I ran across this article summary on chronic cancer related pain. This study confirms what I have written about here on this blog before. Most of the pain is related to cancer surgery. This news is certainly not very reassuring for me personally. I had completed a course of physical therapy for my post melanoma surgery pain. I was able to take a trip to southeastern Asia in November and did OK. But now the last few weeks, I have been doing more work on my laptop computer, writing and clearing out stuff I no longer want on it, backing up what I do want, etc, and now my arm is bothering me again. The physical therapist I saw before had determined that my ergonomics are not so good for my neck and shoulders and arms when I work on my laptop. So this may be why my arm is flaring up again. I have put back on the "tennis elbow" counter force brace around my lower arm and it helps a little. Is it bad enough to go back for therapy again? I do have a prescription to go back if I need to. I will wait a little bit before I decide to do that. I have reinstituted the exercises that the therapist had shown me. What does all this mean? Well if you read below, it apparently means that I could fall into the 40% of people who still have chronic pain 2 years after surgery. Of course, to keep it in perspective, I am only 8 months from my surgery. We are cancer survivors so I guess we all probably determine that we will have to put up with the pain; we are alive afterall. But what does this say about our cancer treatments and quality of life afterwards? There is certainly room for improvement. I do feel that the medical profession tends to ignore this problem.
Read the following summary of the study. Hit Read More
Pain in cancer survivors persists at 2 years post-Dx
Feb 3, 2011
Urology Times E-News
One-fifth of cancer survivors, including those surviving prostate cancer, have current cancer-related chronic pain at least 2 years after their diagnosis, say researchers at the University of Michigan Health System, Ann Arbor.
A study by the Michigan team, published online in Cancer (Nov. 18, 2010), showed that more than 40% of patients surveyed had experienced pain since their diagnosis, and the pain experience was worse for African-Americans and women.
Adults of ages between 18 and 90 years who had prostate, colorectal, breast, lung cancer, or multiple myeloma at least 2 years to the start of the study were included. Participants were recruited from the Michigan State Cancer Center Registry.
Other findings included:
The most significant source of pain was cancer surgery (53.8%) for Caucasians and cancer treatment (46.2%) for African-Americans.
Women had increased pain, more pain flares, more disability due to pain, and were more depressed than men because of pain.
African-Americans with pain reported higher pain severity, expressed more concern about harmful pain treatment side effects, and had greater pain-related disability.
"All in all, the high prevalence of cancer and pain and now chronic cancer pain among these survivors, especially blacks and women, shows there’s more work to be done in improving the quality of care and research," said lead author Carmen R. Green, MD.
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Showing posts with label cancer. Show all posts
Showing posts with label cancer. Show all posts
Thursday, February 3, 2011
Monday, October 4, 2010
Physical Therapy
As my readers can see, I have not posted a new article for over a month. Yet I am looking over the new flags that made hits on my website and also where some of these viewers came from. I feel I owe you a posting, so I decided to write a little about why I have been delinquent.
I have been accessing the medical profession again from the consumer side of the desk. My elbow has been continuing to have daily pain from my melanoma surgery. I have had various types of strange pains starting about 2 weeks after the surgery. At first it was, I think, a nerve pain with hyperesthesias (extreme sensitivity to normal touch) over the area, and allodynia, which is accentuated pain from stimuli over the area. I saw a physical therapist at the Hand Clinic at the Medical College of Wisconsin. But she really didn't have much to suggest and showed me a couple exercises to try to stretch the nerves, and slapped some corticosteroids cream on the site and gave me an ultrasound treatment. But she said she was not allowed to get the ultrasound head very close to the relatively new incision so she couldn't really get to the area that was bothering. Even so I found the vibration of the ultrasound to be very annoying, accentuating the pain.
This was very similar to therapy years ago for my knee and mostly what was done was modalities ie ultrasound, and electrical stimulation. That time zapping my quadriceps muscles with electrical stimulus while I was voluntarily contracting them was I thought extreme torture. And I did not complete that session. My knee slowly got better on its own.
Since my pain is persisting and some of that hyperesthesia is better, but now I am having deep pain with motion and with hanging my arm down, I have decided to try therapy again. It is after all three months since my surgery. A friend from my Spirit Mind Body group gave me a name of a therapist at the Sports Therapy clinic near my home. After the first visit with him, I was very optimistic. I now think there are therapists and then there are therapists. He was great, treating my whole body, found some things that I didn't know could cause me trouble. Very thorough. and astute at picking up on what I told him about the nature of my pain. He found a lot of tightness in my neck and shoulder, and at the acromioclavicular joint in the shoulder. He also said I was lacking about 40% motion when turning my head toward the surgical arm. He said one of my vertebrae was turned on the other because of that muscle tension. so he took it upon himself to strengthen this out and release those tight muscles. Just with the first two sessions I was felling somewhat better in the arm.
But then he started working on my surgical site and that elbow. He was probably too vigorous that first time. Within a day or two I began to recognize the pain; it was no longer strange or a stranger to me. I now had lateral epicondylitis, or tennis elbow. Somehow all that manipulation of the elbow had centered the pain and inflammation right on that lateral epicondyle. I had experienced tennis elbow before from playing tennis, but this one was created with the help of a surgeon and a physical therapist and it was a wing-dinger. But at least I knew what to do for this. I purchased a fresh new tennis elbow band and wearing it brought some relief. I have been wearing it much of the time since. My physical therapist was bummed out that he had caused a lateral epicondylitis, and stayed away from the elbow until about my 7th or 8th session. He continued to work on my neck and shoulder girdle. He is good, he identifies the muscles and performs maneuvers and asks me to move certain ways against resistance while he is isolating those muscles. My grip strength is lagging and seems to have plateaued at about 30% down from normal. We are able to record increases in neck range of motion, and arm range of motion after these sessions. But then the next session, I have lost all that range of motion and everything is all tightened up again. I have learned that therapy is an example of the cliche: Two steps forward, one step backwards. In fact it may sometimes be one step forward, two steps backward. Once I seemed to get a flare up of the arm pain after attending an Imax movie -- looking up. Once when I seemed to have moved backwards, the therapist took a history of my activities and we decided it might be me working a lot on my laptop, writing blogs and, -- I admit it, playing solitaire, or mahjong on line. So I have limited my computer time or else tried to steal the desktop machine which is more ergonomic from my husband, which is not always easy. So, indeed, you have not seen any blogs for a whole month.
