Читать книгу Live right, live longer - Ludwig Heinz - Страница 5

She appeared as agile and impatient as she had on her first visit to me, a petite, forty-year-old woman. With her findings in hand, I motioned to the seating in my practice. »Well,« she asked, »What did the biopsy reveal?«

I would not have thought Martha Allen younger than she was. However, she was one of those people who have retained at forty the energy of their early youth.

A subway door had closed on her and the pain had not gone away. She remembered that she had had pain previously that she had ignored. She had also suffered from an unusually stubborn flu. Her more recent problems had been emotionally more trying than usual, and she had been altogether more debilitated.

Martha Allen suffered from breast cancer with bone metastases, which was confirmed by the new test results. The fact that I have delivered many such diagnoses in the course of my professional life does not mean that it has become routine for me.

Some patients have great difficulty in processing all the eventualities of a grave diagnosis and prefer the situation to be laid out gradually. I therefore asked her how much detail she wanted me to go into. I also offered to discuss some issues and questions in the course of upcoming appointments to give her time to process the information gradually. But Martha Allen thought nothing of that or of beating about the bush. »1 want to know,« she said. »How does it look?«

»I’m afraid I don’t have good news for you,« I said. She had evidently expected that. In any event, a brief flicker in her eyes was all the emotion she showed.

I handed her the findings and told her the result of the examinations.

She looked at the findings, apparently without reading them. But she did not seem paralyzed; she seemed rather to be pursuing a concrete thought. Finally, she raised her head. »How much longer do I have?« she asked.

Some patients do not want to know that. Others consider for quite a while whether they want to know or not. Understandable, because someone who has to deal with the information, for example, that she has an estimated thirty months left to live, can easily lose the ground under her feet.

In serious illnesses like cancer it is common practice for doctors – at least in the United States, where litigation is common – to turn on a tape recorder and press »record,« before beginning to discuss the situation with the patients and their closest relatives. Their statements are formulated in a legally incontestable manner. The patient is told, »Your average life expectancy is thirty months,« which is documented with the relevant references. Then the available treatments, their benefits, and the risks involved are listed objectively. And this is done with good reason, since every misinterpreted word can be used against the doctor in any possible lawsuit. But when it comes to cancer diagnoses, I do not think much of giving concrete information about expected survival time. These are average values that say little about an individual patient’s prognosis. Patients and the course of their illness always differ. On the basis of the findings and the patient’s status, i.e., the aggressiveness of the cancer and the fitness of the patient, I can assess reasonably well whether the disease course will be favorable or rather unfavorable, but I can’t do more than that.

I currently look after and follow several patients who, on the basis of the statistical average, should no longer be alive. Even patients of mine with difficult-to-cure cancers such as pancreatic cancer, with an estimated life expectancy of eight to twelve months, lived for years after the diagnosis or are still alive.

Unusual disease courses can never be ruled out, especially as medicine is making rapid progress. If patients do not ask, then I do not mention any concrete figures on the subject of survival time. Instead, I tell them about cases in which people have coped particularly well with their illness. That gives them hope, and hope is a strong motivating force. If, however, they insist and want an answer to the question, I draw a survival curve that shows how different the course can be. It shows that there is an average, but that some patients die very early and others survive unexpectedly long.

But Martha Allen was not interested in any curve. She definitely wanted to hear a number. To be absolutely sure, I asked her again. "Are you certain? Please think about it again. Perhaps you‘d like to sleep on it."

She shook her head. "I have to know," she said. "My daughter is still in school and I’m a single parent. I need to know what she can expect."

Her cheeks were now reddened. That was the only sign that she was in a situation that no one would want to be in. She was a fighter, that much was clear, and if a patient wants clarity, then my job as a doctor is to provide it.

"The average life expectancy for your illness at this stage is three to four years," I said. "That’s just an average, as I said. It can be less, but it can also be more. Average values are just average values."

We discussed the therapies available, their advantages and disadvantages, as well as possible side effects. The histological examination showed that the tumor was hormone-sensitive, which meant that hormone therapy could be used and for the time being at least, chemotherapy, which is associated with more severe side effects, would not be necessary.

Martha Allen had already said goodbye when she turned around again at the door of my practice. "My daughter is twelve now," she said. "She has six more years in school. I have to hold on that long. After that she’ll be able to manage without me."

I nodded.

She responded well to the therapy. Again and again, she emphasized that under all circumstances she would have to hold out until her daughter’s graduation. I wished it for her and her daughter, and I thought it was possible from a medical point of view. Six years, that was two to three years longer than the statistical average in her situation.

Time passed. Martha Allen’s daughter, whose name I now knew was Sophie, was a reasonably good student. Without major problems, she moved on to the upper high school levels, successfully passed a make-up test in Latin, and finally reached her senior year.

Around this time, Martha Allen stopped stating her life goals. I got word that Sophie passed her final exams and then went on graduation holiday to Gran Canaria with her class. I asked myself what this event might have triggered in Martha Allen, but she did not speak to it just then and I did not ask.

Not until the autumn of that year did we talk about it again. Martha Allen told me that Sophie wanted to study biology and environmental studies. "I want to be here when she gets her Master’s degree," she said. "After that, I can leave peacefully."

I smiled.

"Don’t worry," she said. "Sophie won’t dawdle in her studies. She has become very purposeful in the past two years."

Could well be she has that from her mother, I thought.

"Eight semesters," said Martha Allen. "That would be another four years."

She said that in a jesting tone, but I could see in her eyes how serious she was. She did not even ask me if I thought that was possible. "What was that again about average values?" With an amused smile, she answered the question herself. "Averages are just averages, right?"

I do not know whether Martha Allen counted the years, I myself did not. One day I found an invitation to a Master’s degree party in the mail. Sophie Allen had completed her studies in the minimum period of time.

I went to the party and saw Sophie there for the first time. She was a tall young woman, elegantly dressed for the occasion, and often at her side was an even taller young man.

Martha Allen came to stand next to me as I studied the two of them. "A good-looking pair, aren’t they?" she said.

"Yes, very. Looks serious," I said. We exchanged a glance. I suspected that Martha Allen had found a new life goal. She presumably wanted to hold out until her daughter was married. We both laughed, because it was clear to us that we were thinking the same thought.

"It can be less than the average, but also more," she said. "You told me that at the time of the diagnosis. Would you tell me again what that means exactly?"

"That it can be a lot less," I said, "but also much more."

She smiled gratefully. She had aged since then, and her illness and the treatments had doubtless contributed a lot to that. But she still radiated some of that energy. "Well, much less is no longer possible now," she said. "Then it can only be a lot more."

A few days ago, as I write this, I received an invitation to the wedding of Sophie Allen. I will also be attending this event and hope that the young couple will soon have children. Then Martha Allen will be able to set a number of new life goals, motivated by her love and the strong feeling of being needed.

Postscript:

Unfortunately, Martha’s disease became resistant to hormone therapy, which required initiation chemotherapy, to which she initially responded remarkably well. But as time passed, the treatment had to be changed because the disease progressed with the development of liver metastases. Although second-line chemotherapy induced considerable tumor regression, it was becoming clear that her life span was nearing its end. But she did not leave before her daughter gave birth to her grandson, whom she was able to hold in her hands with deep joy and love after his birth. A few days thereafter, she was ready to let go and passed away in the evening with a smile on her lips after her young family had visited her.