A Tale of Two Cancers and Two Surgeries

Having read Nancy's post and Marie's post, I just wanted to throw in my medical two cents worth...

Two Cancers

The two cancers I am about to discuss are both cancer of the liver. "Liver cancer is the third most common cancer in the world. A deadly cancer, liver cancer will kill almost all patients who have it within a year."  So, current 2010 knowledge about liver cancer tells that if you contract liver cancer, you are very likely to have met your Waterloo.

The first cancer was my mother's, and it was treated in Canada:

In late December of 2001, my Uncle Leo was diagnosed with liver cancer. By May of 2002, he was gone. Imagine how my mother felt when, in late December of 2002, she was diagnosed with the same type of cancer as her brother. Uncle Leo had led a much more wild life than my mother, specifically drinking significant quantities of alcohol in his younger days, while she had always abstained. I don't know why they both got the same type of cancer, but they did. My mom passed away on April 25, 2003, four months after her diagnosis.

I don't know anything about the medical treatment options that Uncle Leo's doctor may have offered him, but I do know a bit about what was offered to my mother.  When I spent a week with Mom in early April 2003, she was suffering greatly. To this point, she had declined any chemotherapy or radiation therapy that had been offered to her, but because she was feeling so much worse, she requested a meeting with her doctor and her family. Dr. S came to her home for that meeting, and my sister Colleen and cousins Mary and Helen were also at that meeting. Dr. S explained again that liver cancer is deadly, that virtually no one survives it, and that, since we all must die, liver cancer is actually not a bad way to go. It will make you more and more weak and tired, and then you will die. There is some pain and discomfort, but that is something that medicine can help you with.

He also explained that, if my mom wanted, he would be happy to aggressively treat the cancer in any way that she would like...but that in the end, she would still be likely to die of liver cancer. And the treatment would itself be painful and would make her sick in other ways. Treatment would be likely to extend her life by about a year, but he did not think it would offer her very good quality of life. He then told her, and us, that he would do whatever we wanted him to do.

He also brought forms for us to fill out that would direct mom's medical care should he not be around to fulfill her wishes. These papers were legal documents that would dictate the level of care to be given to mom, specifically aimed at telling emergency medical personnel whether to resuscitate her should she go into cardiac or respiratory failure. He explained that, if she chose a low level of intervention, we could always verbally ask for more; but if she chose a high level of intervention, we could NOT verbally ask for less, and medical personnel would be obligated to intervene.

Dr. S was kind, compassionate, and very frank with us. As a group, we were able to make plans for the care of my mother. Her wish was to continue NOT using any intervention, and to let nature take its course. She even said, "Is there any way to speed up the process?" Dr. S just smiled, and patted her hand and assured her that he had faith in her that whatever the cancer would bring, she could take it. We set the intervention level on the low end of the scale, and then made plans for what to do as mom lost mobility. Liver cancer makes a person so tired that just lifting a spoon or a toothbrush, is incredibly taxing, so of course walking and other movement becomes impossible.

The province of Alberta has a wonderful home support option in health care. Mom had been having home health workers in a couple of days a week for months, who gave respite to my brother and sister who most often had been responsible for mom's care. Their visits became more frequent as mom's need for them increased. Toward the end, they moved a hospital bed to mom's house and set it up in her living room, and had nurses there almost round the clock.

She died peacefully in the morning of April 25th, at a moment when she was alone in the living room. My brother and sister were in the house, as was a nurse, but all of them had stepped out just for a moment to do some task for mom, and when they went back to the living room, she was gone. Because of the intervention document we had all signed, the nurse was not obligated to call for emergency resuscitation, so that mom only had to die once.

We felt that our mother had a good death. Her suffering only lasted for four months and she was able to stay at home. She never had to go to the doctor; he came to her. Nurses came to her; she had daily visits from family and neighbors. She bore her illness well, and died with dignity.

The second cancer belonged to my neighbor, Mr. J, and was treated in the United States.