I am still occasionally taking steps backwards. I went to water aerobics on Saturday and had a different and very young teacher. Of course, the moves were different because of the different teacher and she did a lot of arm work with buoys in the water. I stopped using my bad arm about 2/3 of the way through when I saw this, and I iced it after, but still I was pretty sore the next day. My therapist says I must stay positive, so I will try. Thank goodness for tennis elbow bands! And I will get better; I know it. It is just a slow process.
In the middle of this whole therapy thing, I did go back to see the plastic surgeon who operated on my arm. First let me go against rules and generalize that I think many surgeons (my son excepted) do not deal well with postoperative pain, particularly the pain that is different or more than expected. He was not very interested in the neuropathic pain I was reporting to him when I returned to get the sutures out. This 3 month follow up was just as disappointing. He really didn't address the location, nature or degree of my pain. He put his finger on a spot on my forearm which was slightly tender, and brought up a diagnosis that I had never even heard of, called a radial tunnel syndrome, and he suggested I was creating it by wearing my tennis elbow band too tightly. He also criticized my therapist implying he was treating me appropriately. He was otherwise showing off for the medical student that was with him. He also was critical of the report that my oncologist had sent him because she had decided that the total depth of my melanoma was only 0.48 mm which is very superficial. This depth would probably not justify as wide an excision as I had and would not justify a sentinel node biopsy. So he told me that we still do not know the depth. He still said we can't be sure and add up the depths, which of course would be 0.48 mm and 0 since nothing was found in the wide excision specimen. Just to make sure his student knew the degree of surgery was justified, he told me that we still had to be paranoid about this melanoma, that it could come back. Then he said,"Now, if you ask me do I think it has spread, I would say 'No.' but I do think we will never know the depth of this lesion, so I would class it as more advanced class of tumor than your oncologist did." OK, that's going to make me feel good and confident. Needless to say, I found this appointment very disappointing.
In an unrelated experience, I wanted to write another tale of a medical interaction. Amazingly, my husband had a nevus removed from the bottom of his foot about a week after I had my melanoma surgery. A dermatologist in my clinic had been watching this lesion on the bottom of hubby's foot for about 6 months and just could not live with it there anymore. He was going to do a very shallow biopsy of it, but knowing how my depth was disturbed by the shave biopsy, my husband insisted that at least 1 mm of tissue be removed in the biopsy. The dermatologist said he was uncomfortable about doing this and so wanted to send my husband to a surgeon. He called me into the exam room to explain this to both my husband and me at the same time. But then he began speaking to me about my amelanotic melanoma. He related that he made the same "mistake" that my dermatologist made and shave biopsied an amelanotic melanoma on a young woman. He felt bad about this, but then he said: "But it really didn't matter, because her melanoma had already metastasized and she died of a brain met." Yes, he said that to me and I was still wearing the big bandage on my arm from having my melanoma removed. This was an example of the doctor talking with the doctor and his being unable to view me as a patient. He was in truth not very sensitive to the situation. I told this story to my water aerobic lady buddies, and they thought it was terrible. They wanted to know his name, but I refused to give it to them, because this dermatologitst was a good doctor. He was just having trouble telling between the patient and the doctor.
I have been accessing the medical profession again from the consumer side of the desk. My elbow has been continuing to have daily pain from my melanoma surgery. I have had various types of strange pains starting about 2 weeks after the surgery. At first it was, I think, a nerve pain with hyperesthesias (extreme sensitivity to normal touch) over the area, and allodynia, which is accentuated pain from stimuli over the area. I saw a physical therapist at the Hand Clinic at the Medical College of Wisconsin. But she really didn't have much to suggest and showed me a couple exercises to try to stretch the nerves, and slapped some corticosteroids cream on the site and gave me an ultrasound treatment. But she said she was not allowed to get the ultrasound head very close to the relatively new incision so she couldn't really get to the area that was bothering. Even so I found the vibration of the ultrasound to be very annoying, accentuating the pain.
This was very similar to therapy years ago for my knee and mostly what was done was modalities ie ultrasound, and electrical stimulation. That time zapping my quadriceps muscles with electrical stimulus while I was voluntarily contracting them was I thought extreme torture. And I did not complete that session. My knee slowly got better on its own.
Since my pain is persisting and some of that hyperesthesia is better, but now I am having deep pain with motion and with hanging my arm down, I have decided to try therapy again. It is after all three months since my surgery. A friend from my Spirit Mind Body group gave me a name of a therapist at the Sports Therapy clinic near my home. After the first visit with him, I was very optimistic. I now think there are therapists and then there are therapists. He was great, treating my whole body, found some things that I didn't know could cause me trouble. Very thorough. and astute at picking up on what I told him about the nature of my pain. He found a lot of tightness in my neck and shoulder, and at the acromioclavicular joint in the shoulder. He also said I was lacking about 40% motion when turning my head toward the surgical arm. He said one of my vertebrae was turned on the other because of that muscle tension. so he took it upon himself to strengthen this out and release those tight muscles. Just with the first two sessions I was felling somewhat better in the arm.
But then he started working on my surgical site and that elbow. He was probably too vigorous that first time. Within a day or two I began to recognize the pain; it was no longer strange or a stranger to me. I now had lateral epicondylitis, or tennis elbow. Somehow all that manipulation of the elbow had centered the pain and inflammation right on that lateral epicondyle. I had experienced tennis elbow before from playing tennis, but this one was created with the help of a surgeon and a physical therapist and it was a wing-dinger. But at least I knew what to do for this. I purchased a fresh new tennis elbow band and wearing it brought some relief. I have been wearing it much of the time since. My physical therapist was bummed out that he had caused a lateral epicondylitis, and stayed away from the elbow until about my 7th or 8th session. He continued to work on my neck and shoulder girdle. He is good, he identifies the muscles and performs maneuvers and asks me to move certain ways against resistance while he is isolating those muscles. My grip strength is lagging and seems to have plateaued at about 30% down from normal. We are able to record increases in neck range of motion, and arm range of motion after these sessions. But then the next session, I have lost all that range of motion and everything is all tightened up again. I have learned that therapy is an example of the cliche: Two steps forward, one step backwards. In fact it may sometimes be one step forward, two steps backward. Once I seemed to get a flare up of the arm pain after attending an Imax movie -- looking up. Once when I seemed to have moved backwards, the therapist took a history of my activities and we decided it might be me working a lot on my laptop, writing blogs and, -- I admit it, playing solitaire, or mahjong on line. So I have limited my computer time or else tried to steal the desktop machine which is more ergonomic from my husband, which is not always easy. So, indeed, you have not seen any blogs for a whole month.
