A PIECE OF MY MIND

The Gift of Perspective

Sometimes I wonder why so many bad things happen to me. And then I thank God for the strength to handle it. My Patient
HE IS 41 AND, AFTER MANY CYCLES OF UNSUCCESSFUL in vitro fertilization, finally 18 weeks pregnant, when we get the worrisome news. She is sent to a gastroenterologist by her obstetrician to be evaluated for some rectal bleeding. Sigmoidoscopy shows a 4-cm mass with biopsy confirming adenocarcinoma, stage III at the time of diagnosis. She sees three different oncology teams for opinions, and everyone says the same thing: chemotherapy, radiation, surgery ASAP . . . not wise to carry pregnancy as the cancer may progress to untreatable disease . . . advised to abort. She is not interested in abortion despite the repeated urging of the consultants. She doesnt want to let myself down. This is the child they have worked so hard to have. I am humbled just to watch her digest all of this. She is so small, but so strong. I deeply respect her decision. At the same time I think about her and her family, and I want to start infusing the chemotherapy. I am reviewing her staging CT scan reports and find mention of an incidental splenic artery aneurysm. I am not sure what this means, but soon find out this is a high-risk situation. Many such aneurysms rupture during pregnancy or delivery leading to massive hemorrhage. I wonder how so many things can go wrong at once. Her vascular surgeon recommends urgent coiling for the aneurysm and successfully performs this within days. I wonder if the workup for her rectal cancer has strangely saved her life. After a lot of discussions and recommendations, we all agree on a plan. She will undergo cesarean delivery at 29 weeks and immediately start treatment for her cancer while her daughter is in the NICU. She delivers a baby girl right after Christmas and starts chemotherapy and radiation, which she tolerates poorly while her daughter struggles in the NICU with an infection. She quickly goes for her surgery, during which an enlarged para-aortic lymph node is found adjacent to her duodenumstage IV. Treatment planning transitions to palliative chemotherapy. Although it makes her sick for several days after each monthly cycle, she continues this. She takes treatment holidays, and her disease progresses to involve peritoneal metastases, a brain metastasis, a pneumothorax. Her
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chemotherapy is restarted. Somewhere along the way her husband loses his job. Ive stopped counting tragedies because she never does. As her primary care physician for the last three years, I have deeply felt the limits of what I can offer. I can link her to the best oncologists. During times of cancer stability, I can offer her the comfort of clinic visits spent discussing minor ailments, flu vaccines, the basics. And I can be there on the other end of her e-mails and telephone calls, which I am still afraid to answer sometimes . . . afraid to let her down with my limitations one more time. Despite this, she is my most grateful patient. Always remarking on how lucky she feels to have such good doctors. She sends me thank-you notes and holiday cards with pictures of her family, and I hang them up. She is grateful that I am present and that is enough. It is not fair. She gives me so much more than this. To me she is a hero. She is mother of the year. She is full of grace and power. I wish I could tell her how grateful I am for what she is showing me, but it would embarrass her. She shrinks from the bright light of my amazement at her strength. Hers is the quiet courage of living each day. Of watching her kids grow and of being there. Of carrying on because What else can I do? I rarely see her cry. When she questions why these years have been filled with so many challenges, it is with more wonder than grief. She fights for more than three years, the full extent of her disease often masked by her youth. She dies in the ICU after her lungs quickly fill with tumor. It is hard to let her go, but she made it clear she is not afraid to die. As her strength fades, I can see it ripple through her husband as he makes choices she would have made. Her daughter is 3. Her son is 8. Sometimes I wonder why she had to die so young. Why she had to suffer. Why the bad news kept on coming. Why I couldnt help her more. And then I thank God for the gift of knowing her.
Wendy Stead, MD
Author Affiliation: Division of General Medicine and Primary Care, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (wstead@bidmc.harvard.edu). Acknowledgment: Thanks to my patients family for sharing her with all of us and for permission to publish her story. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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