Parallel Lives Diverge
Authors: Daniel Rayson
Journal: Journal of Clinical Oncology (2012)

DOI: 10.1200/JCO.2012.42.2824 Two women younger than 40 years of age as new consultations did not bode well for an easy afternoon. Not that any afternoon of newly diagnosed patients was ever easy in the general sense of the word. No matter how small the disease or potentially favorable the outcome, walking into any new oncology patient consultation is fraught with danger. Between the date of diagnosis and the first consultation, terror builds. Fueled by wellmeaning people, Web sites of variable quality, and cancer stories of uncertain relevance, tension ratchets inexorably tighter every day. This fear needs to be managed in the most constructive way possible, avoiding explosion or meltdown. A controlled experience is required. Not easy in the general sense of the word, ever. It was a remarkable coincidence. The first patient was 37 years old, married to a software developer, and a mother to two beautiful girls ages 4 and 7 who were at home with their grandmother while mom and dad spent time with another doctor who was going to help mommy’s hurt. The second patient was 35 years of age, newly married to a solid-looking paramedic. Ten months before our consultation, they had become parents to a baby girl who was also with grandparents as mom and dad went back to the hospital to find out what was next. Both women presented with a 2to 3-month history of ignorable but highly predictive symptoms; intermittent constipation, thinning stool caliber, and increasing pelvic unease. Both had sought help at their family physicians’ offices and had been directed to the appropriate set of investigations and referrals leading to a diagnosis of locally advanced rectal cancer. Both had undergone computed tomography (CT) scans and colonoscopies with results that argued for curative-intent intervention. Approaching with the trepidation inherent in new consultations with young patients unfairly targeted by a cancer diagnosis, I was struck by the dramatically different styles of my two patients. One was a paragon of stoic determination, as was her husband. Carefully sifting through my explanation of the pathology report and its implications, she easily fixated on the most relevant features: “potentially curable,” “need to treat first to shrink things before surgery,” “combined chemotherapy and radiation to maximize successful surgery.” Her questions came in answerable volleys: “Will I get sick from the chemo?” “Do I need to have treatment in hospital?” “When does everything start?” After a careful explanation of the definite and potential toxicities of the combined treatments as well as the sequencing of treatments with surgery, she repeated all salient points back to me, as if to prove that she had not only heard but also understood what was to come. Hand in hand with her husband, she turned and thanked me before leaving the office, seemingly treating the meeting as if she had just dropped off her daughters at a familiar daycare for a few hours while she went to do some shopping. Fresh from this encounter, I walked into a dramatically different setting in the next room. Here was someone more in line with my expectations. Freshly damp rivulets on her cheeks and shifting uncomfortably in the chair, her anxiety was electric, almost palpable. The tremor in her voice was clearly uncontrollable as she sat paralyzed, a proverbial deer in the headlights of the oncoming cancer train bearing down on her. Examining every element of her radiology report, she had somehow missed the point that there was no evidence of cancer spread outside the pelvis and that treatment goals would be curative in intent. An hour later, I had still not managed to convince her that a 2-mm incidental finding in her liver on the CT scan was benign in nature. Over the next 3 weeks, there were multiple visits with clinic nurses and telephone calls addressing shape-shifting concerns and anxieties. Finally, with the intervention of our psychosocial team and the support of her gently heroic husband, she agreed to proceed with the planned treatment. She eyed me suspiciously while signing the informed consent document and collapsed onto her husband’s shoulder once the pen sealed her fate. Treatment began for both of these women on the same day, unbeknownst to them. The plan was 6 weeks of radiation therapy to the pelvis along with an old chemotherapeutic agent, fluorouracil, delivered concurrently as a continuous infusion through a peripherally inserted central catheter (PICC) line, with the aim of sensitizing the cancerous tissue to the impact of the radiation. Once completed, a repeat JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 16 JUNE 1 2012