I am still occasionally taking steps backwards. I went to water aerobics on Saturday and had a different and very young teacher. Of course, the moves were different because of the different teacher and she did a lot of arm work with buoys in the water. I stopped using my bad arm about 2/3 of the way through when I saw this, and I iced it after, but still I was pretty sore the next day. My therapist says I must stay positive, so I will try. Thank goodness for tennis elbow bands! And I will get better; I know it. It is just a slow process.
In the middle of this whole therapy thing, I did go back to see the plastic surgeon who operated on my arm. First let me go against rules and generalize that I think many surgeons (my son excepted) do not deal well with postoperative pain, particularly the pain that is different or more than expected. He was not very interested in the neuropathic pain I was reporting to him when I returned to get the sutures out. This 3 month follow up was just as disappointing. He really didn't address the location, nature or degree of my pain. He put his finger on a spot on my forearm which was slightly tender, and brought up a diagnosis that I had never even heard of, called a radial tunnel syndrome, and he suggested I was creating it by wearing my tennis elbow band too tightly. He also criticized my therapist implying he was treating me appropriately. He was otherwise showing off for the medical student that was with him. He also was critical of the report that my oncologist had sent him because she had decided that the total depth of my melanoma was only 0.48 mm which is very superficial. This depth would probably not justify as wide an excision as I had and would not justify a sentinel node biopsy. So he told me that we still do not know the depth. He still said we can't be sure and add up the depths, which of course would be 0.48 mm and 0 since nothing was found in the wide excision specimen. Just to make sure his student knew the degree of surgery was justified, he told me that we still had to be paranoid about this melanoma, that it could come back. Then he said,"Now, if you ask me do I think it has spread, I would say 'No.' but I do think we will never know the depth of this lesion, so I would class it as more advanced class of tumor than your oncologist did." OK, that's going to make me feel good and confident. Needless to say, I found this appointment very disappointing.
In an unrelated experience, I wanted to write another tale of a medical interaction. Amazingly, my husband had a nevus removed from the bottom of his foot about a week after I had my melanoma surgery. A dermatologist in my clinic had been watching this lesion on the bottom of hubby's foot for about 6 months and just could not live with it there anymore. He was going to do a very shallow biopsy of it, but knowing how my depth was disturbed by the shave biopsy, my husband insisted that at least 1 mm of tissue be removed in the biopsy. The dermatologist said he was uncomfortable about doing this and so wanted to send my husband to a surgeon. He called me into the exam room to explain this to both my husband and me at the same time. But then he began speaking to me about my amelanotic melanoma. He related that he made the same "mistake" that my dermatologist made and shave biopsied an amelanotic melanoma on a young woman. He felt bad about this, but then he said: "But it really didn't matter, because her melanoma had already metastasized and she died of a brain met." Yes, he said that to me and I was still wearing the big bandage on my arm from having my melanoma removed. This was an example of the doctor talking with the doctor and his being unable to view me as a patient. He was in truth not very sensitive to the situation. I told this story to my water aerobic lady buddies, and they thought it was terrible. They wanted to know his name, but I refused to give it to them, because this dermatologitst was a good doctor. He was just having trouble telling between the patient and the doctor.
Monday, June 7, 2010
Waiting, Waiting, Waiting ....
Yes, I am waiting ... one of the hardest things to do when associated with the diagnosis of cancer.
My wide excision and reconstruction and sentinel node dissection and excison is completed. I did fine. I was of course nervous about it never having had a general anesthetic before. My blood pressure was 174/70, a number which has quite a high systolic compared to my recent blood pressure control (since I retired). This was a sign of my anxiety. The nurse was worried about my blood sugar because it was 65, a little on the low side. I had been increasing my insulin to handle my sugars in conjunction with a reinstitution of prednisone for a vasculitis which relapsed now as well.
I took a book to the day surgery suite because I had been told that the nuclear medicine procedure that identifies the sentinel nodes takes about an hour and a half and I pictured that I would be sitting and waiting for this radioactive tracer to go up my arm to the node basin in the axilla. Yes one does wait but that occurs lying down under a camara. And the wait was only about 1/2 hour. Then they saw the nodes light up and marked them. So the whole nuclear procedure took about 1 1/2 hour but there was really very little down time which would allow reading -- only about 5-8 minutes while I sat in a wheel chair and waited to be wheeled into the nuclear medicine suite. Once I was back in Day Sugery it was bam, bam, bam -- start the IV, get the venous leg pump wraps on, the electrocardiogram monitor patches on, speak with the plastic surgery resident, speak with the anesthesia resident clarifying my history twice, getting my blood sugar checked one last time, and speaking ever so briefly with my plastic surgeon who came in to sign the left arm as the correct arm on which to do the procedure.
I told the anesthesia resident that I had received 8 mgm of Versed when I had my colonoscopy and never went to sleep at all even with the Demorol. She just commented that they had different things than Versed to use also. Shortly later the anesthesia resident said she had given me some Versed in the IV right there in the Day Surgery room and asked me if I was starting to feel relaxed as they were starting to wheel my gurney out of that little Day Surgery room. I said, "Yes, I feel a little drowsy." And that was the last I remember until it was all over and I started to hear voices around me in the Recovery room and opened my eyes. The nurse said, " Why don't you try a good hard cough; you have been clearing your throat a lot just now." I didn't know anything about that. So you do things and make sounds that you don't recall afterwards. There was a little trouble getting off the oxygen; I was desaturating with oxygen but seemed to be able to remedy that with coughs and deep breaths. I proceeded quickly back to the Day Surgery area. My blood sugar was 150 so that was OK. I recovered uneventfully in the Day Surgery room, got a hydrocodone, one pill for pain at about 130 PM after I was back in the Day Surgery suite for about 1 hour. At home by 3:45 PM and took one hydrocodone at about 5 pm and then another before I went to bed. I slept in two large periods of sleep and took another hydrocodone at about 5 am. I had some sweating from low blood sugar in the middle of the night and had to get up to get something to eat and some juice to drink. After that all I took for pain was two 500 mgm Tylenols for Thursday and then after the dose on Thursday night I took nothing further for pain. The plastic surgeon saw me Friday morning mainly because he had jury duty to do next week Monday through Wednesday and he didn't think he should wait to look at me until Thursday of the next week. He thought I was doing OK also. But he does want me to see an oncologist. I had begun to think about this and realize that the plastic surgeon doesn't want to follow up on this. There will likely be a need for imaging, maybe even CT scans from time to time and the oncologists will order this I think. So that is the likely reason for that follow up.
