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Friday December 31, 2004: Cancer and Christmas

          I spent last week on the hospital rotation, which is probably why much of the time before Christmas was spent thinking about death. Our job in cytopathology is to clinically screen for cancer cells, yet I lost my edge of objectivity; I found myself hesitating to call a case malignant. 

         My first case on Monday had a history of bladder cancer, treatment, two negative reports and a report last time of atypical cells. I begin screening and find abnormal cells right away. Malignant? It doesn't have to be malignancy, I tell myself. It could be viral changes. Polyoma virus creates an overly large nucleus and we frequently see it in follow-up specimens from cancer patients. I scan more cells, realize my differential probably does not fit. I then cling to a diagnosis of suspicious--anything to give the patient a respite, a chance to spend the holiday with some smidgeon of hope. Finally, I come across a cell which is irrefutable -- the case is malignant.

        My next case is also a urine specimen, this one with a history of hematuria (blood in the urine) but no previous diagnosis of problems. I find more abnormal cells and fight the same resistance before finding cells I cannot deny. My first two cases of the day -- both malignant. Anxiety grows. This is the week before Christmas -- how many malignant cases might I end up screening?

        In my early years as a screener, I remember experienced cytotechs always shaking their heads, commenting on the increase in malignant cases diagnosed before the holidays. But I've never seen a scientific study to back up the claim. Perhaps the old axiom was a subjective reaction; no one liked the idea of a patient's lifestyle being disrupted with news of cancer right before the holidays.

        Back then, I had hopes a patient's doctor might wait a few days or a week before breaking the bad news. Nowadays, test results are entered in the computer and each patient has internet access to his or her own medical records. Test results show up online as soon as the reports are completed. There is no way to stall bad news.

        A resident once asked if I knew the difference between pathology and all other branches of medicine. I thought he was going to say that our interaction is with other doctors, instead of patients. He explained that in every other field of medicine, the doctor's first responsibility -- the bottom line-- is the well-being of the patient. In pathology, the first responsibility is the truth.

        Remembering his remark, I focus on regaining my objectivity. While I might be a tad more conservative than usual in my calls, I return to marking slides more aggressively. The cytotech's job is to find and mark abnormal cells; the pathologist reviews and makes a final diagnosis. Does that make the week before Christmas any easier for pathologists? As the week progresses, I suspect not. The lab is swamped by larger than usual number of tests, ordered by hospital doctors hoping to release their patients before the Christmas weekend.

        The cytopathologist covering FNA (fine needle biopsy aspiration) service this week has two cases that involve young people (young for us means their twenties or thirties). Patients know when they arrive for an FNA why they are being sent to cytopathology. They carry their fears and anxieties with them, knowing the FNA procedure is used to check out newly discovered nodules and growths deemed suspicious.

         A very thin needle is introduced into a superficial mass or nodule, and individual cells are pulled out and smeared on slides. Some of those slides are stained with a rapid stain and viewed under a microscope while the patient waits. Multiple passes can be done until diagnostic material is obtained. There is less trauma and risk than doing a regular tissue biopsy, and most of the time the diagnosis made on-site (by looking at air-dried slides) matches with the final diagnosis made after reviewing permanent slides and cell blocks the following day.

        Still, it is not uncommon for a cytopathologist to hold off giving a preliminary diagnosis, saying there is an adequate sample but he or she wants to review all the material collected. The patient is told to get back to their regular doctor in a few days for a final report.

        So...early in the pre-Christmas week, the cytopathologist faces the dilemma: do you tell these people -- in the prime of their life -- that they have cancer? Do you hold off giving a preliminary answer and let their own doctor break the news to them, when he or she can discuss options and follow-up? No matter how much training and expertise doctors have, they are still human, and some wrestle with their own feelings about death and dying.

        The cytotechs discuss the subject off and on all week. Is it better to not know, to celebrate the holidays with family and friends believing all is well? I suspect the fear of not knowing is worse than having the truth out in the open. I think about my family, who are relatively open about discussing death and dying, and realize that being hit with news of a family member's diagnosis would draw us closer together in support. Yet I know not all families are this close.

        Some of my co-workers have been dreading the annual extended-family gatherings. Some must deal with bickering factions, members still nitpicking and holding onto old grudges. Some have relatives who take advantage of one person's/family's generosity year after year, while contributing nothing of their own. Some have relatives who are just downright cranky and demanding. We may laugh about family bringing out the best and the worst in people, yet -- even with the most irritating individual -- wouldn't members behave differently if they thought this might be the last Christmas that they'd all be celebrating together?

        The more I think about it, the more I want time spent with family and friends to be embraced and cherished. We never know when someone may pass from our lives. It is not a matter of age or health. The unexpected happens; it may or may not give warning. I vow that from now on, when I become impatient with the extra company and confusion, I will think about cancer and Christmas; about what holiday memories will be left behind if loved ones are later to be separated by time, space, or death. Every time I think about what I would miss, my heart opens wider and the love run sweeter. 

 Such strange thoughts to have at Christmas.

Posted on Friday, December 31, 2004 at 07:38AM by Registered CommenterThe Skeptical Mystic | Comments2 Comments

Reader Comments (2)

the other Janus face of this:
eight years ago before Chrismas
I drove to Chicago to attend my son's
last chemo session for Hodgkin's lymphoma

this year he and his wife (fourth year medical student0
and their five month old daughter
came here

those fine needle biopsies
especially in young folks'nodes
can sometimes be
the beginning of what turns out to be
a happy ending

blissings on you
December 31, 2004 | Unregistered Commentersuzanne
I am so glad to hear your story. How it warms my heart!!

While the purpose of cytopathology is to look for cancer, most of the time we don't find it. Ninety-some percent of women's pap smears are negative. What is held for review usually consists of milder changes requiring only repeat pap smears or additional tests to clarify the patient's risk for future problems. The more intense changes (high grade lesions) can still be successfully treated while changes are in a pre-malignant stage. We rarily see malignancy in gyn cases (women's pap smears) these days, and we're all happy about that.

The bulk of our hospital or non-gyn cases (all other body sites) are also negative and can aid the doctors in following cancer patients: in ruling out fungal and viral infections or the recurrence of a previously treated cancer. Again, most of what we see turns out to be negative, and the patient can be reassured.

Even with FNA's, which show the highest case rate of malignancy, our usual pattern is to find not malignancy but a benign or reactive condition. Let me tell you, we in cytopathology all are happier when we can give the patient and clinician good news.

I am so happy for you and your son. I stay in the field because I hope we can stop cancer at an early stage. I stay because I hope it provides an easier, faster, and less traumatic test for patients who must go through medical ordeals. It's always heartwarming to see someone, diagnosed with cancer, who can be successfully treated and go on to live a full and rich life.

Hope your family enjoys many happy holidays. I know that new baby made your Christmas extra special.
January 1, 2005 | Registered CommenterThe Skeptical Mystic

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