general cleansing of the blood vessels of cholesterol and fat, thereby reducing atherogenesis and thus the incidence of coronary heart disease. They also provide nutrition without promoting obesity, lower blood pressure and reduce the incidence of breast and colorectal cancer.

What is the take home message of this research? Dr. Nikolaos Scarmeas of Columbia University, one of the authors of the study, said it most clearly: “An overall dietary pattern is likely to have a greater effect on health than a single nutrient.”

Does everyone understand that sentence? It is so essential to promoting good health that I feel compelled to put it into the vernacular:

“STOP EATING JUNK FOOD, YOU FATTIES!”

Ahem…using more scholarly language, the point I’m trying to make is that we cannot ever hope to lose weight and avoid the ravages of heart disease and cancer just by adding a bran muffin or a Diet Pepsi to our cheeseburger-doughnut-frothy-latte-ice-cream diet. In order to truly live with respect for our bodies, in order to truly fulfill the wish within our hearts, our souls and our compos mentis minds for a long and healthy life, we need to change the way we look at food. Whether standing over the steam tables at Sunday brunch, or lovingly fingering a menu at Alain Ducasse, it is our responsibility to think before we choose. Just as a little child is taught to avoid eating certain items, such as bleach, we can train our adult selves to avoid stuffing our adorable little Kewpie doll-like figures with foodstuffs that are certainly as pernicious to our health as a bottle of great-grandma’s homemade cough syrup.

Even the heartiest of trenchermen, with a little counseling and friendly persuasion, can learn to like the Mediterranean Diet. Why not give it a try?

You might even try a glass of red wine with your Tagliatelle al Pomodoro Fresco. Salut!

…a poor player,
That struts and frets his hour upon the stage,
And then is heard no more;

William Shakespeare, Macbeth

There’s nothing more exasperating than to be caught standing at the nurses’ station fretting over a patient, which is what happened to me earlier this week. Doctors don’t like to be caught fretting, or even come close to gaining a reputation as fretters, not to mention worrywarts, sourpusses or fussbudgets. To lament publicly about a patient creates an aura of frailty that to the casual observer suggests indecisiveness. It infiltrates the air with a mousiness that can lead both peers and patients to surreptitiously raise the appropriate eyebrow (I forget if it is the right or left) signaling a loss of confidence in our leadership. To put it in nautical terms, those who find themselves swept off the deck by a strong wind are not particularly encouraged when they see the crew rending their garments in agony while the life preserver hangs undisturbed. A firm gaze, a strong grip, a voice brimming with dash and daring, a man, a plan, a canal, Panama! - that is what our patients are looking for in their doctors. That is what sends the family back home with a hearty sigh of relief, saying “Thank goodness the doc gave us hope.”

That All-American brand of steadfastness is precisely what I lacked as I deflated over the news contained within the chart before me. The patient I had been asked to see was a young man with left-sided back pain. The pain was due to a pelvic soft tissue mass destroying his ilium. The soft tissue mass, most likely cancer, possibly one of the really bad ones, was the source of my fretfulness. Other than lymphoma, it was difficult to think of a diagnosis in a patient of his age that was going to be encouraging news. I walked down the hall to meet him.

Within the hour I was back at the station, completing my dictated consultation. Even though the hour was late [Translation: He’s got an office full of patients reading copies of Family Circle magazine circa 1983. - Ed.], I lingered over the chart, pondering about this young man’s future and about what I could do to violently yank it off the tracks and place it on a set of rails leading to a more hopeful destination. His nurse approached me to inquire about my plans. I informed her of the need for a biopsy, staging studies and then likely chemotherapy and more.

“You know, he’s so young he’ll have trouble getting insurance because of this,” she said. “The insurance companies reject people like him with pre-existing conditions. Twenty years from now he probably won’t be able to get any health insurance unless he’s with a huge company.”

Somewhere over our heads, away from the stale confines of this brick building, a song of joy fills the spring air. It comes from the smallest of divas who sits high within the green shade of the afternoon, completely hidden from us except for the sprightly melody with which she bathes the sidewalk below. Her voice is a piccolo of nature and perhaps a reminder of a promise made long ago, a promise that those of us in the business of healing have the privilege of helping to keep. Suddenly my anxiety was swept away and I turned toward the nurse and gave her a look like a professional wrestler just before jumping off the top turnbuckle.

“Yes, that would be a huge problem, wouldn’t it? My job is to make sure he’s here twenty years from now to complain about it.”

“A new study finds that people who have had near-death experiences are generally more likely to have difficulty separating sleep from wakefulness.”

Goodness gracious! Who are these folks who don’t seem to know if they are asleep or awake, and why do they insist upon proving it to the world by changing lanes at seventy miles an hour without signaling? Just what we need - a pack of thrill-seeking somnambulists. Go on, Mr. Science Reporter - tell us more:

“Researchers surveyed 55 people who’d had a near-death experience (NDE) and 55 who had not. For 60 percent of those who had been through an NDE, the rapid-eye movement (REM) state of sleep intrudes into their regular consciousness while awake, the study found. Only 24 percent of people who had not had an NDE report this REM intrusion.”

