I still see a number of patients at the Carbone Cancer Center while wearing my “Medical Oncology” hat, although I will confess to always having my “Palliative Care” hat on, each hat helping the other in optimizing the care I provide.
I saw Lisa (not her real name) a few weeks back. She is in her late forties now and I first met her when she was diagnosed with breast cancer in 2000. She underwent a mastectomy with reconstruction followed by AC x 4 and weekly Taxol x 12 on a research study. She then had five years of Tamoxifen. Then in 2010 she presented with an biopsy proven axillary node recurrence. She had neo-adjuvant chemotherapy, followed by surgery with no evidence of cancer and she had recently finished radiotherapy and started on an aromatase inhibitor.
She came to clinic for followup and asked the question,”What’s the scoop? What’s the chance of me beating this cancer?”
The response that came to mind initially was the factual one (not on the tip of my tongue) recalling the data I had reviewed at the time of her recurrence. “The 5-year Kaplan-Meier overall survival rate estimate after axillary recurrence was 49.3% (95% confidence interval, 42.0-56.3). Median survival time from the isolated axillary recurrence was 4.9 years (range, 2.0 months to 15.1 years). Overall (P < .001) and disease-free (P = .006) survival times were highest in those treated with a combination of surgery and radiation. Other factors associated with improved overall survival rate were an interval from diagnosis to relapse greater than 2.5 years (P = .003), no initial axillary radiation (P < .001), asymptomatic presentation of the recurrence (P = .05), and subsequent systemic treatment (P = .02).” Konkin et al, Arch Surg. 2006 Sep;141(9):867-72.” We had done everything recommended to reduce her chances of further recurrence.
But the answer that came to me was not that factual one. My response came from a NY Times Blog I had just read, “After breast cancer, wishing for a magic number.” Peter Bach is a Pulmonologist and Health Services Researcher at Memorial Sloan Kettering and he has been writing about his wife’s experience with breast cancer. Ruth and he were meeting with their oncologist, a colleague of his at Memorial. Peter writes…
“All of this progress meant that the chance that Ruth’s breast cancer would come back was a lot lower than it might have been years ago. But what was that chance, anyway? It was the obvious question, and we put it to her oncologist at our first appointment with him. He paused and then offered a peculiar answer. He said we should realize that it didn’t matter. It would either happen or it wouldn’t.”
Peter goes on to describe his thoughts, reviewing the concepts on survival as broad as Stephen Jay Gould and Atul Gawande, before turning back to the clinical interaction.
“Ruth’s oncologist elaborated on his refusal, promising he would tell us the number just as soon as we told him what probability of recurrence would cause us to make different choices for our lives. Neither of us had an answer.
What he was proposing was that we adopt neither Dr. Gould’s rosy view that our chances are somehow just better than the statistics, nor take Dr. Gawande’s implicit advice that we confront the number and plan accordingly. Because the truth is that no number, no matter how low, would have let us go skipping out of the office confident that this monster was slain for good. And no number, no matter how high, would keep us from living our lives.
I never asked again.”
Lisa and I read this together on the computer screen in the room and there was silence. She spoke first.
“Wow! I don’t have a number.” She understood the same truth as Peter and Ruth. We parted, with her committing to live life to its fullest, enjoying her daughter and working hard to look after herself, including smoking cessation.
It struck me as I reflected on Peter’s writing that in fact, we have our magic numbers in palliative care. “Would I be surprised if this patient were to die in the next 6 months?” But perhaps we have a new answer to the question, “How long do I have to live, Doc?”
“I’ll tell you a number if you tell me one that would cause you to make different choices in your life.”