I wanted strongly to go to my son's home for the weekend because our 3 1/2 year old was participating in a daycare program on Saturday. My husband didn't think I should go and my son on the phone didn't think I should try to ride all the way down to Indianapolis just 2 days post surgery. But I really wanted to go. I was really feeling down and worried on Thursday and I thought that going would knock off 3 days of the wait for the pathology results. I would be with my grandkids even though I would need to rest while elevating my arm and I wouldn't be able to pick up Will at all. But the weekend would pass much more quickly and much more pleasantly. It wouldn't be possible to worry as much as when just sitting nursing my arm at home. That's what we did and I am glad that I did go. Enjoyed seeing Sam perform; he was put in the lead of the small group of children just as last year. I am sure that the teachers do this because they know that Sam takes instruction well and he will do exactly as he is supposed to do. When I am with those two little kids, I am not obsessing and I am reasonably at peace.
Now it is Monday I am back home and back to waiting. I probably won't know the results until Tuesday. Usually it takes 5 working days to get the pathology readout. I am worried about the sentinel node because the path report on the shave biopsy says that it was at least a Clark's Level IV. But this doesn't make complete sense because the depth of the shave was only 0.48 mm deep so how could they determine it was a Clark's Level IV. That level is usually 3 mm deep. I don't quite understand this even as a doctor and my son the surgeon didn't understand it either.
I keep imagining the call about my results. I imagine hearing the first words saying there is good news, the nodes are clear. Or I imagine hearing the worst that there is cancer in those nodes. Then I will have to proceed to complete lymph node dissection under that arm, a procedure that will I assume carry more side effects and more risk of post surgical lymphadedema as a long lasting complication. Also I think I would also likely be recommended to have Interferon as a immunotherapy for a year which can also produce a lot of side effects. I really dread both of these possible needs. I really am having trouble getting these vascillating thoughts out of my mind. Periodically I reach some kind of equilibrium with the statement: "Hoping for the best; preparing for the worst." Concentrating on this provides some degree of relief in my obsessional thoughts. Does everyone go through this when they have had a biopsy? Am I just a worry-wart, or overthinking the whole process like my son says I am? Or is this a function of my being a doctor and knowing too much? I just know that it is the hardest thing that I am having to go through, much harder than the pain and morbidity of having a surgical procedure.
My wide excision and reconstruction and sentinel node dissection and excison is completed. I did fine. I was of course nervous about it never having had a general anesthetic before. My blood pressure was 174/70, a number which has quite a high systolic compared to my recent blood pressure control (since I retired). This was a sign of my anxiety. The nurse was worried about my blood sugar because it was 65, a little on the low side. I had been increasing my insulin to handle my sugars in conjunction with a reinstitution of prednisone for a vasculitis which relapsed now as well.
I took a book to the day surgery suite because I had been told that the nuclear medicine procedure that identifies the sentinel nodes takes about an hour and a half and I pictured that I would be sitting and waiting for this radioactive tracer to go up my arm to the node basin in the axilla. Yes one does wait but that occurs lying down under a camara. And the wait was only about 1/2 hour. Then they saw the nodes light up and marked them. So the whole nuclear procedure took about 1 1/2 hour but there was really very little down time which would allow reading -- only about 5-8 minutes while I sat in a wheel chair and waited to be wheeled into the nuclear medicine suite. Once I was back in Day Sugery it was bam, bam, bam -- start the IV, get the venous leg pump wraps on, the electrocardiogram monitor patches on, speak with the plastic surgery resident, speak with the anesthesia resident clarifying my history twice, getting my blood sugar checked one last time, and speaking ever so briefly with my plastic surgeon who came in to sign the left arm as the correct arm on which to do the procedure.
I told the anesthesia resident that I had received 8 mgm of Versed when I had my colonoscopy and never went to sleep at all even with the Demorol. She just commented that they had different things than Versed to use also. Shortly later the anesthesia resident said she had given me some Versed in the IV right there in the Day Surgery room and asked me if I was starting to feel relaxed as they were starting to wheel my gurney out of that little Day Surgery room. I said, "Yes, I feel a little drowsy." And that was the last I remember until it was all over and I started to hear voices around me in the Recovery room and opened my eyes. The nurse said, " Why don't you try a good hard cough; you have been clearing your throat a lot just now." I didn't know anything about that. So you do things and make sounds that you don't recall afterwards. There was a little trouble getting off the oxygen; I was desaturating with oxygen but seemed to be able to remedy that with coughs and deep breaths. I proceeded quickly back to the Day Surgery area. My blood sugar was 150 so that was OK. I recovered uneventfully in the Day Surgery room, got a hydrocodone, one pill for pain at about 130 PM after I was back in the Day Surgery suite for about 1 hour. At home by 3:45 PM and took one hydrocodone at about 5 pm and then another before I went to bed. I slept in two large periods of sleep and took another hydrocodone at about 5 am. I had some sweating from low blood sugar in the middle of the night and had to get up to get something to eat and some juice to drink. After that all I took for pain was two 500 mgm Tylenols for Thursday and then after the dose on Thursday night I took nothing further for pain. The plastic surgeon saw me Friday morning mainly because he had jury duty to do next week Monday through Wednesday and he didn't think he should wait to look at me until Thursday of the next week. He thought I was doing OK also. But he does want me to see an oncologist. I had begun to think about this and realize that the plastic surgeon doesn't want to follow up on this. There will likely be a need for imaging, maybe even CT scans from time to time and the oncologists will order this I think. So that is the likely reason for that follow up.
I wanted strongly to go to my son's home for the weekend because our 3 1/2 year old was participating in a daycare program on Saturday. My husband didn't think I should go and my son on the phone didn't think I should try to ride all the way down to Indianapolis just 2 days post surgery. But I really wanted to go. I was really feeling down and worried on Thursday and I thought that going would knock off 3 days of the wait for the pathology results. I would be with my grandkids even though I would need to rest while elevating my arm and I wouldn't be able to pick up Will at all. But the weekend would pass much more quickly and much more pleasantly. It wouldn't be possible to worry as much as when just sitting nursing my arm at home. That's what we did and I am glad that I did go. Enjoyed seeing Sam perform; he was put in the lead of the small group of children just as last year. I am sure that the teachers do this because they know that Sam takes instruction well and he will do exactly as he is supposed to do. When I am with those two little kids, I am not obsessing and I am reasonably at peace.