Oh, no…don’t tell me that after years of reverent admiration of those souls who stand at the shining gates of heaven, toothbrush in hand and are told that it was not their time then unceremoniously shuffled into the the next Earth-bound train, we now have evidence that it’s all just a fantasy of the mind!

“‘These findings suggest that REM-state intrusion contributes to near-death experiences,’ [study author Dr. Kevin] Nelson said. ‘People who have near-death experiences may have an arousal system that predisposes them to REM intrusion.’”

For the record, let’s list the sensations that those who experience an NDE enjoy. They are:

~a sense of unusual peace

~alertness

~being outside their bodies

~seeing intense light

How wonderful! Who wouldn’t want to be overcome with such peaceful, easy feelings after attending yet another class reunion of the School of Hard Knocks? Unfortunately for those of us eager to get a preview of the accommodations in the afterlife, not to mention what the fee is for digital cable, this line of research may lead to a profoundly disappointing conclusion.

“‘One of the basic features of REM state is activation of the visual system,’ Nelson said. ‘REM-state intrusion could promote the prominent visual phenomena of near-death experience.’”

Well, if this is indeed the truth it makes sense to me. Some of us are just born with overactive brain stems that when stimulated by a certain level of stress hit the panic button and send us off to dreamland. I guess I can’t blame these brains for being overly protective, as long as they don’t get into the habit of flipping the switch during normal business hours, which might lead to insufferably long lines at the local Starbucks.

How discouraging to hear that an out-of-body-boogaloo may be just the product of our limbic system behaving like a toddler with a hammer left alone in a room with a sleeping cat. I wonder if scientists will ever be able to show the human brain and the paranormal converging to produce a window into a world beyond our realm. I suppose that with all the publicity surrounding this story they will undoubtedly be looking for more volunteers, and myself having experienced a horrifying near-death experience just last Saturday night, I should probably notify the researchers.

I just hope they don’t ask me to relive the incident in too much detail.

“All knowledge comes useful to the detective.”
-Sir Arthur Conan Doyle

While at the unit secretary’s desk last Friday afternoon I placed a chart in the rack and paused to strike a pose of thoughtful dignity, no doubt causing nearby onlookers to wonder who that man with the Lincolnesque comportment was. Why I lingered I haven’t the foggiest idea - if I had used common sense I would have dropped the chart and run like the March Hare on his way to tea. I didn’t slip away fast enough, though, and the secretary pounced on me with a smarmy grin and announced in her sing-song voice:

“I’ve got a consult for you!”

Oh, no…just when I was ready to peel out of the parking lot, secure in the fact that not being on call I could therefore enjoy my usual weekend activities without interruption. I fought the urge to slump into a chair and begin whimpering, and bravely took up the new chart. Sure enough, there was the order with my name on it, written into the permanent record just minutes before. I flipped a few pages and suddenly produced a facial expression like a nun at a Friar’s Club roast. Approximately twenty minutes later I was out the door for good, still shaking my head at the inhumanity of it all.

You see, the consult was for anemia; more specifically it was for a woman whose hemoglobin level was normal when she was admitted but now was low. How could this have happened? Why on earth would such a nice lady be stricken so mysteriously with such an insidious turn of events, or in other words - where did the blood go? In the spirit of the famous resident of 221b Baker Street I decided to approach the case deductively:

“Well, Watson, fact number one is that we know she had a history of diverticulosis which can produce gastrointestinal bleeding.”

“That’s all very well, Holmes, but not one of the staff observed any blood in her bowel movements.”

“Not with the naked eye, dear fellow, but notice in the laboratory section of the chart that of the three stool specimens submitted for analysis, one was indeed reported as positive for occult blood.”

“Not enough to send her haemoglobin level that low, I would say.”

“And right you are. Do you observe anything else about this section of the chart?’

“Hmm…there are lots of test results, aren’t there?”

“Precisely, and each test requires a sample of blood, does it not? Look here, Watson - for the past three days she has had a fever and has had six sets of blood cultures drawn.”

“Six sets, at twenty milliliters of blood per set - that’s certainly a bit more blood gone, isn’t it? Let me see the chart. I say, Holmes - do you notice this entry from last Tuesday? ‘Patient found out of bed on floor - complaining of right hip pain.’ You don’t suppose she fractured her hip that night, do you?”

“Did you happen to examine the patient’s right hip when we were in the room?”

“No, I didn’t even think of it, old boy.”

“Well I did, and it was covered with an enormous ecchymosis. I believe that hip fractures can produce blood loss, n’est ce-pas?”

“Oui, tout a fait - up to three units of blood can leak into the soft tissues around a break in the femoral head or neck. Don’t tell me you’ve found the cause of the old girl’s anemia?”

“Not one cause, Watson, but multiple causes. In my experience most patients who develop occult anemia during a hospitalization do so from several sources, the most likely being multiple phlebotomies for laboratory testing, or silent gastrointestinal bleeding.”

