The Doctor Will See You Now Read online

  3

  HOW OLD IS TOO OLD?

  * * *

  Old age has its pleasures, which, though different, are not less than the pleasures of youth.

  —W. SOMERSET MAUGHAM

  IN A CONTROVERSIAL ARTICLE in a 2014 issue of the Atlantic, Dr. Ezekiel Emanuel wrote, “Seventy-five. That’s how long I want to live: 75 years.” The controversy is not strictly because of the sentiment he expresses; many people feel the same way he does about growing old. Even Psalm 90 in the Bible describes a similar life span for man: “The days of our years are threescore years and ten [70]; and if by reason of strength they be fourscore years [80], yet is their strength labor and sorrow; for it is soon cut off, and we fly away.”

  Nor, to his credit, does Emanuel draw cheap attention to himself by advocating for legalizing euthanasia and physician-assisted suicide. He has always been against those movements and in favor of improving hospice and end-of-life care. But his remarks are provocative because he is one of the most influential doctors in America—a key health adviser to President Barack Obama, as well as a brother of Chicago mayor Rahm Emanuel. When he advocates life past seventy-five is not worth living, at some point there may be public policy implications.

  In the article, he wrote, “The fact is that by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us. . . . It is true, people can continue to be productive past 75—to write and publish, to draw, carve, and sculpt, to compose. But there is no getting around the data. By definition, few of us can be exceptions.”

  Before consigning everyone over seventy-five to the fate of Soylent Green (if you’re under fifty, google that reference), Emanuel should be reminded what his world might look like were it not for those exceptional people over seventy-five. When he was over seventy-five, President Ronald Reagan gave his famous speech challenging Soviet leader Mikhail Gorbachev to tear down the Berlin Wall. No speech was more crucial to ending twentieth-century European Communism.

  While Emanuel, a Democrat, may hold no special fondness for Reagan, in terms of political balance he need only look at Edward Kennedy, the longtime Democratic senator from Massachusetts. In 2008 when Kennedy was over seventy-five, he compared his brother, President John F. Kennedy, to Barack Obama. The senator then made the momentous decision to endorse Obama for the Democratic nomination for president at the expense of Hillary Rodham Clinton. Without the Kennedy endorsement, Obama might not have won the nomination and become president.

  In his eighties, British leader Winston Churchill completed one of the twentieth century’s greatest historical works, A History of the English-Speaking Peoples. Astronaut John Glenn, the first American to orbit the Earth, became the oldest person, at the age of seventy-seven, to fly in space. In a remarkable and underreported life, adventurer Barbara Hillary, having survived cancer, at the age of seventy-five became the first African American woman to reach the North Pole. Four years later, she made it to the South Pole, becoming the first African American woman to visit both poles.

  In the Atlantic, Emanuel despaired of the declining contributions of elderly scientists. Yet when he was eighty-eight, Dr. Michael DeBakey, America’s greatest heart surgeon, supervised Russian cardiac surgeons who performed bypass surgery on Russian president Boris Yeltsin. DeBakey practiced medicine, lectured, and wrote well into his nineties. His medical career alone spanned Emanuel’s natural life span of seventy-five years. Barbara McClintock won the Nobel Prize in Physiology or Medicine when she was in her eighties for her groundbreaking work in genetics.

  If any group has the right to take issue with Emanuel, it is attorneys. When he was seventy-eight, Supreme Court justice Oliver Wendell Holmes Jr. issued an opinion, familiar to every law student, that outlined the limits of free speech: he wrote that the First Amendment “would not protect a man falsely shouting fire in a theater and causing a panic.” His colleague, Louis Brandeis, served on the court for twenty-three years, well into his eighties. Three of the nine current Supreme Court justices are over seventy-five. Great authors including George Bernard Shaw and Johann Wolfgang von Goethe did some of their best writing after they were seventy-five, and two of the immortal artists of the Renaissance, Michelangelo and Titian, worked prolifically until they were nearly ninety.

  But put aside all the accomplishments of the extraordinary elderly. Emanuel has overstepped his bounds for reasons other than those “exceptions.” Simply consider ordinary people over seventy-five—all the love and affection they give to others, as well as all the love and affection others give to them. Imagine how much poorer our country would be without that love.

  Emanuel’s ostensibly commonsense advice that people should not live past seventy-five brings to mind what the philosopher Bertrand Russell once wrote: “This is one of those views which are so absurd that only very learned men could possibly adopt them.” Russell happened to be eighty-seven when he wrote that.

  4

  THE MISSING PIECES OF BREAST CANCER

  * * *

  Women agonize over cancer; we take as personal threat the lump in every friend’s breast.

  —MARTHA WEINMAN LEAR

  MARTHA LEAR, a health care writer and advocate, has aptly characterized breast cancer as a disease that not only strikes women individually but also threatens the entire community of women. The statistics are sobering—it is the second-most common cause of cancer in females (next to skin cancer) and is the second leading cause of cancer deaths in females (next to lung cancer). This year, there will be more than 250,000 new cases diagnosed and more than 40,000 deaths from breast cancer in women in the United States.