Mr. J. worked with my husband Bruce. He was a jovial, kind-hearted man. It was September of 2008 when the liver cancer diagnosis was made. Mr. J began chemotherapy. He stopped working and didn't go to church, so I never saw him anymore. I knew that I should go and visit. Since I am kind of slow to do things that I should do sometimes, it took me until November to visit him. Knowing as I did that liver cancer is a terminal illness, I had geared myself for the kind of visit with Mr. and Mrs. J that I thought it would be...

I was so wrong! Although Mr. J looked terrible and clearly could not move very well, he and Mrs. J extolled the wonderful treatment that he was getting, and how the doctors were going to try some new experimental things, and that they knew it was just a matter of time before Mr. J was well again.

I was so shocked that I hardly knew what to say. Their misplaced faith--that the doctors could cure something incurable--astounded me. Now, I was never at any meetings with their doctors, so I don't know what was said or how the Js chose to interpret it, but it seemed to me that there was no recognition or acceptance that they were up against a fatal illness.

Mr. J continued to undergo treatments that left him a shell of himself, barely able to talk or move and with loss of memory and reasoning, until finally a year into his cancer treatment, he said it was enough, he couldn't take it anymore. At that point, they let nature take its course, and within a few months, he was gone.

I have no idea how much all of the treatment Mr. J had cost, or how his family managed to pay for it, but I definitely saw the emotional toll it took on everyone. I know that his family believed they were making the right choice, by doing everything they could to keep him alive. But I am not sure that ethically it is right to lead people to believe that treatment will save a life when really it is just extending a life. At least by the time death came for Mr. J, he was ready to go--so tired of being poked and prodded and treated to death.

For him, no visiting doctors. He may have had visiting nurses, if he paid for them. He had to drag himself to the car and to the hospital for treatment until he could drag himself no more, and then his wife and family had to drag him. It may have been comforting to his family to have him around for an extra year, but I don't know. I know that toward the end, he was too sick to want any kind of visitors around him.

I am not a big fan of the way he died. I think my mom got more honest care, more loving care, and a better death out of the deal. Plus, she was not hammered financially, and I am sure that the J family was, as they were encouraged to pay for more and more treatments that might "cure" him.

Two Surgeries 

As my son Patrick entered puberty, be began to have some medical problems that necessitated him seeing a urologist. The urologist scheduled Patrick for a surgery to fix the problem.

At age 12, Patrick underwent the first surgery just after the summer vacation began. This was a full-on, in hospital, anesthetized surgery requiring a large incision. It went well, Patrick came home. He had to take it easy for several weeks to a month, making his summer a little less physically active than he would have liked, but he dealt with it.

Unfortunately, the problem was still there after the surgery. Back to the urologist. He explained that sometimes the surgery didn't work, but there was another surgery that we could try.

First day of Christmas vacation, we are back in the hospital for Patrick's second surgery. This one was really different. He would just be under a local anesthesia. They would use lasers and coils, and just do two very small incisions. I sat in the hall and read a book while I waited.

After it was over, the surgeon called me in. He wanted to show me the films of the surgery, where the laser went, where coils were placed (seven total) in Patrick's body. The surgeon was very forthcoming, explaining in detail the procedure he had done so that I could understand it.

He was also forthcoming in another way. He expressed his frustration that Patrick had to have two surgeries when only one was needed. He explained that the first surgery Patrick had has a 75% FAILURE rate, while the second one has a 98% SUCCESS rate. But the insurance company will not pay for the second surgery unless the first one has failed! At the time, I knew the costs, which I have forgotten now, but I did the math at the time, and found that if the first surgery had an 80% failure rate, then it would be more cost effective to jump right to the second procedure.

I guess I just grew up with socialized medicine and that is why the power of the insurance company to dictate treatment astounds me. I can't imagine a doctor in Alberta or British Columbia doing two surgeries on a child when one would do. They would opt for the one that would work! Mind boggling to me.

Two cancers, two surgeries...I leave you to draw your own conclusions about how medicine should be practiced. Should medicine be about using treatments that you know don't work, either to make money (example one) or to save money for the insurance company (example two)? Or should it be about the best care possible in circumstances that are honestly explained to the patient?