The Cancer We Think We Know…


In those early, once-upon-a-time days when I thought I knew everything and before humility had forced itself upon my stage, a haggard middle aged woman named Mary walked into my office a week early for her appointment. It was in the young days of my career and as it happened, a patient who was scheduled for that time had not shown up. So, I agreed to see her.

She had a wild look in her eyes, and they immediately pinned me to my side of the desk. Well-groomed despite her jeans and tattered grey sweatshirt she could have been mistaken for someone ten years her junior. But she had been referred by a family doctor that I, of decidedly conventional western medical training, had come to associate with fringe issues -homeopathy, hair analyses, colonic cleansing and the like- so I prepared myself for sifting through a ream of details I could not hope to understand.

“I don’t feel well, doctor,” she started, her voice as serious and worried as her face. “I’m 41 and for the last six months I’ve had a constant ache in my lower abdomen on the left side -my pelvis, actually. My periods are light, non-painful, and as regular as a calendar with no intermenstrual spotting; I have never had any pregnancies, operations or illnesses. I’m not on any medications, don’t smoke, and have no allergies. In fact, you’re the first specialist I’ve ever been referred to.” She managed a brief smile. “I had my family doctor order an ultrasound 4 or 5 months ago months and it showed a thin, normal appearing endometrial lining of the uterine cavity, but a 4 cm. complex cyst on the left ovary. A repeat ultrasound last month found it was still there, albeit somewhat smaller.” She hesitated briefly and then added: “I’ve had this kind of cyst before but usually without symptoms, and the cyst is always  gone by my next scan.” She looked at me for a moment and finally said, “So now I’m worried, of course.”

I have to admit I was a bit taken aback that she’d already answered most of the questions I had intended to ask, so I just sighed when she appeared to have finished her summary. “You seem to know your way around medical words…”

A smile appeared briefly on her lips, but one that couldn’t disguise her anxiety. “I have a PhD in pharmacology and am doing some research at the Cancer Agency so I guess I’ve picked up a few words…” She was sitting bolt upright in her seat, but the expression on her face said she wasn’t finished so I waited for her to speak. And anyway, I was running out of questions to ask.

“I’d like you to take everything out,” she said, suddenly leaning forward over the desk.

“Meaning..?”

“Meaning uterus, tubes, ovaries… everything!” She took a deep breath. “Look, I’m really afraid that all these cysts I’ve been getting on my ovaries are telling me something. There’s not a shred of cancer in the family, but I have this feeling about my ovaries that I can’t explain: I know  there’s cancer in one of them. Don’t ask me how I know it -I just do. And it’s only a matter of time before it becomes obvious in one of the ultrasounds… maybe too much time.

“I don’t want any kids; I’m not in a relationship; and I’m willing take hormones…” She blinked. “But I can’t take cancer.”

I’d been writing all this in her chart, but I put down my pen and looked at her. “Do you mind if I examine you and then we can talk about it?”

She agreed with a shrug of her shoulders. “Okay, but don’t tell me the recurrent cysts are just the result of anovulation…”

I had to smile at that one: it was precisely what I had intended to tell her. Anyway, I couldn’t feel the cyst and I told her so when we returned to the office after the examination. She seemed surprised.

“Are you sure? I mean I’m not questioning your findings, but why would it just disappear when it was still there last month? And a complex cyst as well,” she added, obviously aware of the possible ramifications implied by the term and searching my face for answers.

“Would you mind if I repeated the ultrasound?” I could see my findings had not reduced her concern in the slightest. “And maybe I’ll order some tumour markers, just in…”

“They’re usually not very helpful at my age.” The words seemed to escape her mouth before she could stop them, so she plastered an embarrassed smile over her lips. But she did agree to the repeat ultrasound.

*

I’m afraid I forgot about her until she returned a couple of weeks later, after the ultrasound.

“Well, it was normal,” I said as soon as she sat down. “But I suspect you already know that.”

She nodded. “I still want you to operate, though.”

I sighed, looked at the ultrasound report again and then at my notes in her chart. “But that left ovary is completely normal in appearance now -both of them are. The uterus looks normal… everything  looks normal.” I riffled through the few lab tests I’d managed to convince her to take. “Your periods are normal, so I admit that it makes non-ovulation as a cause for the cysts less likely, but the tumour markers are normal, the…” I glanced at her face. “No, I’m not putting too much reliance on them, but at least they’re reassuring as well.” I could see her fidgeting in her chair all the while staring at me. “Look, I can’t just take everything out in a woman your age without some good reason.”

She crossed her arms and a stern expression captured her face.

“So, how about we consider a couple of options?” I suggested, looking her in the eyes. She blinked, and I took that for an agreement. “The first is that we repeat the ultrasound in, say, six months and then…”

She shook her head firmly, and stared at me. “What’s the second option?”

“We get a second opinion -a female gynaecologist, maybe. If she agrees, then maybe she can do the…”

“I chose you, not another doctor,” she said slowly. “If the second doctor -the female– agrees, will you do the operation?”

I have to admit I felt a little flattered by that, and I suppose it’s why I agreed. But by the time she got a reluctant agreement from the other doctor and I was finally able to book the surgery, it was six or seven months later.

I went to see her on the ward the day after the surgery. “Everything went well, Mary. The uterus and tubes appeared normal, and the ovaries were both outstanding-looking citizens.” I don’t know why I said that; I suppose I was trying to make her realize that I was happy with what I’d seen.”

“When will we..?”

“Get the pathology report? It’s probably going to take about a week. But I’m not expecting any surprises, you know,” I said with a smile as I gently squeezed her hand.

But her eyes were wiser than my words. “Now that my ovaries are out, that bad feeling I used to have is gone; you got the cancer. I can tell…” Her voice faded as she closed her eyes and drifted into a narcotic-driven sleep.

*

I called her to come in to the office as soon as I got the report.

“It was cancer all along, wasn’t it?” she said in a soft, worried voice even before she sat down.

I nodded slowly and reached  across my desk for her hand. “But it was in the uterus, not the ovaries…”

Her face softened, and her shoulders relaxed; her response was a statement rather than a question: “That’s a better cancer to have, though, isn’t it?” Then she smiled and squeezed my hand this time.

 

 

 

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