True courage is in facing danger when you are afraid.
—L. Frank Baum
Chief complaint: “I'm doing okay, considering.”
Her cancer was diagnosed years ago. It was resected, and she did well. Until she found a lump in her armpit. Several lymph nodes were excised, and she completed radiation therapy to the axilla. Scans revealed no evidence of disease. Until she started getting headaches and falling. Brain metastases. She had those resected, too. The radiation therapy to her brain left her exhausted and her mind clouded. She complained that her memory was poor, and conversation wasn't always linear, as she was easily distracted by competing thoughts. Yet her sister said she was still sharper than most people, and she was. She had a good sense of humor and a husky laugh. Her blue eyes, full of mischief, danced.
Chief complaint: “I just want to get this treatment over.”
She had already survived more than twice as long as others with advanced disease. She beamed when told she was doing “terrifically well.” After several months, she noticed a firm nodule near her prior excision. It did not appear to be a recurrence. A diagnostic mammogram and ultrasound revealed that the left breast and axilla were clear. But there was an incidental finding of microcalcifications in the other breast. She was young, and her breast tissue was so dense that it was hard to image. Breast MRI revealed multiple clusters of asymmetry that spanned several centimeters in aggregate. Breast cancer primary. Completely unrelated to her first cancer. Damn.
Chief complaint: “Will I be able to have a baby?”
She was single and hadn't focused on fertility at the time of her initial diagnosis. Now, years later, she wanted the option to have a family if she and her boyfriend ever married. The multidisciplinary tumor board recommended that she complete 1 year of immunotherapy for her metastatic malignancy before surgery for the new breast diagnosis, and she had months to go. This therapy could harm a fetus for months after the last treatment. We also wanted to initiate endocrine therapy quickly to block the estrogen that fed her breast tumor. We referred her to reproductive endocrinology to discuss fertility preservation, but she would not get the chance to freeze her eggs. Large tears silently slid down her face and dripped onto her blouse, staining it.
Chief complaint: “Just when I thought I was out... they pull me back in.”
She had lost a lot during her first go-round with cancer. She didn't want to lose her breast, too. We hoped tamoxifen might arrest tumor growth enough to make lumpectomy feasible. Following breast-conserving surgery, radiation would reduce the risk of local recurrence. She was wary because of her previous experience. This would target not her brain, but the breast and possibly lymph nodes. “If I take a deep breath at the wrong moment, it could damage my heart or lungs. Then what would I do?” Fair question.
Chief complaint: “Don't take one of the few pleasures I have left.”
“What can I do to help you quit smoking?” She wondered why I asked these questions. Tamoxifen increases the risk of thrombosis, too, and this risk is higher in smokers. She rolled those blue eyes at me. “I need to enjoy something.” She was stubborn.
Chief complaint: “Today is my last day of chemotherapy!”
I ducked my head into the examination room to say hello before the oncologist arrived. “I'm anxious about this breast cancer.” Her voice trailed off. I stepped in and closed the door. “I trust the doctor who did my other surgeries. But she seems worried, and I don't know why. It makes me nervous.” Her breasts were small. Breast preservation might be a challenge given the size and location of the tumor. It wasn't my place to surmise. I was relieved that the oncologist entered just then, and I had to go see a patient of my own. “I'll be thinking of you.” We wouldn't see her again until several weeks postop to discuss adjuvant therapy.
None of us knows what the future will hold. Those with a cancer diagnosis, present or past, together with their families confront an often ominous future. Wondering if each lump or pain heralds recurrence. If this blood test will demonstrate rising tumor markers. If that scan will reveal disease progression. I wish many tomorrows lie ahead for these patients. So many of them face their days with boundless strength, humor, and hope. I wonder at their courage.