One Strong Woman

“Executive Director in a high-profile company.” This is what was written under occupation in her medical chart.

I was reviewing charts of patients that were new to me to go over their medical histories and order any tests that I wanted to be done before seeing them in a couple of weeks. I like to browse social history to get to know patients before meeting them. Sometimes, I find clues that would help me get to know them better and provide a way for me to connect with them. Her case was a routine breast cancer case for me, and I ordered the tests that were required to be done prior to our meeting.

Two weeks later, she arrived for her appointment. I walked into the room and found a woman in her early sixties sitting alone. It is always intriguing to see who a person is accompanied by when they come for their medical appointments. A meeting with an oncologist, especially the first one, is usually a very detailed affair. There is so much information exchanged, and so many emotions tested that most people try to bring someone with them. Sometimes “for an extra pair of ears,” and other times just to be with someone while going through one of life’s most difficult times.

Sometimes, the room is full of family members to the point that one has to bring extra chairs. These, to me, are the best kinds of visits because they ensure upfront that the patient has a lot of support. Yes, there are a lot of questions, but it is very gratifying to answer all of them to their satisfaction. The most common is when a patient is accompanied by only one other person. Usually, it’s a significant other, a sibling, or a best friend. It is uncommon for someone to come alone. It leaves one wondering whether they did not have any close people in their life who could take the time to accompany them or whether they did not think much of the appointment and were underestimating the seriousness of the situation. Maybe they are a private person and do not want to burden others with their problems.

She got up from her seat and extended her hand for me to shake. After the pleasantries, we both sat down. She was a tall woman dressed up in a suit. The kind of suit that a business official wears. She had penetrating eyes and did not lose eye contact even for a moment during our conversation. She was carrying a notebook filled with notes. On the other hand, she had an iPad with her digital calendar pulled up, suggesting that she was also tech-savvy, unlike a lot of other sexagenarians.

“My name is Dr. Imran. I’m a medical oncologist. I have gone through your records in detail, and I have a good understanding of your medical history, but I would still like to begin by asking you some questions.” I started with my usual line reserved for all my new patients.

We reviewed how she had found a painless lump in her right breast a few weeks ago while showering. She was surprised because she was always up to date on all her medical tests including having yearly mammograms religiously. Her mammogram only a few months ago had not shown any problems so whatever this lump was, was either missed by the radiologist or had grown too fast. Within a couple of weeks, she had seen a breast surgeon and undergone surgery to have it removed.

“The first thing we do after cancer is diagnosed is to see how much it is spread inside the body. These are the so-called stages of cancer. Your cancer was found at an early stage and has been all removed. But cancer can come back after a few months or years as a stage IV cancer, and to prevent that, we have to do additional treatments that include chemotherapy and hormonal therapy.” I explained the plan and its rationale to her.

“Based on your cancer’s pathology, you will need two intravenous drugs. One of them is a chemotherapy drug that will go on for three months and the other one is a special targeted biological drug that continues for a year.” I elaborated.

“When do you think I need to start these treatments?” She asked.

“We should start within the next month or so,” I answered.

“Can I start in September?” She seemed to be calculating her options in her mind.

“That will be too late. The latest that we have started chemotherapy is within three months after surgery. That is what is done in clinical trials. We don’t know how effective chemotherapy is if it is started after a longer time period than that. It has not been studied. Many think that the window of benefit is lost by then.” I countered her suggestion.

“But do we know for sure that it doesn’t work if started later?” Now it was her time to counter me.

“No, we don’t.” I kept my answer brief.

“Will I lose my hair?” She asked.

This was a very common question asked specifically by women when discussing chemotherapy.

“Not with the biological drug that I was talking about, but with the chemotherapy, yes, unfortunately. For the first three months, you will lose your hair but then it comes back in another few months. I know nobody wants to lose their hair, and this is one of the biggest stigmas still attached to undergoing chemotherapy, but in the big scheme of things, it is a very small price to pay for such a huge benefit. To save your life.” I opined.

“What if I just do the biological drug and don’t do the chemotherapy?” She asked.

“Well, I don’t think that would be a good decision. We don’t have any studies on the biological drug alone, and we don’t know how much its benefit is if used without chemotherapy. Intuitively, one would think that it should work, but I don’t have any clinical studies to back it up with.” I responded.

“Can I do just the biological therapy and not do the chemotherapy? I don’t think that I’m in a position where I want to lose my hair.” She concluded.

“I would highly suggest against that.” I shared my concern with her.

