HEALING WELL

Dr. Abu-Rustum did a thorough exam. I don’t know why I thought he might not. Was it because I felt so fragile, had barely moved since St. Joseph’s Day, was still bleeding just a little bit? It was a gentle, but thorough exam, and as he moved the speculum around to examine what was left of my cervix he muttered a tiny, soothing, “I’m sorry.” I reassured him he wasn’t hurting me. He told me that the biopsy was surely a generously-sized cone, and that I was healing well.

Back in his office, the doctor explained in clear and pertinent detail, the staging of cervical cancer, the reason for such a big cone (corroborating my GYN’s stance that she was going for a therapeutic excision), and the likelihood that the bleeding was from tiny but vigorous cervical branches, exposed when the healing tissue/eschar sloughed off, like a scab falling off prematurely. He reiterated that he thought I was healing well, that I should make a full recovery, and that my cancer would be cured by a total hysterectomy. He showed us a chart with fractions of percentages describing the slim chance of cancer in the tissue surrounding my biopsy, the almost negligible chance of spread to regional lymph nodes, and the minimal expectation of cancer spreading to the ovaries or recurring in the vaginal cuff.

An expert in minimally invasive techniques, he rose to my request that he attempt a laparoscopic assisted vaginal hysterectomy, agreed with my GYN that the chances of conversion were higher in me due to adhesions from my previous c sections and the narrowness of my pelvis, but encouraged me that even open, though a pfannensteil incision, that my recovery would be swift. “Two to three weeks, at the most,” he said. “I just can’t see you lying around for six to eight weeks…after all, you’re young, you’re thin (hubby elbows me), and you’re a surgeon.”

For the first time in over a month, I was healing well.

SECOND OPINION

Memorial Sloan Kettering Cancer Center is an amazing place. My first understanding of it was as a General Surgery Resident, when I was doing a rotation at MD Anderson Cancer Center in Houston (another amazing place). I was tagging along with a GI Surgical Oncologist named Doug Evans. Never, I thought, have I met a surgeon so well read, so in command of the literature…and not just the way he pushed it around a copy machine…he actually knew what to copy! Anyway, he used to always talk about the guys at Memorial, and their latest work like I would talk about the Yankees and their latest homestand – far away, and heroic.

As a Colorectal Surgery Fellow I cultivated my own command of specialist literature, and found that more and more of the studies that I was reading were coming out of MSKCC. I followed the career of another Doug, Doug Wong as he continued his groundbreaking work in ultrasound staging of rectal cancers and minimally invasive treatment of early staged rectal cancer from Minnesota to New York at, you guessed it, Memorial.

As a young attending surgeon joining a practice on Long Island, I didn’t feel any closer to MSKCC than during my years in training, until my uncle got colon cancer. Suddenly everything I had ever learned and anyone I had ever known took on immediate importance. If I couldn’t take care of him myself…where would be the best place for him to be treated? I knew the answer was Sloan Kettering. I gave him Doug Wong’s name, but they couldn’t get an appointment with him for weeks. We put our trust instead in a young surgeon named Martin Weiser. He took great care of my uncle, did a laparoscopic sigmoid colon resection, and had him home and recovering in 4 days.

Almost a year later, I ran into Dr. Weiser at a course we were both attending on Pelvic Floor Physiology. I thanked him again for taking care of my uncle. He confided that my uncle underwent one of the first laparoscopic colon cancer surgeries performed at Memorial and he had such a great outcome they put his picture and his case on the cover of the hospital’s annual report!

I have since sent many patients of my own to Sloan Kettering for second opinions, and some of my most challenging cases, like very advanced or recurrent cancers, that I thought would be best cared for at a tertiary care center with a multidisciplinary approach I have sent to Dr. Weiser.

But never would I have imagined I would be referring myself there.

For weeks I’ve been rolling this diagnosis of cervical cancer around in my gourd. Looking at the slides with the pathologist, discussing it with colleagues, family, friends, and my doctors. I’d done the research, heard the recommendations, considered my options. Who am I now to take my little early stage, microscopically invasive, and completely curable cancer to the Mecca…to Memorial.