Now it is Monday I am back home and back to waiting. I probably won't know the results until Tuesday. Usually it takes 5 working days to get the pathology readout. I am worried about the sentinel node because the path report on the shave biopsy says that it was at least a Clark's Level IV. But this doesn't make complete sense because the depth of the shave was only 0.48 mm deep so how could they determine it was a Clark's Level IV. That level is usually 3 mm deep. I don't quite understand this even as a doctor and my son the surgeon didn't understand it either.
I keep imagining the call about my results. I imagine hearing the first words saying there is good news, the nodes are clear. Or I imagine hearing the worst that there is cancer in those nodes. Then I will have to proceed to complete lymph node dissection under that arm, a procedure that will I assume carry more side effects and more risk of post surgical lymphadedema as a long lasting complication. Also I think I would also likely be recommended to have Interferon as a immunotherapy for a year which can also produce a lot of side effects. I really dread both of these possible needs. I really am having trouble getting these vascillating thoughts out of my mind. Periodically I reach some kind of equilibrium with the statement: "Hoping for the best; preparing for the worst." Concentrating on this provides some degree of relief in my obsessional thoughts. Does everyone go through this when they have had a biopsy? Am I just a worry-wart, or overthinking the whole process like my son says I am? Or is this a function of my being a doctor and knowing too much? I just know that it is the hardest thing that I am having to go through, much harder than the pain and morbidity of having a surgical procedure.
Sunday, May 30, 2010
"When It Rains, It Pours"
For me the title applies to my current medical condition.
I have been battling with achy muscle, sometimes very significant, interfering with sleep and certainly with quality of life. I had thought it was due to my cholesterol medication because the strength of that medication had been changed recently. I had spent some time stopping and starting that medication to see if it made any difference with my symptoms and it did seem to me to help. My blood tests that might show the muscle damage that can occur with cholesterol medication were normal. Since I have recently been treated and cured from giant cell arteritis, a blood vessel inflammatory condition tht requires high dose prednisone to supress, I have a risk of a complication of that disease called polymyalgia rheumatica. This is a small vessel inflammation that involves the muscles of the proximal extremities that cause achiness and fatigue. But we had thought of this and the blood test that would help confirm this had remained normal. All through our trip to Eastern Europe I was very achy, and had difficulty sometimes getting around the castles and ruins that we explored on this trip. It made this trip very difficult for me and fraught with suffering. We arrived back in town on May 27 and I went through with my preop testing and exam as planned. My internist suggested I contact my rheumatologist about these aches. Id did and even over the phone he agreed that I did have polymyalgia rheumatica -- the complication I referred to above. He told me it occurs 60% of the time when patients are coming off prednisone for treatment of giant cell arteritis. He suggested I go back on prednisone but in low dose. In two days of 10 mgm per day my symptoms are about 70 % better, though not gone. So again my blood sugars are out of control due to even the low dose prednisone. I am told none of this should have any negative affect on my melanoma surgery planned for June 2 so that will proceed next week on June 2.
Even though I myself was (am) a physician, I never liked going to see a physician as a patient myself. I always went when I had to, but strangely enough I got nervous, my blood pressure would go up (so called white coat hypertension), and I experienced some dread about the visit ahead of time. As I have gotten older, I have had to go to the doctor more frequently to check my diabetes, my cholesterol, my blood pressure and then of course the giant cell arteritis, so I have become some desensitized to these visits and my blood pressure no longer goes up. But lately I am getting an idea that life is being unfair to me. There should be a rule that says any individual patient only needs to be struck with one life threatening illness at a time. Alas, there is no such rule. So I just plod along and do what I have to do to treat each individual condition but it ain't easy. As a physician, sometimes I have felt great compassion toward patients who are going through cancer treatment just because of all the tests, and treatments, repeat status checks etc -- constant visits and procedures. I wondered how these people keep going through all these machinations of their bodies. When an obituary says: "After a battle with cancer, so and so died of the disease..." I truly realized that indeed that person was in a battle, maybe more of a war with repeated battles won and lost against the cancer. I can see under some circumstances where the patient would just get tired of this battle and decide not to proceed with the next recommended treatment or testing procedure. Of course, I am not at that point; I will do what needs to be done. But the classical question: "Why Me?" and this feeling of unfairness, and "Enough is enough." are upper most in my mind right now. Again stay tuned.
I have been battling with achy muscle, sometimes very significant, interfering with sleep and certainly with quality of life. I had thought it was due to my cholesterol medication because the strength of that medication had been changed recently. I had spent some time stopping and starting that medication to see if it made any difference with my symptoms and it did seem to me to help. My blood tests that might show the muscle damage that can occur with cholesterol medication were normal. Since I have recently been treated and cured from giant cell arteritis, a blood vessel inflammatory condition tht requires high dose prednisone to supress, I have a risk of a complication of that disease called polymyalgia rheumatica. This is a small vessel inflammation that involves the muscles of the proximal extremities that cause achiness and fatigue. But we had thought of this and the blood test that would help confirm this had remained normal. All through our trip to Eastern Europe I was very achy, and had difficulty sometimes getting around the castles and ruins that we explored on this trip. It made this trip very difficult for me and fraught with suffering. We arrived back in town on May 27 and I went through with my preop testing and exam as planned. My internist suggested I contact my rheumatologist about these aches. Id did and even over the phone he agreed that I did have polymyalgia rheumatica -- the complication I referred to above. He told me it occurs 60% of the time when patients are coming off prednisone for treatment of giant cell arteritis. He suggested I go back on prednisone but in low dose. In two days of 10 mgm per day my symptoms are about 70 % better, though not gone. So again my blood sugars are out of control due to even the low dose prednisone. I am told none of this should have any negative affect on my melanoma surgery planned for June 2 so that will proceed next week on June 2.
Even though I myself was (am) a physician, I never liked going to see a physician as a patient myself. I always went when I had to, but strangely enough I got nervous, my blood pressure would go up (so called white coat hypertension), and I experienced some dread about the visit ahead of time. As I have gotten older, I have had to go to the doctor more frequently to check my diabetes, my cholesterol, my blood pressure and then of course the giant cell arteritis, so I have become some desensitized to these visits and my blood pressure no longer goes up. But lately I am getting an idea that life is being unfair to me. There should be a rule that says any individual patient only needs to be struck with one life threatening illness at a time. Alas, there is no such rule. So I just plod along and do what I have to do to treat each individual condition but it ain't easy. As a physician, sometimes I have felt great compassion toward patients who are going through cancer treatment just because of all the tests, and treatments, repeat status checks etc -- constant visits and procedures. I wondered how these people keep going through all these machinations of their bodies. When an obituary says: "After a battle with cancer, so and so died of the disease..." I truly realized that indeed that person was in a battle, maybe more of a war with repeated battles won and lost against the cancer. I can see under some circumstances where the patient would just get tired of this battle and decide not to proceed with the next recommended treatment or testing procedure. Of course, I am not at that point; I will do what needs to be done. But the classical question: "Why Me?" and this feeling of unfairness, and "Enough is enough." are upper most in my mind right now. Again stay tuned.
