Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
Dr. Buckman:
Okay so, from your point of view, everything is fine, no symptoms.
Mrs. Wright:
Right.
Dr. Buckman:
Now, before I go into the results
of the blood test, let me just make sure I've got it straight. And you
remember this, the blood test that I've watching regularly, that CEA
blood test, it had gone up at the last visit, but now that was about 5
weeks ago, it had gone up. That's why we repeated it to see whether it
was still going up and, in fact, it had gone up a bit further. At that
point, I was a little bit worried about that situation. Does that make
sense to?
Mrs. Wright:
Yes. Yes.
Dr. Buckman:
That's why I organized the liver
ultrasound to see if there was anything going on that would explain why
this blood test was getting abnormal.
Mrs. Wright:
Right.
Dr. Buckman:
Is that all making sense so far?
Mrs. Wright:
Yes.
Dr. Buckman:
Okay, I'll go ahead and tell you
the results of the ultrasound, shall I? I'm sorry to say that the
ultrasound shows that the cancer of the bowel has come back and made
metastasis, secondaries, in the liver. That's what happened and that's
the explanation of the abnormal CEA. I'm sorry, that's obviously quite
a shock.
Mrs. Wright:
Yes, it is. So, where do we go from here? What do we do?
Dr. Buckman:
We know seondaries are in the liver
and what we should do is to try and shrink them down with some more
chemotherapy, different chemotherapy to the stuff I gave you nearly two
years ago. A different type of chemo and that's what we should try and
do to try and shrink the metastasis down a bit with more chemotherapy.
Mrs. Wright:
Will it get rid of them or I mean,
the last time around you said it was to prevent anything from coming
back or try and prevent it?
Dr. Buckman:
Try and prevent it, correct.
Mrs. Wright:
So, would this chemotherapy get rid of it?
Dr. Buckman:
That is a very important point. If
you mean to get rid of them permanently so they never come back again,
is that what you are...?
Mrs. Wright:
I guess that is what I want to hear.
Dr. Buckman:
Yes, I know. I know that is what
you want to hear. In this situation, Mrs. Wright, this is a difficult
thing to say and a difficult thing to hear. In this situation,
unfortunately, the chemotherapy will not get rid of the liver
metastasis forever. It may well control them for a time, but it is
unlikely to get rid of them forever.
Mrs. Wright:
What do you mean when you say for a time?
Dr. Buckman:
Would you like me to try any sort
of explain the situation and maybe guess at some time? I'm sorry. This
is very upsetting for you.
Mrs. Wright:
I know. Well, I guess because I kind of thought it was all behind me, you know.
Dr. Buckman:
I think that's quite a reasonable
thing to hope. In a fair proportion of patients, it does not come back.
In many, it does. I am sorry. The way it happened was that your cancer
was obviously resistant in some respects to the chemotherapy we gave
you after the surgery.
Mrs. Wright:
So, if we do this chemotherapy and it works, what can I hope for? What can I expect?
Dr. Buckman:
Would you like me to try and guess the time?
Mrs. Wright:
Uh, huh.
Dr. Buckman:
It is probably measured in many
months, not many years, probably not many years. It can be, but it
probably isn't. It is probably not a few months, but it is probably in
the range of several to many months. The chemotherapy might make the
metastasis shrink down and they might stay shrunken down for quite a
time. And then if they start getting bigger again, and the blood test
goes off and the liver ultrasound may show that they are on the move
again, we would try further chemotherapy. And that might, or of course
might not, cause another period of shrinkage and so on.
Mrs. Wright:
So, could I optimistically hope to get some years out of this?
Dr. Buckman:
The chance of it being some years is, I'm sorry to say this, is not very high. It can happen, but it is not very high.
Mrs. Wright:
I just was thinking it would be nice if the boys could be grown up, you know.
Dr. Buckman:
I know. I know.
Mrs. Wright:
Anyway.
Dr. Buckman:
Do you know what I think we should
do Mrs. Wright? I think we should do two things simultaneously. Plan
for the worst and hope for the best, and the human mind is usually
capable of doing those things. I think you and I, with the boys and
with anyone else that we can think of, should, as it were, plan for the
worst. And at the same time after we have done that, we can actually
hope for the best. It is far better to make the plan and then be
surprised by how well things are going rather than be caught, sort of
caught by something going wrong unexpectedly. Am I making sense?
Mrs. Wright:
Absolutely. So, the last time I had
the chemo, it made me feel kind of sick. Would it be the same thing
again this time? What I am thinking is that if I do not have a whole
lot of time left, is it worth it to spend part of it feeling absolutely
lousy.
Dr. Buckman:
I can answer both of those points
directly. I do not know how the chemo will make you feel this time
because this is completely different from 5FU and the folinic acid we
gave you last time. It could be different chemo. It might or might not
make you feel lousy. Some patients, it doesn't actually. In some, they
have a bad time with it. I mean you and I will talk about it.
Obviously, every time I see you, we'll adjust all the stuff. But this
is a very important point. Hear me clearly. We would only continue the
chemotherapy if it seems to be doing good in terms of shrinking the
cancer down. If the ultrasound and the CEA show that the cancer is
shrinking down, we will continue for six courses and stop. If the CEA
and the ultrasound show that it isn't making the cancer shrink and the
cancer is getting larger, then we would stop after two courses. You and
I will sit down and we will think about what we do next. So, if it's
working, you continue the six. Last time, with the 5FU and the folinic
acid, we didn't know whether it was working because there was not any
evidence of cancer. We had to go through the whole thing. We had no
idea whether it was killing the cancer cells or not. So, we will be
able to keep an eye on it and we will not give you unnecessary therapy,
therapy that isn't working. We stop it. It is not much consolation, but
it is some.
Mrs. Wright:
No. I didn't really expect this, I guess, is the truth of it at all. I sort of felt like it was all behind me so...
Dr. Buckman:
You did, didn't you?
Mrs. Wright:
Yes...
Dr. Buckman:
And, you know, so did I until the
CEA started going up and, sometimes even, there can be a little lab
error or sometimes the CEA slips up or flips up just a tiny little bit
and then down again. But in your case, unfortunately, it was a sign
that something was on the move again and this time in the liver. I was
hoping that wasn't going to be the case too.
Mrs. Wright:
Well. I guess I have great deal to go home and think about, don't I?
Dr. Buckman:
You do, and please if you would
like to bring your sons to the next visit, my feeling, Mrs. Wright, is
that this is obviously quite devastating. Why don't we meet next week
when you've had a chance to think about it and discuss the treatment
again in greater detail? And go with the situation with your sons if
you like or with someone else if you like, whoever you like and make
some plans and have detailed discussions.
Mrs. Wright:
All right.
Dr. Buckman:
Should we do that?
Mrs. Wright:
Okay.
Dr. Buckman:
Are there any other questions sort of immediately?
Mrs. Wright:
I don't think so.
Dr. Buckman:
I am extremely sorry. This has
obviously been... this is very, very upsetting for you. I am sorry that
at this second I can't tell you whether the secondaries will get
smaller with the treatment or not, so it is going to be uncertain for
you as well.
Mrs. Wright:
Well. I just, I just have to come to grips with all that. I guess.
Dr. Buckman:
Why don't you sit yourself down in
the waiting room and take a few minutes before you go home and then you
and I will meet again next week.
Mrs. Wright:
All right.
Dr. Buckman:
Is that okay?
Mrs. Wright:
Okay.
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