  But the news is not all bad. The vast majority of breast lumps, about 80 percent, prove not to be cancerous. For women diagnosed with breast cancer, both the number of patients cured and the long-term survival of others have been increasing for the past two decades as a result of earlier diagnosis and more effective treatments. These figures will only continue to improve, owing to extensive research in many areas—better diagnostic modalities for early detection, improved surgical procedures, a more complete understanding of tumor cell biology and molecular genetics, and more effective pharmacotherapy tailored specifically to the individual patient. There are currently a number of promising areas, including a new understanding of the relationship between breast cancer and estrogens, a possible preventive role for vitamin D, and new drugs that might actually forestall tumors in genetically predisposed women. Compared to a generation ago, breast cancer has become a manageable and, in many cases, a curable disease.

  Today much of the relevant breast cancer information is available and readily accessible, not only through your doctor’s office or local medical center but also via the American Cancer Society, the National Institutes of Health, Women’s Health Initiatives, and a number of valuable websites on the Internet. These are resources to take advantage of—the more you know, the less anxiety you will feel. But some observations and advice are best gleaned through the personal experiences of patients with breast cancer and the doctors caring for them.

  Before writing this, I talked with two women with breast cancer who have received chemotherapy, one of whom happens to be an oncologist. I also talked to two doctors—one a local surgeon who is a national leader in the field, and the other one of the country’s top breast cancer researchers. Generalizations about an area as complex as breast cancer are fraught with hazards, and some recommendations may not be right for everyone. Nevertheless, the four interviewees were fairly consistent in their thoughts. Below are some of their observations.

  Be Your Own Patient Advocate

  The first and most important point: If you’ve noticed a lump or other breast abnormality, take it seriously. Don’t put off getting an answer, and don’t be afraid of returning to the physician until you have an answer as to what it is. Denial remains an obstacle to early diagnosis, and early diagnosis is the key to treatment. If the lump turns out to be breast cancer, once you’ve been diagn
osed, your life becomes an emotional roller coaster, with all the attendant highs and lows. Swings in emotion are part and parcel of breast cancer—fear of the diagnosis, anxiety waiting for lab results and tests, reluctance to bother busy physicians, and frustration with bureaucracy and insurance companies (if you’re fortunate enough to have insurance). These are normal reactions, and you must work to remain in control. Coordinate your goals with your health care team. It may be an uphill fight, but it is not an insurmountable struggle.

  In your initial meetings with your doctor, bring a spouse or trusted friend for support, someone who will maintain equanimity. Come prepared to assimilate lots of information by bringing in well-thought-out, written questions. Be assertive but polite regarding information you require, especially issues like therapeutic alternatives and side effects of therapy. Listen closely to what your doctor says, write down relevant answers, and don’t let important details fall through the cracks. Between treatment regimens, side effects, testing schedules, and how to cope, it’s easy to be overwhelmed. Ask the doctor or nurse if they can provide a written care protocol—instructions and a schedule indicating important appointment intervals, as well as dates and times of post-op care, testing, and chemotherapy. At every point of your care, always remember to speak up for yourself.

  You will have no better allies than intelligent, caring physicians and nurses. Nevertheless, if your insurance and time allow, feel free to ask your physician to seek a second opinion, with the assurance it’s no reflection on him or her. It’s important to consider various options and opinions on the treatment of different lesions depending on your particular case. Ask whom they would go to (or send a family member to).

  Breast cancer is a difficult disease to deal with and more difficult if you’re alone. Make use of the best support team you have—family, friends, and neighbors. Talk to other people with breast cancer and share experiences. The Internet can be a godsend. Besides providing informational websites and support groups, it offers interactive websites where you can tell your story and learn about those of other people, from your neighborhood or other parts of the world. It’s an effective way of sharing information without having to constantly retell your story. An interactive website is also a good way of keeping a diary of your experiences.

  Besides complications that required hospitalization, some of the more bothersome complications mentioned by the patients I talked to were chemotherapy-induced hair loss (expensive wigs were not always better, and some support organizations offered more affordable wigs that were just as attractive, while some women simply opt for bandannas); postoperative lymphedema (arm swelling), often managed best with special massage by an experienced nurse or therapist; and skin rashes so severe they required consultation with a dermatologist.

  If you have children, when they are old enough, be open about your disease. Talk to them about it and answer their questions. Once you have breast cancer, it is a part of your life forever, and it’s impossible to hide from your children. Once you’ve told your children, discuss the situation with a responsible adult at their school.