“You don’t understand, doctor. I know what you are saying but my situation is different. You know society has come a long way but it’s still a man’s world out there. I am an Executive Director at my company. There are six directors and I’m the only woman. There has never been a female director at this company. I’m the first one on their record. How do you think I reached that level? By being weak? By being indecisive? No. I have worked hard to be here. I have been tough. I have endured emotional ups and downs and worked my ass off to be here.”

“In the corporate world, nobody is your friend. Success is your only friend. It is a cut-throat culture out there. If I do not perform at any level, I lose my credibility. I cannot afford that. There are others who are waiting for me to slip, and they would be happy to push me over to take my place. But I cannot let that happen. I am towards the end of finishing a high-stakes project that involves billions of dollars, and I have to present it to the board in three months from now. I cannot let anybody know that I have cancer and am going through chemotherapy. The minute they see me without hair, everybody will know and there is a very good chance that I will lose this project. This project is the fruit of my labor, and I cannot let someone else eat it away.” She said all that with a straight face. If she was trembling inside, she did not show it.

“I have explained to you what the national guidelines for treatment are in your situation. If you want to get a second opinion, you are more than welcome to do so, but I’m fairly confident that wherever you go, you will get the same recommendation.”

“But at the end of the day, the decision is yours. If based on your situation you think this is what you want to do, I will support you. I just wanted to make sure that you are making an informed decision.” I agreed with her, and we planned to start the biological treatment as she wished for.

She did well with her treatments and finished them without any major complications and, more importantly, without any hair loss. Nobody knew that she was dealing with a diagnosis of cancer. Most people take time off of work while going through cancer treatments, but she continued to work full time and finished her project like she wanted to.

We often follow patients for a few years after the treatment of their cancer, and if there are no signs of the cancer returning, we discharge them from our practice. About five years later, after concluding her annual visit, we said our goodbyes, and I quipped, “Let’s hope that we never see each other again.”

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During the middle of a busy day, I got a call from the emergency room.

“I have a seventy-two years old female who was your patient several years ago. She has a history of breast cancer and now presents with headaches for a few weeks. Initially, this was treated as migraine, but the headaches were not improving. She was at the grocery store and fell on the floor, violently shaking from head to toe. She bit her tongue and had urine incontinence. The seizure was not breaking, but the emergency response team arrived just in time to secure her airway and give her medicine to break her seizure. She has been found to have multiple tumors in the brain on MRI and also multiple lesions in the bones, suggesting the return of her breast cancer. She is stable now and will be admitted to the floor. I thought I would let you know.” The ER attending gave me a sign out.

“OK thanks for letting me know. I will arrange for her to see me in my clinic as soon as she is further stabilized and discharged from the hospital.” I said.

A few days later, Lisa was sitting across from me in the clinic room. Despite what was going on, she was still sharply dressed. Her face appeared puffy and she had gained about ten pounds because of a heavy dose of steroids. She was still sharp as a tack but she was repeating her questions suggesting a possible mild impairment of cognition because of the radiation to the brain. She was still holding her notebook in her hands and had a number of different colored pens to write and highlight with. She was accompanied by a man who she said was someone close to her. They had never given a name to their relationship but I could call him her significant other.

“I have reviewed your biopsy with the pathologist but this is the same breast cancer that we treated six years ago that has returned. This time it has spread to the brain, bone and the liver. It is stage IV meaning it’s incurable but we can still do treatments that can control it for some time.” I explained.

“Some time? How much time are we talking about?” She inquired.

“Well, we do the same treatments for all patients with Stage IV cancer, but the response varies widely. If this was some other cancer like pancreatic cancer or gallbladder cancer, the prognosis is much easier to determine, but in cases like yours, I have seen patients survive only a few months if some major complication happens, but we all have cases where the treatments are so effective that patients can live for many years to come, with a good quality of life.” I elaborated.

“So you mean that if I do these treatments I could live for a few months or several years?”

“That’s right,” I confirmed.

“That’s very confusing to me. I have always been a very focused and organized person. I have had a very successful life, and if anyone were to ask me what my greatest strength has been, I would say that it’s my discipline. I am a planner. I plan every little detail of my life and then I stick to the plan. If any plan doesn’t go as I want it to, I come up with a plan B. But now you’re telling me that I cannot plan anything because it is uncertain how these treatments will work and how much time I have to live.” She complained.

“I”m afraid that’s how it is. Cancer damages the organs of your body but it is more sinister in how it plays with your mind. It comes unannounced in your life. Sometimes it comes with the certainty of taking your life in a short time period but other times when it doesn’t take your life, it leaves you in this state of uncertainty. It is never easy.” I said.

“But how do I plan my life in this situation? Look at my calendar. There are family events. There are road trips. I have to travel for work. I volunteer at the church. How can I plan for anything if I don’t know exactly how long I have left to live? This is making me very anxious.” She shared her worries.