Then again, and my friend Nance convinced me of this, how blessed am I to live so close to such a quality institution? A reputable Cancer Center where the best minds care for cancer patients every day. A place where I have sent my own patients, my own family. How could I not take advantage of such a resource? Why not?

My husband said as he met me at the 3rd floor registration area, “People must have to take a personality test to work here…” It did seem so, everyone, from the doorman to the front desk to the registrars, the aides, the nurses, so calm, so welcoming, so warm.

And there, around me, I saw people, all ages, all stages, all different types of cancer, most with help, some alone. And strangely, it made me feel…OK. It made me finally understand how very, very fortunate I am. To have my husband beside me, someone to practice being old with, my beautiful children, our loving families, my friends, a rewarding career, and this cancer…thank God they found it early!

SUNDAY'S, TOO

“What did I know, What did I know,
Of Love’s austere and lonely offices?”
--Robert Hayden

Stayed in bed almost the entire weekend…feeling absolutely horrible. Drained, achy, depressed. Frustrated with myself, too, at how week I feel. My husband says it’s because I did too much the last couple of days. He’s probably right.

I went to Mass today. Father says I look kind of bushed. I almost passed out, spinning around to give everyone the sign of Peace, then came home and rested some more. Appointment for second opinion tomorrow.

DOUBLE DIGITS

Had an appointment with my Primary Care Physician today. Told her the whole story, and she just shook her head. Said my hemoglobin was up to 10.1 now , but that my WBC’s were still elevated. Probably from the physical stress of the sudden blood loss and second surgery, my system was in overdrive.

She also told me to take another week off, and not to feel guilty about it, that I absolutely would need it to continue to recover. I slumped out of her office and proceeded to feel horrible for the rest of the day. Taking my vitamins, eating healthy, drinking lots of fluids, but still very shaky.

Made a series of phone calls today to confirm my appointment at MSKCC, and to be sure I had all the slides and information they would need to make their best recommendation.

MARCH MADNESS

Thank God also for College Basketball. On modified bedrest over the last few days I have watched over forty hours of NCAA Men’s Basketball. It’s great recovery entertainment. You don’t have to think too hard, you get to watch beautiful, young, healthy bodies subject to seasoned coaching and expert strategy perform natural feats of wonder, skill, and speed. This season was especially exciting, as many of the top-seeded teams won and then lost games, in the final few minutes, or in overtime. This week, my Alma Mater, Georgetown, fell to the mighty Florida Gators.

I guess what I’m really avoiding talking about is that I met with my Gynecologist today about the biopsy results. She is recommending a “simple hysterectomy,” in other words, removing my uterus, but preserving my ovaries. She believes this will take care of the cancerous tissue and remove the most at risk organ. The part that is throwing me off is that she is adamant that I take 6 weeks off to recover afterwards, and would not recommend a laparoscopic assisted/ vaginal approach, mostly because of the difficulties she had during these first two operations “bringing the cervix down” through my narrow pelvis.

I am really miffed, and still shaking as I think about the events of the past week, the past few weeks. I am achy, although less so each day, don’t feel like I’m bouncing back like I should. She was real flippant about things, said that I should be resting and not doing much really until Monday. She recommended a second surgical opinion prior to the hysterectomy, and gave me the name of a GYN oncologist nearby, who has taken care of her own mother for uterine cancer. I told her I was going to Memorial to see a GYN ONC there.

BAD ATTITUDE DAYS

I woke up the next day very achy and despondent. Why me? Why now? All the gratitude, all the joy, and all the faith that had filled the last two days, seemed completely depleted. They were replaced by questioning, anger, and depression. The wake up call was there. My cousin’s sister-in-law, a nurse from MSKCC called to get some information so she could intervene in arranging a consultation with her favorite GYN ONC surgeon there.

Despite all the help, all the comfort supplied by my family, I felt very isolated, very alone. Like no one could feel how I felt. Like nobody cared. Which, of course wasn’t true. Had dinner in my bedroom with my bros and sister. Said Grace with the kids over the walkie talkies…

The next morning, I couldn’t believe how achy I still felt. Still hurts to cough? This is unbelievable. How much Iron should I be on? How much water? How much Gatorade? What were my electrolytes? Didn’t anybody care???