Sunday, May 2, 2010
Where do I begin? A diagnosis of malignant melanoma!
I am engulfed, embroiled in a universal experience and want to write about some of the events and the overwhelming feelings that become involved.
Ten days ago I went to a dermatologist about a lesion on my arm. It had been there a long time and had at times been scaly, but then in the last couple months, it had developed some projections in its profile and the edges had become rolled. I knew the latter was characteristic of basal cell carcinoma of the skin which is a cancer, but a low grade one which does not usually spread elsewhere but can destroy normal tissue locally. There was no pigment in this lesion; it was a reddish pink. I knew it needed checking and probably removal. I went in and even the dermatologist was fooled. She thought also possibly a basal cell or a squamous cell carcinoma or lichen planus. She did not suspect melanoma and she did a shave biopsy. That is a no-no if you are considering melanoma because this interferes with the calculation of a depth of the lesion, information which is important in planning how to proceed with treatment. Well, surprising all of us, on Wednesday, 3 days ago I got the call from the dermatologist that she had bad news which she apologized for but I had a malignant amelanotic (without melanin pigment) melanoma. So now it is Wednesday night and we are due to depart on a 3 1/2 week trip on Monday -- 5 days later. The path report says the biopsy specimen had cancer clear down to the base of the biopsy and to the edge of the lesion in several places. So I still had the cancer on my arm. The dermatologist had told me that a new portion of the pathological report rates the mitotic rate of the tumor ie the number of cell divisions per mm squared. If less than 1 it is a lower risk lesion; if greater than 1 it is a higher risk lesion and very new changes to the classification of melanoma takes that into consideration also in determining who might need a further diagnostic test ie the sentinel node biopsy. My mitotic rate was greater than 1. So now I have an inadequately removed cancer still on my arm which has some high risk characteristics. Now what? A list of questions began to run through my head and my husbands. Should we cancel our trip that had been planned for 8 months? Is it safe to travel with this cancer still on my arm and to further delay definitive treatment. Should I push for a sentinel node dissection? Should we do something to try to establish the depth of the lesion by a small re biopsy or should I have the wide excision of the lesion done before we go on the trip. Which doctor should I see?
I began calling everyone I could find to try to begin to answer these questions. Two of the surgeons that I have worked closely with as a colleague over the years were out of town at conferences. Another third surgeon who is a close friend was not available by phone. My own internist is out on medical leave. I tried to get ahold of a plastic surgeon in town who trained with my surgeon son to see what he could tell me. He was supposed to call me back. And I was trying to get ahold of my son of course but they were not answering their phones because they were busy putting the kids to bed at this time of night. Finally when I couldn't get ahold of anyone I called the clinic to find out which surgeon was on call. It was Dr. Brooks. He was very thoughtful and when I explained the situation with the inadequate biopsy and our upcoming trip, the first thing he said was; "Well, I can see you tomorrow and we can talk about the pathology and we can try to redo the biopsy to try to get a Breslow depth with the second try. I can give you a suture removal kit and you can take the stitches out yourself on your trip." At this point it sounded like a plan. But he did not know about the mitotic rate being used as an indication for a sentinel node biopsy, a fact that the dermatologist had said was entirely new. He said there was always vascilation back and forth, whether Breslow 0.75 or 1 mm should be the cutoff and it always just comes back to the 1 mm as the cut off. If your depth is 1 mm or more you need the further surgery so we would try to reestablish the Breslow depth with a further excision or punch biopsy at the site. That was the plan.
But by the next morning I had heard from Don, from Dr. Pele*, the oncologist I had seen in the past for a polyclonal gammopathy which is a benign condition, and most importantly from Dr. Whit* and his partner at his plastic surgery office who does only melanoma surgery. Dr. D was very nice and after I explained the situation to his nurse, she got a message to him and he called me back directly. He said we would never restablish a Breslow level and this unknown in and of itself was an indication for a sentinel node biopsy. Now I felt like I had a plan and some options. I went to see Dr. Brooks in the afternoon, but after some discussion we decided not to do any further excision of the biopsy. I had sort of decided to go with the surgery. He had researched the situation and now realized that the mitotic rate is now used in the risk assessment as of new guidelines about 2 months old and therefore I probably should have the sentinel node biopsy.
But jDr. Brooks had found another issue. He even as a surgeon had heard a new heart murmur that I didn't know I had. Where did that come from? I wasn't really worried about it but the surgeon and my internist would probably want an echocardiogram done before the surgery. And now my husband was throwing a fit and maintaining that he was not going to take a wife with a new heart condition to Europe with him. He was almost yelling at my cardiologist friend I was talking with to do the stress echo immediately. How was I going to get that test done within the next day when my internist was out on medical leave and as I learned through another phone call the echo technician at the clinic was out on Friday due to her own minor surgical procedure. So I began throwing my MD after my name around again, calling other clinics and hospitals in the area. I finally found a 10:15 appointment at CSM Ozaukee Hospital. But now I needed an order. So I called my old roommate from when I was working who is on the staff at that hospital and he called in the order. So now I was off to get the echo. I had spoken with my friend and cardiologist who wanted to do a stress echo since I should have the stress part because I am diabetic, but he strongly maintained that this could all wait until I had returned and even til after all the surgical management of the melanoma. But I knew my internist and my surgeon would need the echo so I still worked to get it.
My cardiologist friend read the results and called me in the afternoon with the non-serious results. "No one every listens to me," he whined. "I wanted to do the stress echo so we would have both the echocardiogram results and a stress at the same time."
" I know," I said, "but you would have had to write up a consult saying I could wait for the echo and you haven't even seen me in person. My hands were tied so I got the echo. But you're wrong, I did listen to you." My diagnosis was tricuspid valve regurgitation and a slight elevation of the pressure on the right side of heheart. Nothing needs to be done about this, though I don't know why this has developed now. Anyway the echo is done and checked off my list.
