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Sometimes no matter what I do, I can’t win…

Today I had a very unfortunate patient encounter and I felt completely helpless.

A few months ago I saw a patient who was diagnosed with a melanoma of the vagina.  Some may think that melanoma is strictly from sun exposure, but this isn’t always the case… sometimes it is purely bad luck.  This last is a patient whom I saw back in August.  I received a phone call one day from my close friend who is a gynecologic oncologist telling me he has a lady with a primary vaginal cancer that he thinks will do better with radiation than with surgery – “small volume disease” as we frequently say.  She had a primary tumor coming off of the vaginal wall about midway thru the vagina.  The biopsies that had been obtained are consistent with a melanoma.  I felt confident when I initially saw her, as my mentor has treated a number of these and he taught me a particular treatment technique that has so far seemed very effective.  I did a complete workup including a PET scan (a type of scan that looks at the entire body to see if there are any other areas looking like a cancer). She had some uptake in the lungs so I coordinated for her to have a bronchoscopy (a scope into the lungs to see if anything doesn’t belong) with a biopsy, which turned out to have no signs of cancer.  The consensus at the time was to treat using radiation alone, so I treated her pelvis and primary tumor with radiation, and these areas seem to be completely cleared now.  I last saw her in October and she returns today for a 2 month follow-up visit with a repeat PET scan which I coordinated because I wanted to keep a close watch on her.

So she comes in today with the PET scan I never hoped to see.  All I can say is I was shocked and completely taken aback.  This doesn’t happen often, but what was a relatively normal scan 3 months ago, now shows metastatic cancer everywhere: lungs, liver, bone, mesentery,…everywhere.

As a cancer doctor, you never really now how is the best way to break this type of information to a patient.  I wish there was a positive way to spin it, or some way to make the situation bright.  This, however, does nothing.  I generally just think of how would I want to hear it, or how would I tell my mother if she were in front of me, and my answer is to be as straight forward and honest as I can.  I walked into the room to see my patient this afternoon (fortunately, my resident essentially cleared the next half hour by staffing my next few follow-ups with my partner so I had some added time).  I asked her what current problems she was having… as in pain, trouble breathing, which shockingly was minimal, and then I immediately broke the bad news to her.  No filler, no pleasantries.  Just that this was a bad situation that no one would have predicted, and a clear explanation of what I see on her scans. She didn’t want to see the scans.  I shared with her son, and he too didn’t really want to see either.  They trusted me and understood what I was describing.  I always like to have a plan of action, so before seeing them today and discussing the bad news, I had already spoken with the medical oncologist who handles chemotherapy for melanoma patients and we had already put together a plan regarding the next step and which chemotherapy would be given.  Thankfully, we had a full plan of action which included multiple addition studies and a start date of Christmas Eve eve (23rd) to begin with chemotherapy.  The unfortunate reality is that melanoma that has spread does not have a good outlook, so this is one of those unspoken understandings between the two of us, where we (the medical oncologist and I) both know the ultimate result.

The most amazing thing about today is that when I was finished with the clinic visit, I truly felt terrible to be delivering such terrible news a few days before christmas.  I gave my patient a hug.  I wish I could say that everything is going to be alright, but I know in my heart this is not going to be the case.  She gave me a very compassionate and long embrace and whispered in my ear, “its okay, I know you did everything you could have done and you tried your hardest, this is just the Lord’s way of saying this is what must be.”  Its rare that I have a patient essentially apologize and give an excuse for my treatments not being successful, but I truly which I could have gotten rid of this tumor, and have told her today all is well, and have a Merry Christmas.  Sometimes, things just don’t happen as I would like, and I pray for my patient.

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