  Confidence in Caregivers

  The outside world can be a threatening and unfriendly place to a breast cancer patient. The patient will interact with a multidisciplinary team consisting of physicians, surgeons, oncologists, radiologists, chemotherapy nurses, social workers, physical therapists, and others. This can be intimidating, and not every patient has a primary care doctor involved with her breast cancer care. In some centers, the primary care role has been minimized, but a good primary caregiver can be a facilitator to coordinate care. Confidence in the delivery system is crucial to the patient. (In a charity clinic where I work, some women without insurance won’t go for free screening mammograms simply because they lack confidence in the centers they are sent to.) Every caregiver, especially on initial encounter with the patient, must recognize and appreciate the patient’s vulnerabilities and fears and strive to win her confidence.

  Both competence and a caring nature are indispensable characteristics for everyone working on a breast cancer team. Though competence is essential, most patients don’t appreciate the competent but “cold” caregiver. Next to the actual care the patient receives, the most important aspect of her treatment is the information she receives and how it is imparted. Yet many studies have documented shortcomings in how professionals deliver information to patients.

  Whenever possible, patients should receive bad news in person. It is generally preferable to have the patient come to the office rather than explain complicated information over the phone or via e-mail. However, the phone and e-mail have their place. When the doctor or nurse receives and returns messages from patients in a reasonable period of time, it demonstrates their concern and minimizes patient anxiety. Small gestures also can be important. Hospitalized patients appreciate the concern of a doctor who may not be active in their current care but who stops by anyway, if only for a moment to say hello.

  From the time of the diagnosis through every stage of treatment, clinicians are confronted with a whole host of diagnostic and therapeutic options. Often the “right answer” is not known with certainty or is changing according to the medical literature. In individualizing therapy, physicians should explain therapeutic options to the patient. When time and insurance companies permit, if the patient asks for a second opinion, the physician should make it easy for her to obtain pertinent medical records.

  Every caregiver, whether they are performing surgery, delivering radiation or chemotherapy, or inserting intravenous lines, should encourage the patient to ask questions. Some doctors fall back too readily on answering questions with scientific jargon or statistics without giving context. Statistics are invaluable—it’s impossible to practice medicine without them—but patients who suffer rare complications take little comfort in the statement, “It happens less than 1 percent of the time.”

  The team approach to breast cancer is a key reason for the improved survival statistics. But even a team approach sometimes has its drawbacks, including poor communication or unnecessarily duplicated tests. Also, a negative or counterproductive attitude by a single person on the team can undo the good work of ten others. It is imperative every caregiver demonstrates patience and tolerance and does what he or she can to instill the patient with courage. Most important, a major part of every caregiver’s role is to be an advocate for the patient.

  What People Can Do for Themselves

  Early detection is the sine qua non of breast cancer treatment. Patients diagnosed early tend to have better survival and cure rates. While there is some give-and-take about the value of regular self-breast examinations, this is indisputably how many patients detect their own cancer. An experienced physician or nurse should educate women on the proper technique and timing of self-examination. Along with self-exam, women should learn breast cancer signs and symptoms, in addition to lumps. Skin changes, unusual breast thickening, nipple discharge, and breast pain can all persist for a long time before the patient brings them to the doctor’s attention.

  Mammography (imaging) is the cornerstone of early detection, an essential aspect of contemporary public health. Unfortunately, in many parts of the country, mammography services are disappearing. There are fewer imaging machines and fewer doctors to interpret them because mammography is a frequent source of litigation and not always a high-profit area. (Sadly, some in the insurance and medical industry have lost their way in pursuit of profit at the expense of patients.) The good news is that despite some controversy, there is strong consensus that screening through imaging saves lives. Moreover, better and more sophisticated imaging techniques are being developed that will only enhance detection. Be an advocate for more screening mammography programs through your job or place of worship.

  Another emerging area of research and treatment where women can take an active role is in the genetics of breast cancer. Women in certain high-risk categories and those with a strong family history of breast cancer are candi
dates for genetic profiling. In certain cases, the genetic profile suggests the best approach is prophylactic mastectomy. This is an area women should discuss with their doctors to see whether they are candidates for risk assessment and genetic evaluation.

  In terms of prevention, much remains to be learned. There are indications that moderate exercise, avoiding obesity, and minimizing alcohol intake may all play a role in lowering the risk of breast cancer.

  What You Can Do for Family, Friends, or Acquaintances with Breast Cancer

  Become part of their support system in any way possible. Don’t avoid them or rationalize “it’s better if I don’t say anything.” In fact small gestures like a phone call, a card, or a pleasant remark mean a lot to the patient. After surgery, tests, and chemotherapy are completed, volunteer to transport the patient to and from the hospital, offer to help with carpooling and caring for kids after school, and provide meals for them and their family. Chemotherapy may only take a few hours, but between travel and the medication side effects, it’s usually an all-day event. Patients need help. Coworkers and bosses can be of assistance in adjusting patients’ workloads and providing flexibility with work schedules.

  Heroes and Gratitude

  A word on heroes: While not all patients are candidates for breast cancer studies, a debt of gratitude is owed to those who have participated in studies for most of our advances in the field. They are true unsung heroes of medicine. Demonstrate your gratitude by donating in some way, either money or time, to a breast cancer–related charity.