“Well I would say that now that the cancer is back with a vengeance, you will have to cut down on your activities a little bit. The goal is still for you to be able to do many things that you want to do but it might not be the same as before. Also I can tell you that I’m a planner too. I know exactly what you mean by becoming anxious if you cannot plan meticulously for anything but my advice would be for you to pencil in your plans rather than putting them down with a pen so that you can be more flexible if you are not able to follow your plans.”

“In a few weeks to months, if your treatments are successful, hopefully you will return to a quality of life as close to prior as possible. But if things are not going well, I will tell you. My job is to tell you about your prognosis exactly how it is and not to sugarcoat things for you.”

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She started her treatments and never missed an appointment. She always showed up prepared with her questions, notebook in hand, taking notes, and marking dates off her calendar. She told me that she had slowed down as much as she could in her social life. Her symptoms were manageable and the chemotherapy side effects were quite predictable to her by now. We were getting scans every few months and saw the progress of her cancer. With every scan result, she would be ready with her pens and notebooks to write down the comparisons of dimensions of her cancer lesions down to the closest millimeters. If there was a reduction in the size of the tumors, she would express satisfaction but she would get very anxious if there were even a few millimeters increase in size of any of the tumors despite my reassurances that we would see some growth in the cancer from time to time.

We were discussing the latest scan. “So it looks like the cancer did not grow at all in the liver but there are some areas in the lungs that have grown and there are also some new spots on the lung. I think it’s now time to change your treatment to a different kind of chemotherapy.” I suggested.

“You said in the beginning that I could live either for a few months or several years with this cancer. With these scan results, how do you think my prognosis changes. How much time would you give me now?” She asked.

“Lisa we have had this discussion multiple times in the past and my answer remains the same. I still have another few different treatment options remaining for you and if they are successful, you could have several more months or even years of good quality of life but it is hard to give you an exact number. It happens only in the movies when the doctor is able to tell you exactly how long you have to live.” I said.

“OK let me ask you this. If I stop all treatments, then can you say with a bit more certainty how long I have to live?” She inquired.

“Well, in the absence of any cancer-directed treatments, the prognosis can be relatively easier to determine. I would say that you would not have more than three to six months to live. Based on state laws, you would qualify to be enrolled under hospice level of care if we were to stop all treatments. But I would not suggest that because your life can be prolonged by a few years with these treatments.” I tried to explain to her.

“Well I may live longer but that would also mean that I would be living with uncertainty. If I stop the treatments, I would have more certainty and I can get all my affairs in order. No matter how much I try, I’m having a hard time not knowing about the future. What good is life if I have to remain anxious and uncertain all the time. I cannot plan for anything. If I stop these treatments, although I may have a few months or years less to live, at least I will be in control of the situation. I have already paid in advance for my funeral. I can write my obituary and leave it with my family to send to the newspaper when I die. I can distribute my assets amongst my family and be prepared to leave this world and not worry about trying to live some extra months or years filled with confusion and unpredictability.” She said.

“Well it is a difficult decision to make but at the end of the day it is your decision. If remaining in control of the situation and avoiding uncertainty is more important to you than living longer, then I can see how you can justify stopping all these treatments. We typically don’t see this in our cancer clinics. Most people will take any treatments available even if they are told that the chances of the treatments working are negligible. A drowning man catches at a straw. But make sure you have thought it over and talk to some of your loved ones and people who you trust just to make sure that you are convinced that you are making the right decision.”

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Lisa stopped her cancer treatments despite knowing that there were another few treatments available that could extend her life but without accurate predictability. She enrolled in hospice. She stayed at her home and instead of going to doctors offices and emergency rooms, a hospice nurse would go to ther home and give medicine to keep her comfortable and ensure that she was not suffering. She canceled all her engagements and had all her affairs in order and waited for death to knock on her door. I saw her one last time via video. She had lost a significant amount of weight. Her cheeks were sunken and her wrinkles were more pronounced but there was a calm look on her face. She seemed to be in total control of the situation. She did not complain of much during that video visit and thanked me for the care over the years.

A few weeks later, the news came that she had died peacefully at her home surrounded by her loved ones. My nurse read her obituary and we exchanged a few words in her remembrance.

“She always knew what to do but more so, she had the strength to make difficult decisions. The cancer tried to bend her on her knees and give the reigns of her life in its hands but she did not comply. She showed the cancer who was the boss. She did not want to deal with the uncertainty that cancer brings and decided to stay in charge. Boy, I have seen many patients but Lisa; she was one strong woman.”

November 10, 2024

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