“By Jove, Holmes, you’ve done it again!”

“Thank you, my dear doctor. Now let us write an order for a roentgenograph of that right hip and suggest a visit from a good orthopaedist.”

I’ve said it time and time again - a good doctor in many ways is like a good detective, with the visual acuity of an eagle, the mental dexterity of a supercomputer and a keen sense of intuition best exemplified in the stories describing the exploits of the most famous sleuthing duo in all of literature.

This just in from the frontlines of basic science:

Lung cancer cells grown in vitro are protected from apoptosis (the process by which damaged cells commit suicide) induced by chemotherapy when nicotine is added to the cells.

Adding a small amount of nicotine to the cells increased the activity of two genes capable of stopping the natural death process of apoptosis. Without nicotine exposure the genes were suppressed and the cells successfully completed apoptosis (also known as being blown to kingdom come).

The study authors therefore warn that lung cancer patients who continue to smoke may have a lower probability of responding to chemotherapy. In fact, they state “Our findings are in agreement with clinical studies that patients who continue to smoke have worse survival profiles [my italics] than those who quit before treatment.”

Worse survival profiles? Compared to what? Take a look at this graph which shows the survival curves of advanced non-small cell lung cancer patients who receive chemotherapy compared with those who receive only supportive care. How can a “survival profile” get much worse than this? In fact, the last time I saw a slope this steep I think I screamed like a banshee and wet my britches.

I always tell my lung cancer patients that they will tolerate their treatment better if they stop smoking, but as far as increasing their chances for long-term survival by stopping all nicotine consumption - don’t make me laugh, let alone pull out my little friend and start blasting.

This research is extremely raw and may not apply to living, breathing human beings, but until I see results from actual clinical trials I am not going to rant and rave at my patients who choose to continue to smoke. After all, as Petrarch said:

“Vos vestros servate, meos mihi linquite mores,” which translates loosely as “Shadduppa yo face.”

How beautiful it is to do nothing, and then to rest afterward.
-Spanish Proverb

Rest when you’re weary. Refresh and renew yourself, your body, your mind, your spirit. Then get back to work.
-Ralph Marston

Ahem…excuse me…may I have your attention please! Please…excuse me - QUIET! Thank you. Would those of you in the audience who either work for a living or who are attending school with the goal of eventually finding a job please raise your hand?

Very good - almost half of the auditorium, I see, and I assume that most of you who didn’t respond are retired - am I correct? Good. Now, may I see by a show of hands how many of you feel stressed out or exhausted?

Oh, goodness…um, perhaps it would be easier if I asked how many of you do not feel this way. May I see your hands? Anyone? Anyone at all?

Well then, you see - I’ve already made my point, namely that we need to find a way to escape from the straitjacket of stress and worry that we unwittingly don each morning. Consider that image for a moment, if you will - all of us walking around with our arms tied to our sides, looking like extras from a cheap horror film. This is what stress does to us. It is no wonder, therefore, that we sleep poorly and shovel enough fat and sugar into us to drop a band of gorillas, not to mention a pandemonium of parrots, the poor little darlings!

It’s not just enough, you see, that we get our eight hours a night, exercise regularly and pledge to eschew all the goodies for sale at fast food places, or packaged within plastic bags, or just now being wheeled on a cart to your table by a smiling waiter. We need to find time in each and every day to do absolutely nothing - to boycott the turning of the earth, remove our prisoner’s jumpsuit and dive into the clear rejuvenating waters of freedom from thinking. For some of you this may mean getting out of doors, which is a good way to watch clouds and sunsets I am told. For others it may be doing a puzzle, or reading a book, or perhaps just resting in front of the fireplace on a chilly night and watching the flames perform belly dances in front of your weary eyes.

I’m sure some of you feel guilty when you’re not doing anything constructive like watching television, or maybe you have succumbed to the mass hypnosis offered by modern communication technology and find yourself constantly cell-phone-chatting-texting-e-mailing-My-Spacing your friends like a battlefield commander anxiously trying to stay in touch with his fighting units. This is no way to keep wits sharp and vision keen. You must designate a period of time every day, whether it be for half an hour or three hours, where no one can reach you and you are free to read the epigrams of Marcus Aurelius, or listen to cardinals high up in the trees whistling to each other, or daydream about your greatest achievement, or simply stare at your navel if you so desire. Think of this time as a little reward for putting in a hard day’s work, or surviving a full day in the classroom. If you should ever find yourself wavering - considering a trip to the mall, or fingering the remote control like a pre-embargo Cuban cigar, or revising your Nobel Prize acceptance speech, just remember this jingle I shall now recite, and thank me when the inky night envelopes you while nodding off under the sweet scent of viburnum.

Ladies and gentlemen, take my advice -
Just one or two hours a day should suffice.
Slip away from the world and sit on your bum,
Let your voice and your cell phone both become mum.
Pamper your mind with whatever you please,
Let stress drift away with the evening breeze.
Soon all of your worries will come to a halt,
But if all else fails, sip a nice single malt.