I called my PCP’s office. Had her order some labs to be drawn before our appointment on Friday. Then I called work to tell them I’d be out for at least another week. My boss, not feeling well himself, and shouldering the burden of my abandoned half of the practice, told me to take a look at my contract “While you are lying there,” to determine how I wanted to handle this disability. I took the liberty of taking his tone and his comments the wrong way and let myself feel hurt and indignant by whatever he was implying. I found out from my office manager later that he has no intention of paying me for any medical leave or disability term, and that I should take all my vacation time now, if I want to get paid. The syrupy sweetness of her voice could not hide the stress and anxiety she was feeling managing my absence.

My husband, meanwhile was working on issues of his own. Saving my life, raising the children, and running out of his blood pressure medicine all finally took their toll during my second Bad Attitude Day. He exploded at the condescending tone of my voice as I dictated which forms needed to go where to get the children enrolled in a private school next year. His BP was 180/110 and his head was about to shatter with ache.

In one fell-swoop, things started to get better. We went out to get his prescription refilled, and he brought me to the lab to have my bloodwork drawn. As the medicine kicked in, he grew calmer. I took his arm in the parking lot at the outpatient lab, my first trip out of the house since the day I bled. This lab, just 100 yards and across the street from my own office, where the bleeding started. I leaned on him as we took those first few steps out of the car. He laughed, and said, “ Look, were practicing being old!”

THE MISSION

When I got home Sunday night, I asked my Dad to call out all the troops. I was no longer going to go it alone, now I needed everyone to know, and everyone to remember me in their prayers.

So today, I got many, many calls, from cousins, aunts, and uncles. It still hurts to breathe heavy or to cough. I should have brought home my incentive spirometer. I think if I am going to be in bed much longer, I should wear anti-embolic stockings or something.

The call that really touched me today was from one of my aunts, who is very devoutly religious. She told me that she was praying very hard for me, and that Jesus would help me feel better, because I have a mission. She reminded me that I have patients that rely on me, that I am a kind, skillful, and compassionate doctor, and that I do God’s work each day. My children, my husband, are part of that mission, too. Jesus will make me better, because I have a reason to live. So many people suffer, she said, and they search for their mission in life. I am already blessed with a mission, and for this reason, I will be saved.

And I started to feel better.

i thank You God for most this amazing

I will never forget the moment that I opened my eyes to the dawn unfolding outside my hospital window. A wall of glass, facing east, revealed the sky, changing in slivers from night into day. My throat was sore, but I was…breathing. I am alive, I thought, thank you God, I am alive. I thought of my husband, my children, my family, my friends, and was deeply merry. I thought of the secrecy, the discretion, since I’d learned of my diagnosis, how bad, what stage, what next, how long? I didn’t know, so I didn’t want to alarm anyone. I was ashamed and trying to tackle this all alone. But now… here I am… lying in this bed…alive… only by the very Grace of God. I must tell them. I must thank Him. Tears streamed down my face as I started to pray and a poem by E. E. Cummings danced with my prayer, and I thanked Him.

THE ANGEL ON THE HILL

When we got to the Emergency Room, I was happy to see a friendly face. I was at the Hospital On The Hill, and thanks to the magic of downsizing, the struggles of single-parenting, and corporate and personal obsessions with multi-tasking, the nurse who triaged me was a friend. I had known J since my first days as an attending at that hospital, six years ago. She was a member of the Endoscopy Unit with whom I would do colonoscopies each week. She used to talk about her adventures in the ER, where she often took shifts to support her two teenaged children. When the Endo Unit was consolidated into an Endo Room, J was cross trained as a circulating nurse in the Operating Room, so I would still get to see her almost every week.

It was now evident that the angel taking care of me that night would be working through J. She quickly got me triaged, had my husband register me, got me into an exam room, showed me where all the pads were, found my doctor, assisted her with my exam, and when it was decided the bleeding would be best dealt with in the operating room, stayed with me until they rolled my stretcher into the room. “You shouldn’t be alone right now,” the angel said, piling warm blankets on me and changing my diaper (the bleeding was now too heavy for pads).