I slept on and off those two nights, actually getting maybe 6 hours each night but the first thing you think about when you wake up is this diagnosis and what it might mean. I vascillated between complete confidence and optomism and panic and assumption of the worst. This must be almost universal feelings in everyone who has received this diagnosis. My husband says he went through the same thing when he got his diagnosis of prostate cancer. He is telling me that these obsessions finally subside though they never completely go away. I did have times when I was feeling more spiritual than usual, trying to live each moment and feeling a great gratitude for this gift of life and vowing to myself to maintain that gratitude at this high level.
On Friday, two days after receiving the diagnosis, I saw Dr D, the melanoma plastic surgeon. He was very nice and was very complete with me. He certainly had little pieces of information that no one else had given me. He told me that he was going to proceed as though I didn't have any medical knowledge so he used his audiovisual chart to explain the pathology. Indeed I didn't know that my cancer was a Level IV tumor, having extended beneath the basement membrane and he said that in and of itself was an indication for a sentinel node. I was surprised about the smaller size of his planned incisions and yet he was going to more widely excise the lesion than Dr. Brooksarad planned. He does the axillary node resection through a 1 inch incision. I changed my mind. I decided to go with him. He does this type of surgery all the time. He has a surgical suite for giving the radioactive injection and for the patient to wait for this magic stuff to do its job to identify the sentinel or "gateway" node that is removed to look for the cancer. He quoted studies to me and one of them was that the prognosis was no different for those patients like myself whose tumor had been cut through by a shave biopsy or other type of inadequate biopsy. That was good news to hear. So I left there with my surgery scheduled for June 2nd when we get back. When I got home I called the nurse for my internist who was working in the WIC even though my internist was not there. She said they had put me in for a preop exam on Friday May 28 at 11 am and the receptionist had been supposed to let me know this. So that was set up. I would get the chest xray and EKG either Thursday when we returned or Friday morning as well as the fasting blood work. I think I was finally scheduled up with everything.
I had to let Dr. Brooks know that I was going with plastic surgeons for this operation. I felt bad that he had been so helpful but now I was not going to have him do the surgery but he had said that he wouldn't be hurt if I went with someone else. But I still worried that he would. I left a message with his nurse about my decision and told her I wanted to speak with him anyway and to thank him. But he didn't call back. Probably to be expected. What surgeon in his right mind would want to call back the old woman/colleague who had just thrown him over for another surgeon. I spoke with my son that night and told him of my decision. He chastised me and said Dr. Brooks had every right to be pissed; that I was engaged in blatant doctor shopping. I guess I was, but people do get second opinions and they sometimes go with the second opinion. If you get a second opinion and you then decide that's the way you want to go, you go with that option and that doctor. right? Well, I am still feeling bad about that. I should have handled that better and told Dr. Brooks that I was going to see a plastic surgeon and there was a possibility that that is where I would go. When he didn't call me back I sent him a long email and told him why I was switching and thanked him for all he had done for me. I hope that helps. I want to make amends and I want to apologize if I caused any negative feelings in him. What else can I do? I think the need to get something done fast in this case because of the trip has led to me moving much faster and impulsively than I usually would.
So we are going on the European trip with the remains of this lesion still on my arm. I have my pre op and tests, and the wide excision and sentinel node biopsy scheduled with the plastic surgeon at the medical school. I hope I can enjoy the trip. My husband said he was able to do so when we went to Peru with prostate cancer riding in his mind and the need for radiation treatment right away when we returned. I think I will be able to enjoy the trip. Actually given that adverse events in life often increase the appreciation for positive moments in life may help me maintain this positive mindfulness and appreciation, gratitude for every moment.
I had said half jokingly that "life sucks, then you die" but I don't really believe that. Life is good and every moment of it that we have is a beautiful gift. I can truly say that I believe that even in the face of this adversity.
Ten days ago I went to a dermatologist about a lesion on my arm. It had been there a long time and had at times been scaly, but then in the last couple months, it had developed some projections in its profile and the edges had become rolled. I knew the latter was characteristic of basal cell carcinoma of the skin which is a cancer, but a low grade one which does not usually spread elsewhere but can destroy normal tissue locally. There was no pigment in this lesion; it was a reddish pink. I knew it needed checking and probably removal. I went in and even the dermatologist was fooled. She thought also possibly a basal cell or a squamous cell carcinoma or lichen planus. She did not suspect melanoma and she did a shave biopsy. That is a no-no if you are considering melanoma because this interferes with the calculation of a depth of the lesion, information which is important in planning how to proceed with treatment. Well, surprising all of us, on Wednesday, 3 days ago I got the call from the dermatologist that she had bad news which she apologized for but I had a malignant amelanotic (without melanin pigment) melanoma. So now it is Wednesday night and we are due to depart on a 3 1/2 week trip on Monday -- 5 days later. The path report says the biopsy specimen had cancer clear down to the base of the biopsy and to the edge of the lesion in several places. So I still had the cancer on my arm. The dermatologist had told me that a new portion of the pathological report rates the mitotic rate of the tumor ie the number of cell divisions per mm squared. If less than 1 it is a lower risk lesion; if greater than 1 it is a higher risk lesion and very new changes to the classification of melanoma takes that into consideration also in determining who might need a further diagnostic test ie the sentinel node biopsy. My mitotic rate was greater than 1. So now I have an inadequately removed cancer still on my arm which has some high risk characteristics. Now what? A list of questions began to run through my head and my husbands. Should we cancel our trip that had been planned for 8 months? Is it safe to travel with this cancer still on my arm and to further delay definitive treatment. Should I push for a sentinel node dissection? Should we do something to try to establish the depth of the lesion by a small re biopsy or should I have the wide excision of the lesion done before we go on the trip. Which doctor should I see?
I began calling everyone I could find to try to begin to answer these questions. Two of the surgeons that I have worked closely with as a colleague over the years were out of town at conferences. Another third surgeon who is a close friend was not available by phone. My own internist is out on medical leave. I tried to get ahold of a plastic surgeon in town who trained with my surgeon son to see what he could tell me. He was supposed to call me back. And I was trying to get ahold of my son of course but they were not answering their phones because they were busy putting the kids to bed at this time of night. Finally when I couldn't get ahold of anyone I called the clinic to find out which surgeon was on call. It was Dr. Brooks. He was very thoughtful and when I explained the situation with the inadequate biopsy and our upcoming trip, the first thing he said was; "Well, I can see you tomorrow and we can talk about the pathology and we can try to redo the biopsy to try to get a Breslow depth with the second try. I can give you a suture removal kit and you can take the stitches out yourself on your trip." At this point it sounded like a plan. But he did not know about the mitotic rate being used as an indication for a sentinel node biopsy, a fact that the dermatologist had said was entirely new. He said there was always vascilation back and forth, whether Breslow 0.75 or 1 mm should be the cutoff and it always just comes back to the 1 mm as the cut off. If your depth is 1 mm or more you need the further surgery so we would try to reestablish the Breslow depth with a further excision or punch biopsy at the site. That was the plan.
