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The Skeptical Mystic
Weblog:
31st Dec 2004
- Cancer and Christmas
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- 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.
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- 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.
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- 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?
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- 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.
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- 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.
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- 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.
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- 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.
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- 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.
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- 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.
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- 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.
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- 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?
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- 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.
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- Such strange thoughts to have at Christmas.
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