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Iron Faces

One of the most difficult topics to discuss with patients diagnosed with a cancer (besides giving the actual diagnosis itself) is discussing their overall prognosis, or more specifically, what their chances are for a cure. There are many people that we will be able to cure – some will be easy, and some will be difficult. Nowadays, with the improved methods for screening and prevention, we can detect some cancers at the earliest stages, and for these patients, the “cancer talk” is an easy and straightforward one. On the other hand, there are many cancers that we quite frankly don’t stand a chance, either because the cancer is too advanced to reverse or too aggressive to respond. These situations are always difficult for two reasons: First, no one wants to hear that they are likely to die from their current illness; and second, depending on the person, hearing this kind of news could cause them to throw in the towel and completely give up. Although the main function of my job is to create and administer treatments, an often and equally important task is catching those patients who have become derailed and getting their heads back in the game to for treatment.

Early on in my training, I once came across a patient who was recently diagnosed with pancreatic cancer. For purposes of anonymity, I’ll refer to him as Jimmy, and I was a medical student at the time rotating on the surgical oncology service. He was initially planned to undergo a curative surgery called a Whipple procedure, but when the surgeon opened his abdomen, his tumor was found to extend around the blood vessels supplying his intestines, so the procedure had to be aborted. I accompanied the chief surgery resident to the patient’s bedside in the recovery unit as he attempted to explain the situation to the patient and his family. Despite the fact that he was being told he had an aggressive cancer, very likely to take his life in the next year, and that we do not have an effective treatment, Jimmy just kept telling us, “Well you’re wrong, I’m going to fight this, and I’m going to beat this.” We pressed on attempting to convince him otherwise and the only thing we did was make him resent us more. As a physician, this puts you in a difficult position. I know the facts and expected outcomes for cancers such as his own from my education and personal experiences. I knew that he was very unlikely to beat his cancer, despite the fact that deep down I sincerely hoped he would. That day I really began to question my authority as a physician to force a patient to understand and see the situation the way I do. Denial and sublimation are defense mechanisms to a serious life-threatening diagnosis, but I do think that remaining positive and progressing through cancer treatment with optimism has significant benefits.

I am definitely a glass-is-half-full kind of guy, but I do my best to be honest and a straight shooter with patients when it comes to difficult questions. My focus is more to maintain any and all of their optimism and goal oriented thinking, rather than my own. I’ve seen it happen over and over – once a patient gives in and accepts that they are not going to beat their cancer, their ability to tolerate and receive treatment and their overall quality of life diminishes. Take a motivated patient and they will try in every aspect to improve their current position. They eat right, they sleep right, they take their medications correctly, and they do all of the supportive care necessary to ensure they are capable of continuing to receive treatment. They also frequently reflect on their lives up to this point, and many begin to make efforts to reconnect with family members or friends. Because every aspect of their lifestyle and care is optimized, their outcomes are improved and their quality of life is similarly better. In contrast, patients who have given up are frequently just going through the motions. They are no longer engaged with their treatments, they eat less, sleep less, do not take their medications on time, and in effect have more side effects and a more difficult time completing therapy. I always inform my patients that the one unifying feature most related to how long someone will survive is how functional they are, and this corresponds directly to their resiliency and drive. The person who gets up everyday, continues to exercise, takes care of themselves, etc. is always going to live longer than the person who remains sedentary and doesn’t get out of bed or off the couch. So it is of the utmost importance for me to keep my patients positive and actively engaged with their treatments. It may sound silly, but I frequently talk to my patients about breathing techniques, visualization, etc. in order to prepare them to lie still.

For adults, its much easier to reason and coach them to remain positive, but this is a much larger challenge for young children, as they are dominated more by fear than the idea that they have a deadly disease. For some children, I have to use anesthesia so they sleep during their radiation treatments, but this has its downsides – the kids are forced to not eat for usually 4-6 hours before; they have to go to a recovery room after every treatment, and what should take 15 minutes can actually take hours. One of the hardest things for parents is to have a young child scheduled for 2pm, and be forced to tell the child not to eat all morning (and the kids rarely understand why). This literally makes their side effects and tolerance for treatment much worse, as they effectively fast half of the time they are under treatment. My staff probably curses me to no end, but my approach is to treat the young kids before we open at 6 and 6:30am. Its much harder on the staff and the parents, but you can move kids through quickly and they are finished with recovery by the time breakfast rolls around. For the other kids who are borderline for needing sedation versus able to do the treatments on their own, I focus on engaging them with their treatments too, but encouraging positive thoughts is more difficult. Whenever I use radiation to treat brain tumors (which is the most common indication for children), I have to use a mask to hold their heads still and in the same position. It’s scary for a child, as is essentially the entire experience.

radiation mask

The first lesson I learned about treating children is that kids hate the masks (no surprise – the adults hate them as well)! However, if you can turn the mask into a positive/more pleasant idea – then they are no longer scared and actually want to wear it. The second lesson that I’ve learned (mainly through my own two boys) is that all kids love and want to be Superheroes. They feel empowered when they come in for treatment and rather than receiving radiation, they get to become their favorite superhero:

batman maskspider man

When it came time to actually deliver the treatments for these two boys, I had the treatment staff address them as “Batman” and “Spider Man.” We revealed the masks to them prior to going into the radiation rooms, which I literally referred to as the batcave and spiderman’s lair. Neither of the boys were scared anymore, and in fact they wanted to do the radiation treatments, because for the 15 minutes they were undergoing treatment they were superheroes rather than cancer patients.

One of the benefits of working in a mixed clinic where I treat both young children and adults is that every one is able to feed off each other. This can work both ways in terms of propagating anxiety, or spreading positivity. But when adults who may be scared can see a child walk out of the treatment room smiling and saying “That was nothing!,” it definitely tends to raise the spirits of everyone nearby. Although they are not proven cancer therapies – remaining positive, visualizing, and engaging the treatments are equally important in regular life as they are in athletics, and I am thankful that many of my patients seem to benefit from my own psychological coaching.

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