What the Walrus said.

The media are at it again, beating the data-drums for scraps of hope. It’s not that we don’t all long for reassurance and want to believe in the steady march of Science; it’s more that we can’t shake the suspicion that if we wish hard enough, stuff happens. For some reason I am reminded of the legends of the knightly quests for the Holy Grail where, to mix metaphors, ‘Lord Ronald said nothing; he flung himself from the room, flung himself upon his horse and rode madly off in all directions’ as Stephen Leacock would have it.

A bit of a stretch, perhaps, but a news report that I happened upon, brought it to mind: http://www.bbc.com/news/health-35111443 It was commenting on a large study on screening for ovarian cancer reported in the Lancet that looked at the value of a well-known cancer blood test (Ca125) coupled with ultrasound, and contrasted it with the value of ultrasound alone, or no screening at all. They were trying to ‘establish the effect of early detection on ovarian cancer mortality.’ In all, over 200,000 women were studied over a period of four years. And the results? ‘Their initial statistical analysis of the data showed no benefit to screening. But there was a benefit when they removed the data from any women who may have already started to develop ovarian tumours.’ [Bold letters and italics mine] Umm, I thought the whole idea was to find asymptomatic people who might have tumours…  And, as the news report does acknowledge, ‘…the interpretation is a bit messy and the researchers admit it is “controversial”.’ And yet, the article’s title screams: ‘Ovarian Cancer: Screening may cut deaths by a fifth. Buried in the second to last paragraph, however, is the more important point from Dr. Fiona Reddington, from Cancer Research UK: “While this is an important step in ovarian cancer research, we would not recommend a national screening programme at this point.”

I suppose my somewhat cynical point is that one has to read more than headlines to know the world, and that it is probably unwise to believe everything that is offered by the Media anyway… Then, for some reason, I remembered how I had managed to misread Germaine and her wish to be screened.

I like to see people smiling in the waiting room –it makes me want to choose them as the next patient and forget the scowlers or the eye-predators who attempt to capture me even before I make it past the front desk. Germaine imprisoned me with her eyes the moment I saw her –but more like in a flower than a jail. Her smile grew wider, the closer I approached, and almost exploded when I shook her hand to introduce myself.

But it faded slightly even after she realized she had in fact been chosen as the successor to my last patient, and had firmly ensconced herself in the hard wooden seat across from my desk.

The time has come, the walrus said…”. Those were the first words she uttered as soon as she sat down but when she saw the expression on my face, she managed to produce an embarrassed grin. “I’m an English Lit major…” she added, as if that were the definitive explication of the quote.

“The Walrus and the Carpenter -Lewis Carroll, right?” I said, surprised at how quick I’d got it.

I was rewarded with a twinkle from her eyes. “I have come to talk of many things,” she added, and promptly went on to explain. “I want you to check me for everything.” Her face glowed with expectation.

I tried to keep my eyes from rolling, but I’m not sure how successful I was. I then attempted to disguise my reaction further by scrolling through her records on the computer. I had seen her before, but not for a year or two. At that time, she had been referred for a pap smear and a discussion about becoming pregnant. She was now 26 so I assumed she was probably newly pregnant and was coming to me for her first prenatal visit. But the current referral letter said she was not pregnant and hinted at something else –something unspecified. I hate letters like that. I smiled anyway and looked up at her.

“My partner decided to be unfaithful, and said I need to be checked,” she said quite matter-of-factly as soon as she saw she had my attention.

Now we were on more familiar territory for me. I glanced at the screen. “Well, the pap smear your GP did a couple of months ago was normal…”

She looked as if she were about to roll her own eyes. “Well, of course…”

I politely ignored the unexpected reaction. “And you’re not having any symptoms?” Even if she weren’t I would still do the same tests, but it never hurts to ask.

“You mean like with gonorrhoea or syphilis…?” Her eyes narrowed slightly as she considered the ramifications.

I nodded. “Or chlamydia…”

She shook her head vehemently –almost violently, actually. “No, no. That’s not an issue.”

“Well, are you concerned about HIV, or…”
She threw her hands up in a theatrical denial of the very thought. Her mouth managed to roll up this time to complete the rejection. “Doctor!” she almost whined. “It’s not that kind of thing…!” But her sentence trailed off suddenly, leaving me to wonder if there was something she had been hiding from me. Something that she expected me to investigate without actually naming it.

“What would you like me to check then, Germaine?”

She looked down at her lap for a moment, the smile a mere ghost of its former self. She had pasted on another paler version by the time she looked up again. “Can I ask you a question first, doctor?”

“Of course you can…”

“Ahhh, I umm, read somewhere that ovulation drugs can give you cancer… ovarian cancer… Is that true?”

I had to think for a moment. There had been a spate of studies a few years before looking at the risk of ovarian cancer after the use of Clomid (clomiphene is a medication that tricks the pituitary gland into manufacturing FSH and LH which stimulate ovarian egg maturation and subsequent ovulation). The early and smaller studies suggested a slightly increased risk, but later studies either were unable to establish this, or had mixed results. “Well, those early studies were small and somewhat controversial, Germaine, and even with long term use, the risks were still very small…May I ask why you’re worried about this?”

A silent anguish seemed to drift across her face. “Well, what I read was that the longer you take the medication, especially if you don’t become pregnant, the greater the risk.”

“And did someone put you on it, Germaine?” I scanned through my old history but could find nothing to suggest a reason she would be infertile.

She nodded. “My GP did. We’d been trying for pregnancy for almost 6 months with no success.” She glanced at the ceiling for a moment and then out the window behind me. “And I mean the guy has good sperm –it worked before on another woman…”

I stared at her for a moment; I didn’t mean to, but my eyes just seemed to attach to her face. It was a rather odd way to talk about things. I decided to ignore it. “And how long were you on the treatment?”

She thought about it for a moment. “Well about 6 months, I think. But it didn’t work!” She took a deep breath and let it out slowly. “I told Jo -my partner- that I was worried about the risk of the Clomid… Then we both became worried, and that obviously led to the alternate route.”

“The alternate route?”

Germaine stared back at me with a puzzled expression on her face. “Yes,” she said after she’d thought about my reaction. “We both wanted a child and if I couldn’t be the one to carry it, then we’d have to make other arrangements –and it would have to be with someone else.”

Surrogate pregnancy?  I thought that was a little drastic after only 6 months or so of trying and I said so.

She looked surprised. “Oh it’s okay, she didn’t mind.” Then her eyes narrowed and a naughty expression suddenly laid siege to her face. “It was me… I was just a little surprised at the methodology, that’s all…”

By now I was hopelessly lost. Germaine seemed to find my puzzled expression funny and she started to laugh. Then her eyes twinkled again as the truth dawned on her. “I think you should look a little closer at the history you took when you first saw me.”

I pulled it up on the screen again and blushed. It’s funny how you can miss things when you’re searching for something else entirely.

“Even our eyes get caught in ruts, doctor,” she said when she saw my face. “It seems a shame, the walrus said, to play them such a trick…”

The poem again! But I finally understood; Jo had decided to have the baby.

“And my risk of cancer?” She was in a better mood now, and didn’t seem as worried.

The night is fine, the walrus said…” It didn’t really fit, I suppose, but the line had probably lain dormant in my head since university and I had to try it out.

She looked at me for a second and then giggled. “We’re really milking it, aren’t we?”

“You mean the butter’s spread too thick -as the walrus said?”

She nodded and then corrected me. “It was the carpenter…”

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