Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral
Science
The University of Texas M. D. Anderson Cancer
Center
Mrs. Anderson:
How about a few minutes just to...
Dr. Buckman:
Oh sure, sure. Let me -- I'll pull up a
chair here. Go ahead.
Mrs. Anderson:
Well I just -- I mean it is my back, but I
just -- I've been here for a couple of days now and I just feel like I don't
know what's going on and I'm getting a little panicky.
Dr. Buckman:
Yes. Well, why don't you tell me what you
know is going on, and I'll go on from there? So you tell me what you know so far
and then I'll continue from that moment.
Mrs. Anderson:
I don't know. I just know that I've got
this back pain...
Dr. Buckman:
Right.
Mrs. Anderson:
...that's in kind of a strange place,
because it's my upper back. And I don't remember doing anything.
Dr. Buckman:
Right. And so middle to upper back...
Mrs. Anderson:
Middle, middle yeah.
Dr. Buckman:
Yes, yes exactly.
Mrs. Anderson:
And that it got to the point where I
needed to come and see somebody about it...
Dr. Buckman:
Right.
Mrs. Anderson:
...because it was interfering with
everything.
Dr. Buckman:
Right.
Mrs. Anderson:
And now I've had to have a bone scan and
that...
Dr. Buckman:
Right.
Mrs. Anderson:
...scares me, because I know that's not
good.
Dr. Buckman:
I understand you clearly. And, is it okay if
the results of the bone scan -- do you want to know the exact results of the
bone scan and know what is going on? Is that the kind of way you'd like me to
handle the information?
Mrs. Anderson:
Yes, please.
Dr. Buckman:
Yeah, I'm willing to do that. When I saw you
in the outpatients, I also thought that back pain didn't -- it bothered me as
much as it bothered you that it was in the middle of the back. And it did worry
me that the possibility might be that there was something sort of serious
underlying it. That it could be caused by something serious. And that's why we
did the bone scan to see whether there was anything that could be serious in the
bone that might account for this. Now on the way up to the ward, I got your bone
scan out and I looked at it. I presume you'd like to know what it showed. Is
that right?
Mrs. Anderson:
I didn't know -- yes, I didn't know you
knew. Yes, please.
Dr. Buckman:
Well, I didn't until a couple of hours ago.
What it shows is that in the bone scan, the pattern is very clear that there are
what we call "hot spots." That means that there are points in the bone which are
involved with something. And in your case, it's unfortunate, but it's certain
that those hot spots are caused by a recurrence of your breast cancer from 2
years ago. And that it's come back and caused "secondaries," as we call them, in
the bone. And that's why you've got the back pain and that's what we need to
treat now.
Mrs. Anderson:
So, I thought that it would be -- well I
guess I didn't know. I thought it would go to my other breast. Is that common
that it...?
Dr. Buckman:
That's a very important point. In fact, with
breast cancer -- although the other breast is at risk and has certain, but a
very small chance, each year, of developing a tumor in the other breast, in
fact, breast cancer, as it were, sort of prefers to spread to bone and so the
bone is very often the first place that breast cancer spreads. So that's the way
breast cancer behaves.
Mrs. Anderson:
But now, they told me when I had that
whole big operation and lost a breast, they told me everything's gone. There's
no doubt that everything is gone.
Dr. Buckman:
Yes. That's actually, in technical terms,
they were right that everything that could be seen to be breast cancer was
successfully removed as it is in the vast majority of cases. But there is always
a statistical chance that there may be a few cells hiding elsewhere in the body.
That's why, you remember, you had to have that chemotherapy at the other
hospital. That was to try and kill any cells from the original breast cancer
that were lurking, not in this area, not in the breast and the arm pit, that's
all clear, but lurking elsewhere in the body. And that's what the chemo was done
for. And in some patients, a reasonable proportion, that does it. It kills every
single cancer cell and there's never any cancer coming back. But in some
patients, and that's what's going on with you Mrs. Anderson, is that it was
hiding and it emerges 2, 3, 4 years after the initial diagnosis in the bones or
sometimes in other places.
Mrs. Anderson:
It's only been 2 years. That's it. It's
just been...
Dr. Buckman:
I know. That's not a very long time.
Mrs. Anderson:
So, what happens now?
Dr. Buckman:
What happens now is 2 things. Firstly, we
start some radiotherapy to kill the cancer right in your spine. The radiotherapy
is local treatment and it kills the cancer, as it were, where it shines. And
that will relieve your pain -- there's a high chance of relieving your pain,
actually quite quickly in a few days. After that, we need to work out what kind
of treatment you should be on. Now, I'm just going to go and have to do a little
bit of homework to find out what and if we have any information on the original
breast cancer taken at the other hospital, because it might be that we could try
hormone tablets first of all. Or, we might want to think about chemotherapy. So
I'm going to do some homework. I'll come and chat about that point within the
next say, 2 days. I mean it's not urgent, but in the next 2 days. So the kind of
treatment that we give you depends on what I can find out about the original
primary tumor.
Mrs. Anderson:
So, we may have to do chemotherapy again?
Dr. Buckman:
We may have to do chemotherapy. That may be
one of the options we consider.
Mrs. Anderson:
I don't know how -- I don't know how, oh
boy. I don't know how my husband's going to cope with this.
Dr. Buckman:
I've got some Kleenex for you.
Mrs. Anderson:
Thank you.
Dr. Buckman:
How much does your husband know about it so
far?
Mrs. Anderson:
Well I as much as told him that there was
no way this was going to be cancer...
Dr. Buckman:
Yes.
Mrs. Anderson:
...because, because I just didn't put the
2 pieces together.