I was trembling, not with fear, but with crystalloid, liters of IV fluids “wide open” filling the veins in my arms. In truth, there was no fear. I was a surgeon. I had faith in the power of timely surgical intervention, and felt that we got there “in time.” I had faith in my doctor, the nurses, the ER, the OR, and in God. The angel He had sent was letting me know, now through the suddenly calm eyes of my husband, “Everything’s going to be all right.” I wanted to answer him, but I was weak, and so cold. And then, suddenly, warmth, between my legs, filling the diaper, the warmth of my own blood.

THIS IS NOT MY PERIOD

Friday was St. Patrick’s Day. I bantered with anesthesiologists about great restaurants in Philly, and becoming a girls’ lacrosse coach, but really, I was not feeling well. I had four cases scheduled and helped my associate with another two, but they were all pretty light cases and I couldn’t wait to go home and rest.

I was bleeding. Really all along, since my biopsy. It had turned a blackish brown and lightened some mid week, but by Friday I was noticing a redder tinge and heavier flow. I called my doctor and she returned my call while I was doing my second to last case. She asked if the flow was like a period, and reminded me that irregular periods was the initial symptom that we were working on when we found this. I agreed, that it was not any heavier than a regular period, promised to call if it gets any heavier, finished my cases, passed by the office, then went home to rest. I put my feet up, ate some corned beef and cabbage, and went to bed. I was on call, but only got a call or two that night.

The next morning I got a call at 6 am. One of our patients in the hospital was vomiting and sick. The housestaff had taken care of making sure he wasn’t having a heart attack, but I decided to go in early to make sure he was OK. He was, and after we decided the nausea was some of the after-effects of anesthesia and pain medicine, I let him go home as we had planned.

I then proceeded (late) to a full morning of patient hours. The satellite office where I spend almost every Saturday morning is about an hours drive from the hospital. Seven new patients, and some established and post op visits. I was rushed, stressed, and irritable, although I tried hard not to show it. I was also still bleeding, but was more annoyed that I didn’t have enough pads with me than that it was soaking through the ones I had.

Later that night, my husband, my son, and I were in my office, fiddling with a new computer they had bought me for my birthday. After apologizing for bothering him on a Saturday night, I had the office IT guy on the phone for an hour, trying to install a new driver and port for an old reliable printer. That finished, I went to the bathroom to pee and passed a clot the size of a fist. I told the boys they’d better get me home quick, I needed to lie down, and to call the doctor.

I LIGHTEN UP

Had a great day on Thursday, and my husband really helped. Did three colonoscopies, then picked him up to drop off some forms at the Catholic School where we want the kids to go this fall. They’ve had an OK run at public education, but they’ll do better, they both will, in a smaller, more controlled environment.

We went to lunch in town, before I was scheduled to start my afternoon patient hours. I explained how guilty I used to feel taking time for lunch, but now felt justified, as I had added an additional day of patient hours and planned to fill days I wasn’t operating with office procedures, making for a six day work-week. Besides, we said in unison, just like Terrence and Philip, “I have CAN-SA.” Morosely we joked about my diagnosis, how we should have kept that life insurance, and whether this would ever amount to a good parking spot!

I went to the office, and was sobered when I had to tell a 62 year old woman who complained of bleeding hemorrhoids that she had a large rectal cancer just above her hemorrhoids that was the more likely and more critical source of her bleeding.

I decided to call an old colleague of mine. We were chief residents together, and we still kept in touch via e mails and IM’s. This was a sensitive issue, though, and I wanted to talk to him and hear his voice. He warned me to get out of my comfort zone, to treat this diagnosis with the attention it deserved. He urged me to get a second opinion. He mentioned surgeons he knew at Fox Chase Cancer Center, near where he practices, or recommended I find someone top notch at Memorial. One thing I can say about gynecologic cancers, he said, is that they should be attended to by specialists. GYN oncologists operate more like us, more like general surgeons, than general practice OB/GYN docs. You don’t have to be at a place where you’re known, in fact, that can jynx you, being taken care of in the community where you’re well known. You’re going to be fine, because you are a strong, good person, but I am so sorry to hear that. I guess we’re all getting old, but please have it taken care of by the best you can find, and a specialist.

At least he didn’t say “At least they got it early.”

