Ken, a 70-year-old businessman, shook his oncologist’s hand and thanked her repeatedly, despite having residual cancer in his lung following his initial treatment.
He then added that he wasn’t afraid to die, and he plans to continue living his life to the fullest, until he requires treatment again.
Then there is Nancy, a young and vibrant woman who is now facing her fourth breast cancer relapse. She has just booked a trip to Phuket, Thailand, while simultaneously setting a date for her next chemotherapy session.
Sadly, these two scenarios are not what we oncologists usually see in our daily practice.
There is nothing in this world that can be compared with the devastation of being told that you have cancer.
Once the cancer diagnosis is made, a person’s life is changed forever. Aside from being an “organic” disease, cancer is a real emotional malady, eliciting complex and intricate human emotions in many, if not all, of our patients.
People react differently in coming to terms with a cancer diagnosis, and thereafter in making the journey of battling this disease.
Their minds may be inundated by fears, doubts and anxieties. Some experience guilt and become angry; some fall into deep depression; and others just bottle up their emotions and live in ignorance, trying to suppress their worries and dismay.
As oncologists, it is both a privilege and a huge responsibility to go through this journey with them, and more often than not, we go beyond our capabilities in guiding and counselling them through this challenging time.
When a tumour recurs, advances or no longer responds to treatment, the person with cancer may feel confused, enraged, or they may even swear that they will never have treatment again. They give up.
Sometimes, unfortunately, it may just be best to let go; and this is when it gets even tougher for us doctors to inform patients and their families.
One example is Jeff, who suffered from advanced lung cancer. He was discharged from the ward so that he could spend his last few days at home with his loved ones.
Throughout his hospital stay, his doctors worked tirelessly to keep him as comfortable as possible, providing pain relief, nutritional support and other supportive care, stopping short at giving him “treatment”.
His family was initially hesitant to take him back, still clinging to some hope for a miracle to happen. Later, they began to slowly accept his fate after witnessing how, within a couple of months, his body rapidly became frail and withered, ravaged by his aggressive cancer cells.
When breaking the news to relatives that their loved ones are dying from cancer, we often hear expressions such as, “Doctor, my mother is my world, I just can’t bear seeing her die in pain.”
They usually describe feelings of hopelessness and worthlessness as they realise what limited choices they have at this stage – palliative care and hospice.
This is definitely not easy for patients, loved ones, or even doctors.
When treating and caring for cancer patients, many doctors still find it difficult to discuss the inevitable with the patient or the caregiver.
How do we inform them that further treatment is futile, their body is failing them, and that they are dying?
How do we help them accept that further active treatment or entering a clinical trial is inappropriate?
It is especially hard to break the news of a relapse to patients who have been optimistic and positive all along, those who have coped and adjusted well to the treatment and life circumstances after their first diagnosis.
How do you tell a young mother who has been looking forward to attending her son’s secondary school graduation that you just found out her initial stage one breast cancer has spread to her brain and spinal cord linings?
You know that she will suffer from excruciating pain and the thought of offering sedation out of compassion has crossed your mind, but you cannot offer it because of laws and regulations.
We frequently find ourselves struggling with grief and sadness when death happens to our patients whom we have come to know so well, strangers whom we have built strong trusting relationships with over so many years.
We feel defeated, having to witness patients losing confidence in us, and we carry with us the burden of knowing that there is nothing much that we can do.
Our friends, families, and even our colleagues often ask how we are able to do this job that carries so much sorrow. We get this question at dinner parties, school reunions or during family gatherings.
There is never an easy answer. Oncology is not a sad teary-eyed field all the time because we do see successful cases and patients who are free of cancer after treatment.
It is crucial to know that despite advances and recent innovations in cancer therapy, there are limits to what medicine can do for unavoidable deaths from advanced cancers.
The dying process is always sacred, yet very much unpredictable. Days before a patient dies, we usually see some changes – they start to become more tired and spend more time in bed, their eyes have sunken and their skin colour has changed.
There are many signs that the end is near, but death can also be so sudden.
No matter what the outcome is, we as oncologists always feel honoured in walking this road with our patients and their families. It is our solemn task to make sure that the dying person is as comfortable as possible with optimum relief from any physical, emotional and spiritual maladies.
After all, we humans are just tiny little dots in this vast universe that is not ours, and cancer is like a ruthless assassin that affects every one of us, one way or another.
Dr Mastura Md Yusof is a consultant clinical oncologist; Dr Hariz Iskandar Hassan is currently training in radiation oncology in Prague, Czech Republic.