Dr. Buckman:
Of course. And actually that was an entirely
reasonable supposition. It was absolutely reasonable. The back pain was not
associated in your mind with the breast operation 2 years ago, nor should it be.
Unfortunately, it turned out that there is that connection that there are
secondaries.
Mrs. Anderson:
But they told me, they said for sure...
Dr. Buckman:
Yes.
Mrs. Anderson:
Absolutely. I mean not what you just said.
They said "We got it." So I didn't even you know...
Dr. Buckman:
I think probably most people when they do
the operation for the breast cancer mean genuinely that they got all the cancer
in the breast. And in some respects it's a sort of a technical statement. The
problem is, it's - let me make this absolutely clear, and I didn't make it clear
- there's no technical problem with the surgery. It's nothing they did wrong
with the surgery or anything like that. It's the way breast cancer behaves. In
some people, probably even before the first lump appears, cells fly off and
hide. We think they may hide in the bone marrow actually. And they hide there
and then they emerge a few years later, nothing to do with the operation. But to
say they got it all was probably a technical statement about the breast, but not
about all cells that could have been hiding in your bone marrow where nobody
would have known they were there. It was impossible to know.
Mrs. Anderson:
So...
Dr. Buckman:
That's not much of a consolation is it
really?
Mrs. Anderson:
Well, no but at least it's -- it clarifies
for me what, that I sort of misunderstood the...
Dr. Buckman:
Yeah.
Mrs. Anderson:
...you know, what they...
Dr. Buckman:
Well, not even misunderstood. It sounded
more promising of a cure than it actually was. You said your husband -- you and
your husband sort of thought this was going to be fine. You know, this is also
very, very difficult, you know, to try and break the news to your husband.
Mrs. Anderson:
He's going to go crazy. He's just not good
with this kind of stuff.
Dr. Buckman:
Yes.
Mrs. Anderson:
Especially when it's such a - I don't know
- it's such a helpless feeling.
Dr. Buckman:
Yes.
Mrs. Anderson:
You know?
Dr. Buckman:
A helpless feeling, of course. Yes. And I
guess until we've started the treatment and we can see how things are going,
it's not any help that we don't have answers for you. You know, this is
something that I'm used to helping with. It's quite common for me to talk to you
and your husband together. I do that a lot. Now, I was going to propose that
maybe we book a time, maybe in the next few days. I'll sit down with you and
your husband together; go over it all again, because he may want to hear exactly
the answers to the questions you've just asked. He may have other questions as
well. But it's really important that your husband understand the same facts you
do, so there is no difference between the two of you. I'm sorry, I've forgotten,
but have you got children as well? How old are the kids?
Mrs. Anderson:
Two.
Dr. Buckman:
How old are they?
Mrs. Anderson:
Eight and eleven.
Dr. Buckman:
Again, it may not be now, but in the future
- maybe in 3, 4, 5 months or whatever - there may be a time at which you think
it would be good to hear the diagnosis and the state of things from the doctor
-- again, with you and your husband right there. But with kids of 8 and 11, it's
sometimes very valuable if they hear all about your condition from me with you
there, so they know it isn't your fault. It isn't your husband's fault. Most
important, it isn't their fault. And this happens quite commonly that they then
hate me and that's fine. Much better they should hate an authority figure in a
white coat than blame either themselves or your husband or you. And it may well
help the things at home if I do that. Not now. No urgency about it, but sometime
in the next few months.
Mrs. Anderson:
They've been through so much already.
Dr. Buckman:
Yeah.
Mrs. Anderson:
You know, with the mastectomy.
Dr. Buckman:
When you had the mastectomy, of course. I'm
just saying this may make it easier...
Mrs. Anderson:
Oh, yes please. Yes, please. Yes, because
it's the same with my husband. I think he needs -- I can't possibly tell him. I
would really appreciate it if you'd help.
Dr. Buckman:
Be delighted to. We've covered a lot of
ground. Are there any more immediate questions that you want to...?
Mrs. Anderson:
I guess just the big one which is how
serious is this? I mean do I have...
Dr. Buckman:
Good question and an important question.
When breast cancer spreads to the bone, it is rarely if ever curable in the
sense of sort of killing all the breast cancer forever so it never comes back.
That doesn't usually happen. What usually happens is that you're able to control
it and with radiotherapy certainly, plus or minus radiotherapy and chemotherapy
keep it under control for periods, often reasonable periods of time. But, the
chance of curing this forever is not very high. Mostly, it's a matter of keeping
it under control from time to time.
Mrs. Anderson:
So what are reasonable periods of time?
Dr. Buckman:
Well, in breast cancer especially if it
recurs after 2 years, we're probably talking about a small number of years or a
large number of months. Not an enormous amount of time, but not like a small
number of months or something like that. It's usually in the range of many
months or a small number of years. That's kind of tough, too, isn't it?
Mrs. Anderson:
It's scary.
Dr. Buckman:
It's very scary. What I think we need to do
is to start with treatment, see how things are going with you, keep a fairly -
oh and obviously I'm going to be seeing you a lot - keep a fairly close eye, and
I think I can sort of inform you how things are going and what the future looks
like as time goes on.
Mrs. Anderson:
Okay.
Dr. Buckman:
Although I know at this minute it feels - as
one of my patients says - it feels like something dreadful is going to happen to
me the day after tomorrow.
Mrs. Anderson:
Yeah.
Dr. Buckman:
It isn't. It isn't. You know? Another one of
my patients said, "It's not time to sell the furniture then doctor, is it?" And
I said, "No, it's not." And she said, "Promise me one thing." She said, "If it
is, will you tell me?" And I said, "I would."
Mrs. Anderson:
Okay. I'll make that deal with you.
Dr. Buckman:
Is that a deal?
Mrs. Anderson:
Yes, thank you.
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