By Richard C. Frank, MD
When you are in the throes of cancer treatment, it is sometimes easy to overlook or avoid looking at “the big picture.” The big picture is how you are doing overall with regard to the status of the cancer and whether or not the prognosis for life is long, short, or something in between. As an oncologist, I try to be mindful of conveying the big picture to my patients but sometimes in the course of a hectic day I fail to do so and am jolted by a big-picture moment. Let me explain.
I recently had an office visit with my patient Mike, a 65-year-old man dealing with metastatic prostate cancer. Mike came with his wife, Barbara, as he often does, and they sat in the examination room apprehensively, waiting for me to come in to discuss how Mike was doing. He was first diagnosed with prostate cancer twelve years ago and underwent surgery to remove the prostate gland. The cancer stayed in remission until five years later when his PSA began to rise. His urologist treated him with the testosterone blocking drug leuprolide (Lupron) but eventually the cancer spread to his bones and he was referred to me. I had been caring for Mike for five years, over the course of which we have used several different treatments to control his cancer. There had been many meetings, phone discussions, emotional ups and downs, remissions and relapses. This was another regularly scheduled office visit to check the progress of his cancer.
I inquired how Mike was feeling, how his energy and appetite were, if he was carrying on all the activities he wanted to, or if he was experiencing any new symptoms. His answers were “fine” and “good” and I detected no problems. We discussed his latest PSA value (a measure of the activity of prostate cancer), which was in the low range, only slightly higher than its previous level. His CAT scan and bone scan showed that the disease in the bones and lymph nodes were stable and controlled for the time being. In my estimation, he was functioning normally and the cancer was in remission (though not a compete one as it was still detectable). I answered Mike and Barbara’s thoughtful questions and we concluded on an up note that things were going well overall. Or so I thought.
As Mike walked ahead of Barbara toward the exit, she waited until he had put just enough distance between us before she turned around to me and said with an urgency that took me by surprise, “You have to talk to him. He thinks he’s dying.” “Wow,” I said to myself. “I blew that one.” I hurried to catch up to Mike, saw his long face, grabbed him by the arm and ushered him and Barbara back into my office. “Let’s talk,” I said. We discussed how he had been living with cancer for some twelve years now and that his was a journey with many ups and downs. There were times during that journey when the cancer seemed to be getting out of control but that was not the situation at this time. “You are not dying of this cancer now,” I said, “nor in the foreseeable future that I can tell.” His mood visibly brightened and his tense body relaxed in the chair. We talked some more, Barbara cried controlled tears of relief and they left arm in arm, reassured for the moment that things were good.
I chided myself for missing that signal from them and wondered how many others I was missing. The “big picture” is not easy to talk about in oncology. It takes great skill to read a patient’s emotional landscape, know what they are thinking and then make them feel hopeful regardless of the situation. It is a kind of pep talk. But the talk can only take place when either the doctor perceives that a big picture moment is present or the patient/family bonks him/her over the head with it. Either works.