Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Dr. Robert Buckman: Very highly charged emotionally because the medical condition, in this case recurrence of breast cancer, has a grave prognosis. It may well be that interviews such as this are, in fact, relatively rare in your own practice. Even so, it's still important to have a practical approach to a task like this because all aspects of patient care and all aspects of your relationship with the patient from that moment on may well be affected by the way an interview like this goes.
Mrs. Anderson: Do you have a few minutes just to chat?
Doctor: Oh sure, sure. I'll pull up a chair, here go ahead..
Mrs. Anderson:> I mean it is my back but I've been here for a couple of days now and I feel like I don't know what's going on and I'm getting a little panicky.
Doctor: 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 got this back pain that's in kind of a strange place because it's my upper back and I don't remember doing anything.
Doctor: Right and so in the middle or upper back?
Mrs. Anderson: Middle, middle, yeah and that it got to the point where I needed to come and see somebody about it because it's interfering with everything.
Doctor: Right.
Mrs. Anderson: And now I've had to have a bone scan and that scares me because I know that's not good.
Doctor: 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.
Doctor: Yeah, I'm willing to do that. When I saw you as an outpatient, I also thought that back pain didn't uh, it bothered me as much as it bothered you. 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 and I presume you'd like to know what it showed? Is that right?
Mrs. Anderson: Right. Yes, I didn't know you knew, yes please.
Doctor: 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?
Doctor: That's a very important point. In fact, breast cancer, although the other breast is at risk and that has a certain but 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. 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.
Doctor: Yes. That's, actually in technical terms, they were right, but 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 the chemotherapy at the other hospital.
Mrs. Anderson: Yes.
Doctor: 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 armpit that's all clear, but left 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 and sometimes in other places.
Mrs. Anderson: So we've been 2 years. That's it? It's just been...
Doctor: I know that's not a very long time.
Mrs. Anderson: So what happens now?
Doctor: What happens now is 2 things. Firstly, we start some radiotherapy to kill the cancer right in the spine. Radiotherapy is local treatment and it kills the cancer 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 in this case, I'm gonna have to do a little bit of homework to find out if we have any information on the original breast cancer taken out at the 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 with you in the next, say, 2 days. It's not urgent, but within 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?
Doctor: 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.
Doctor: I've got some Kleenex for you.
Mrs. Anderson: Thank you.
Doctor: How much does your husband know about it so far?
Mrs. Anderson: Well, I as much as told him there was no way this was going to be cancer.
Doctor: Yes.
Mrs. Anderson: Because I just didn't put the two pieces together.
Doctor: Of course, and actually that was an entirely reasonable supposition. It was absolutely reasonable. The back pain was not associating in your mind with the breast operation 2 years ago, nor should it be. Unfortunately, it turned out that there is that connection in the second place.
Mrs. Anderson: But they told me, they said for sure, absolutely.
Doctor: Yes.
Mrs. Anderson: I mean not what you just said. They said we got it. So I didn't even, you know.
Doctor: 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 technical statement. 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. Nobody would have known they were there. It was impossible.
Mrs. Anderson: So.
Doctor: That's not much of a consolidation is it?
Mrs. Anderson: Well, no, but at least it's, it clarifies for me what, that I sort of misunderstood the, you know.
Doctor: Not even misunderstood. It sounded more promising of a cure than it actually was. You said you and your husband sort of thought this was going to be fine. You know, this is also very, very difficult 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.
Doctor: Yes.
Mrs. Anderson: Especially when it's such a, I don't know, it's such a helpless feeling.
Doctor: Yes.
Mrs. Anderson: You know?
Doctor: A helpless feeling, of course, yes. And, I guess until we start the treatment and we can see how things are going, it's not any help, but we don't even 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 could book a time, maybe in the next few days, and 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. You 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 children?
Mrs. Anderson: Two.
Doctor: How old are they?
Mrs. Anderson: Eight and eleven.
Doctor: And again, it may not be now, but in the future, maybe in 3, 4, 5 months or whatever, there may be a time which you think that it would be good to hear the diagnosis and the state of things from the doctor. Again, with you and your husband right there. With the kids eight and eleven, 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 that they should hate an authority figure in a white coat than blame either themselves or your husband or you. It may well help the things at home if I do that. Not now, no urgency rather, but sometime within the next few months.
Mrs. Anderson: They've been through so much already.
Doctor: Yeah.
Mrs. Anderson: You know, with the mastectomy and stuff.
Doctor: When you had the mastectomy? Of course. I'm just saying this may make it easier.
Mrs. Anderson: Oh 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 tell him.
Doctor: I'd be delighted. 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?
Doctor: 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, 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?
Doctor: 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 anything like that. It's usually in a range of many months or a small number of years. That's kind of tough too isn't it?
Mrs. Anderson: It's scary.
Doctor: It's very scary. What I think we need to do is to start the treatment, see how things are going with you. Keep a fairly, well 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.
Doctor: Although I know at this minute it feels, as one of my patients says, it feels like something dreadful is going to happen to you the day after tomorrow. It isn't. It isn't. Another one of my patients said, it's not time to sell the furniture then doctor is it?
[ laugh ]
Doctor: Yeah. 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.
Doctor: Is that a deal?
Mrs. Anderson: Yes. Thank you.
Doctor: Alright, Mrs. Anderson.
Dr. Robert Buckman: That interview was clearly, highly emotional. And as I hope you saw, the 6 step protocol does at least offer some sort of approach to acknowledging and exploring and helping the patient deal with her emotional responses to a serious medical situation.
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