AT LEAST THEY CAUGHT IT EARLY

I remember hearing on NPR the end of an interview with a woman whose husband was stationed with the US Military Troops in Afghanistan. She talked about how she would shrink each time someone would say, “Well, at least he’s not in Iraq.” The comment did nothing to console her, although she kindly assumed that’s how it was meant. Instead it embarrassed her, belittled her, and sometimes made her really angry.

I think I know how she feels. Seems each time I tell someone of my diagnosis, I get the same response, “Well at least they caught it early.” To myself, and sometimes even out loud, I answer, “Yes, thank God.” Although I’m not yet sure that I believe that…one that they got it early, pretty sure that they didn’t get it all, and definitely not thankful yet that I HAVE CANCER!!! Doesn’t anybody believe me, can’t anyone bear to let me mourn this abnormal uncontrolled process going on deep inside, microscopically invading normal tissue, the normal tissue that once housed my beautiful two children? OK. So (hopefully) I’m not going to die from this, but do I have to be thankful…already?

I shared my frustration with my husband. “You know what’s more annoying,” he asked, only half kidding I think, “is when people get so wrapped up in themselves they can’t see when someone’s just trying to be nice.” Ouch.

STAGING

All the world’s a stage,
And all the men and women merely players.

--Shakespeare, As You Like It

I looked at the cells through the microscope. They looked “happy enough” as my friend the pathologist described them as he helped me review the slides from my cone biopsy. Regular, smooth, ordered, each dotted with the small purple nucleus of normal cells. Then he showed me some scarier looking areas…not so happy. Jagged, irregular (mitotic) nuclei, looking all revved up and angry, big bloated dysplastic cells looking just about ready to burst with pink cytoplasm, and glands, functional components of cervical tissue choked with abnormality. A very few, rare, he said in his final report, were actually invasive through the glands. He showed me these areas and reiterated how magnified it all was under the scope. And then he printed out a copy of his report.

UTERINE CERVIX, CONE BIOPSY:
RARE MINUTE FOCI OF SUPERFICIALLY INVASIVE
SQUAMOUS CELL CARCINOMA IN A SETTING OF EXTENSIVE CARCINOMA IN SITU WITH BULKY
ENDOCERVICAL GLAND INVOLVEMENT. HIGH GRADE DYSPLASIA, BUT NOT INVASIVE
CARCINOMA, IS PRESENT AT THE ECTOCERVICAL MARGIN OF EXCISION.

TNM
staging: T1A1, NX, MX.

So that was it. I had cervical cancer. An early form of it, from what the biopsy had captured, but carcinoma in situ/severe dysplasia at the margins, which to me was a concern, and most likely an indication for more surgery.

I told my husband, showed my boss, did some research on the internet, rolled the diagnosis around in my head for days, and counted on seeing my doctor in about a week to hear her recommendations. For whatever reason, I kept it all inside…talking to very few people about it at all.

SEX AND THE O.R.

My gynecologist pushed back the curtain in the Ambulatory Surgery holding area with a flourish. “My favorite line, do you watch Sex in the City,” she asked, then went on, “is when Stephanie is telling Carrie in the car that she has breast cancer, talking about the lumpectomy that she’s having, she says ‘Tuesday we’re going to get the little fucker out!’” she giggled. “That’s how I think you should be thinking about this, get this out, get on with your life, do what you have to do.”

I was not done kicking myself, “Could this have been prevented by more frequent Pap smears?” she and I both knowing I had let four years lapse since having an annual exam. “Yes, could be, could be,” but she was not prepared to join me in the self-flagellation. She then went on with my post-op instructions. The anesthesiologist came in, gave me some Versed, and they whisked me off. I vaguely remember getting positioned on the table.

HAPPY BIRTHDAY TO ME!!!

Had a fabulous dinner at a swanky local steakhouse. My son got all dressed up -- shirt and tie he tied almost all by himself. A pharmaceutical rep, hosting a dinner in the cigar room, paid for our dinner! My dad met us at home for cake and coffee. The kids had me open little presents -- an exercise ball and a memory stick for the digital camera. Then we got on line to order my big present -- a new computer to use at work. It should be delivered the week I get back to work following my procedure.