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Difficult Choices

Posted 1/6/2017

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  Nothing about cancer comes easily. The choices, the decisions, the gray areas, the uncertainties, the slow recognition that nothing comes with a promise--all of these things make a difficult situation even worse. In the beginning, for women with breast cancer, the first choices are about choosing the best doctor (usually meaning the best breast surgeon) and the right institution for care. Sometimes there isn't much choice about this: insurance or geography may dictate what you do.

  In Boston, we are blessed with world-class hospitals and doctors, and I talk often to women about choosing the person and the place that feels right. In all honesty, the care is going to be the same at any of the big Boston hospitals. All of the doctors are smart and competent, and the issue becomes identifying a doctor whom you respect and trust and with whom you can honestly communicate. I sometimes tell people that the cultures and the air space is just a bit different from one hospital to another. If a second opinion is desired, the medical advice may well turn out to be the same, but the place and the encounter and the people will feel different place to place. You will know what is right for you.

  The second set of decisions usually revolves around surgical choices. I have written many other blogs about this topic, and there is no reason to say much this afternoon--except this. There is generally no single right choice, and you have to do the thing that will help you sleep better tonight and five years from now. And that there are no rules about how much information you have to gather or how many opinions you need to seek. You know yourself and what will help you best through this maze and anxiety.

  Systemic treatment, meaning chemotherapy and/or hormonal therapy, is the next decision point, and can be variably difficult. Clearly no one is eager to sign up for chemo, but sometimes the medical recommendation is clear, and you know that it really is a smart idea to cooperate. Different women have different personal beliefs about "toxic poisons" vs "this medicine may save my life", and it helps if you have a doctor with whom you can discuss your views. Sometimes it is not strongly clear that chemo is in order, one of cancer's many gray areas, and you are left with an "It's up to you". Very tough spot!

  This is all an introduction to Susan Gubar's most recent piece. She writes mainly about the next kind of choice selecting a treatment from various possibilities, including clinical trials, when cure is no longer the goal. For breast cancer, adjuvant treatment for early breast cancer is pretty standard. For women with Stage IV cancer, the situation is much murkier, and becomes very much related to the medical oncologist's beliefs and experiences. Here is the start and a link to read more:

Living With Cancer: Difficult Choices

As if confined in a sinister maze, cancer patients often discover that some routes lead to forking branches. It may be impossible to find a way through the bewildering medical labyrinth without feeling lost. My oncologist Dr. Matei, pointing out treatment paths, tells me to choose: “It’s up to you,” she says.

When I had to decide between resuming chemotherapy or entering a Phase I clinical trial, Dr. Matei outlined the pros and cons. She realized that I wanted to participate responsibly in selecting a course that would affect me profoundly. But my ignorance of complex medical protocols led to fearful qualms as I tried to make an informed decision about the benefits and perils of the options.

http://well.blogs.nytimes.com/2014/08/07/living-with-cancer-difficult-personal-choices/?_php=true&_type=blogs&_r=0

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