Ovarian Cancer is Nasty

Any woman who has ever had ovarian cancer – or any person who has known someone facing this disease – is well aware of how horrible it can be. As opposed to most other malignancies, the survival statistics have only modestly improved over the past few decades. The American Cancer Society estimates that 22,280 women in the United States will be diagnosed with it in 2012, with 15,500 deaths occurring. That’s indeed a mortality rate approaching 70%.

My first direct experience with ovarian cancer was during the one-year internal medicine internship I completed prior to beginning my radiology residency. Rotations were a month in duration, and I spent my “inaugural” – July 1989 – on the oncology floor. One of the first patients I admitted had a bowel obstruction resulting from ovarian cancer that had spread throughout her abdominal cavity (this also being the most common cause of death in these women). I was 26 years old at the time; I’m currently 49. I don’t remember her exact age, but she was decidedly younger than I am now. My responsibilities as her intern included rounding on her every morning, during which I was to ask her how she was doing, perform a limited physical examination and then write a progress note in her chart. Later in the day, in consultation with her attending physician, I would order whatever medications and tests we deemed appropriate.

Not surprisingly, this woman (whose name I will never forget but also will never divulge) was miserable. She couldn’t eat or drink without throwing up, and the chemotherapy we prescribed only made her feel worse. But I mostly remember her because she was miserable to me. She cursed at me each and every morning (using words not fit for print in the Patch), usually refused to let me examine her and – on at least one occasion – threw something at me. I absolutely dreaded the morning trips to her room, and I truly began to hate her. I never saw her with a visitor, and I assumed that this was because her nasty behavior long predated her nasty disease. To my naïve egocentric 20-something self, she may have been terminally ill, but I was one the one suffering.

Neither her symptoms nor her demeanor improved for well over a week, and a consulted surgeon was contemplating a limited bowel resection to relieve the obstruction. This would in no way affect her overall survival, but it may have made her feel better. But before this surgery could be performed, her mental status suddenly declined. She was very confused one morning and then over the course of the next day became completely unresponsive. Despite extensive testing (by late 1980s standards), we were not able to determine if this change was because the cancer had spread to her brain or if being immunocompromised by chemotherapy made her susceptible to an unusual infection.

In any event, my morning rounds became far more pleasant. Given that she was no longer responsive, she couldn’t swear at me, refuse to let me examine her or throw objects at me. My anxiety level dropped almost as much as her level of consciousness had, and I felt better. She died about a week after this unexpected deterioration, the timing coinciding almost precisely with the end of July.

Given uncertainty as to cause of death, an autopsy was performed. To my surprise, on my very last day on the oncology ward, her care team was invited to listen to a pathologist explain what led to her demise. To my even greater surprise, this discussion took place in a dark dingy area of the hospital that I never before or again visited, the dissecting room, in front of her dead, naked and literally filleted open body. The pathologist graphically explained how she had succumbed to a rare fungal infection, using her internal organs – her brain in particular – as visual aids.

I was immediately overcome with conflicting emotions. Despite my ardent negative feelings toward this woman, I had an abrupt sense of intense guilt. It was 100% wrong to see her this way, like some graphic scene from a horror movie. It then dawned on me that perhaps her unpleasant attitude was the result of her illness and not being visited by family or friends, even as she was near death. I no longer viewed her personality as a character flaw, or took her actions toward me personally. I realized that to her I was likely just the awkward inexperienced doctor who saw her each and every day but never did a single thing that improved her condition. I was probably the obvious and logical choice to receive her wrath. I grew up both as a physician and human being that day. I’ve had similar moments of “doctor-patient relationship insight” since then. But this was the first time I learned something that no physician should ever forget: it’s always about the patient, not yourself.

[This was written while thinking about my aunt and godmother, who died in 2010 of the same dreadful disease, never once throwing anything at an intern, not that I would have blamed her if she had.]