But by the next morning I had heard from Don, from Dr. Pele*, the oncologist I had seen in the past for a polyclonal gammopathy which is a benign condition, and most importantly from Dr. Whit* and his partner at his plastic surgery office who does only melanoma surgery. Dr. D was very nice and after I explained the situation to his nurse, she got a message to him and he called me back directly. He said we would never restablish a Breslow level and this unknown in and of itself was an indication for a sentinel node biopsy. Now I felt like I had a plan and some options. I went to see Dr. Brooks in the afternoon, but after some discussion we decided not to do any further excision of the biopsy. I had sort of decided to go with the surgery. He had researched the situation and now realized that the mitotic rate is now used in the risk assessment as of new guidelines about 2 months old and therefore I probably should have the sentinel node biopsy.
But jDr. Brooks had found another issue. He even as a surgeon had heard a new heart murmur that I didn't know I had. Where did that come from? I wasn't really worried about it but the surgeon and my internist would probably want an echocardiogram done before the surgery. And now my husband was throwing a fit and maintaining that he was not going to take a wife with a new heart condition to Europe with him. He was almost yelling at my cardiologist friend I was talking with to do the stress echo immediately. How was I going to get that test done within the next day when my internist was out on medical leave and as I learned through another phone call the echo technician at the clinic was out on Friday due to her own minor surgical procedure. So I began throwing my MD after my name around again, calling other clinics and hospitals in the area. I finally found a 10:15 appointment at CSM Ozaukee Hospital. But now I needed an order. So I called my old roommate from when I was working who is on the staff at that hospital and he called in the order. So now I was off to get the echo. I had spoken with my friend and cardiologist who wanted to do a stress echo since I should have the stress part because I am diabetic, but he strongly maintained that this could all wait until I had returned and even til after all the surgical management of the melanoma. But I knew my internist and my surgeon would need the echo so I still worked to get it.
My cardiologist friend read the results and called me in the afternoon with the non-serious results. "No one every listens to me," he whined. "I wanted to do the stress echo so we would have both the echocardiogram results and a stress at the same time."
" I know," I said, "but you would have had to write up a consult saying I could wait for the echo and you haven't even seen me in person. My hands were tied so I got the echo. But you're wrong, I did listen to you." My diagnosis was tricuspid valve regurgitation and a slight elevation of the pressure on the right side of heheart. Nothing needs to be done about this, though I don't know why this has developed now. Anyway the echo is done and checked off my list.
I slept on and off those two nights, actually getting maybe 6 hours each night but the first thing you think about when you wake up is this diagnosis and what it might mean. I vascillated between complete confidence and optomism and panic and assumption of the worst. This must be almost universal feelings in everyone who has received this diagnosis. My husband says he went through the same thing when he got his diagnosis of prostate cancer. He is telling me that these obsessions finally subside though they never completely go away. I did have times when I was feeling more spiritual than usual, trying to live each moment and feeling a great gratitude for this gift of life and vowing to myself to maintain that gratitude at this high level.
On Friday, two days after receiving the diagnosis, I saw Dr D, the melanoma plastic surgeon. He was very nice and was very complete with me. He certainly had little pieces of information that no one else had given me. He told me that he was going to proceed as though I didn't have any medical knowledge so he used his audiovisual chart to explain the pathology. Indeed I didn't know that my cancer was a Level IV tumor, having extended beneath the basement membrane and he said that in and of itself was an indication for a sentinel node. I was surprised about the smaller size of his planned incisions and yet he was going to more widely excise the lesion than Dr. Brooksarad planned. He does the axillary node resection through a 1 inch incision. I changed my mind. I decided to go with him. He does this type of surgery all the time. He has a surgical suite for giving the radioactive injection and for the patient to wait for this magic stuff to do its job to identify the sentinel or "gateway" node that is removed to look for the cancer. He quoted studies to me and one of them was that the prognosis was no different for those patients like myself whose tumor had been cut through by a shave biopsy or other type of inadequate biopsy. That was good news to hear. So I left there with my surgery scheduled for June 2nd when we get back. When I got home I called the nurse for my internist who was working in the WIC even though my internist was not there. She said they had put me in for a preop exam on Friday May 28 at 11 am and the receptionist had been supposed to let me know this. So that was set up. I would get the chest xray and EKG either Thursday when we returned or Friday morning as well as the fasting blood work. I think I was finally scheduled up with everything.
I had to let Dr. Brooks know that I was going with plastic surgeons for this operation. I felt bad that he had been so helpful but now I was not going to have him do the surgery but he had said that he wouldn't be hurt if I went with someone else. But I still worried that he would. I left a message with his nurse about my decision and told her I wanted to speak with him anyway and to thank him. But he didn't call back. Probably to be expected. What surgeon in his right mind would want to call back the old woman/colleague who had just thrown him over for another surgeon. I spoke with my son that night and told him of my decision. He chastised me and said Dr. Brooks had every right to be pissed; that I was engaged in blatant doctor shopping. I guess I was, but people do get second opinions and they sometimes go with the second opinion. If you get a second opinion and you then decide that's the way you want to go, you go with that option and that doctor. right? Well, I am still feeling bad about that. I should have handled that better and told Dr. Brooks that I was going to see a plastic surgeon and there was a possibility that that is where I would go. When he didn't call me back I sent him a long email and told him why I was switching and thanked him for all he had done for me. I hope that helps. I want to make amends and I want to apologize if I caused any negative feelings in him. What else can I do? I think the need to get something done fast in this case because of the trip has led to me moving much faster and impulsively than I usually would.
So we are going on the European trip with the remains of this lesion still on my arm. I have my pre op and tests, and the wide excision and sentinel node biopsy scheduled with the plastic surgeon at the medical school. I hope I can enjoy the trip. My husband said he was able to do so when we went to Peru with prostate cancer riding in his mind and the need for radiation treatment right away when we returned. I think I will be able to enjoy the trip. Actually given that adverse events in life often increase the appreciation for positive moments in life may help me maintain this positive mindfulness and appreciation, gratitude for every moment.
I had said half jokingly that "life sucks, then you die" but I don't really believe that. Life is good and every moment of it that we have is a beautiful gift. I can truly say that I believe that even in the face of this adversity.
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