Reflections in a Head Mirror

“A man's most open actions have a secret side to them.”
-Joseph Conrad  


He was bright, friendly, and gregarious ... and had a hole in his neck. My new patient had undergone a laryngectomy elsewhere and had just moved to town. He needed a doctor to follow him.  

“I would be happy to help,” I said. “Tell me about your treatment.”  

“My surgery was last October. They took out my voice box. The doctor said they got all of the cancer out and there wasn’t any sign of spread. I didn’t need any radiation treatments. I feel back to normal, except for my mechanical voice.”  

“You look great! Tell me where you had your surgery and I will ask the hospital to forward your records.”  

“I can’t remember the doctor’s name." He shrugged and smiled. "I have it at home. I’ll bring it next time.”  

And so it went for a number of visits. He would show up each time dressed in a great looking leather coat, shake my hand warmly, and sit and talk. Each time he would slap his knee, shake his head, and tell me that, once again, he had forgotten to bring the contact information for the doctor or the hospital where his treatment had been done. “Next time,” he promised at each visit.  

One day, after a couple of years, he missed his visit. His girlfriend called. She was distraught.  

“He can’t come in! They just arrested him! Oh, I’m so worried about him!”
 
Over the next several months, we followed his saga — first the arrest, then the trial, then the conviction. It turns out my gregarious, delightful, well-dressed cancer survivor was also a major drug distributor. The government took all of his assets, including, presumably, all those nice leather coats.  

Now, I finally thought I understood why he had persistent memory loss about where his cancer treatment had been completed.  

At the prison system’s request, I forwarded his medical information with suggestions on how to continue his cancer surveillance.  

I usually see long-term survivors yearly. When will this man have his next follow-up appointment? Well, in about 15 years …10 with good behavior.

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The following is feedback received for this blog:

Another great story! - rl bates http://rlbatesmd.blogspot.com/

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“What do you do for a living?” I asked.

“I run all of the food services for a college.”

This was going to be a problem, I thought. His throat cancer was in the region of the tongue where his taste buds were most dense. I told him that there was a very real potential that his cancer treatment would forever lead to a loss of his sense of taste.

He was resolute, though. “Do what you have to do.”

Seven weeks of radiation therapy were difficult for him. Fortunately, his cancer disappeared completely and never came back. I still see him regularly.

“Tell me,” I ask, “how are things going?”

“At first, I could taste nothing! I worried if I would be able to continue working! Fortunately, my assistants helped immensely in the early days after treatment. I could taste next to nothing for a couple of years. Now, it seems that my taste is finally returning! Doc, do you think it will get all the way back to normal?”

There is no way to tell. Taste is a complicated sense that includes the integration of both his sense of smell and the interpretation of chemicals by the taste sensors in his tongue and throat. The treatments not only dulled his sensors but cause dryness which decreases the release of chemicals in his throat. Some of my patients tell me that foods they used to enjoy now bring them no pleasure. Sometimes, the opposite is true – foods they never liked are suddenly wonderful. There is no way to predict.

The dilemma of his loss of taste sensation in a professional that depends on his sense of taste came to mind when Dr. Val told me about a famous chef who is currently being treated for a large tongue cancer. His situation is unusual. He is only 33 years old (very young for tongue cancer). He has a very advanced (Stage IVB) tumor – cancers at this stage are rarely treated with surgery. Nevertheless, the articles about him make the point that he has opted to undergo non-surgical treatment hoping to better preserve his sense of taste.

I hope things go well for him. Based on my food services director’s experience, he might get his sense of taste back someday. Or maybe not. Or it might be altered. No one can predict.

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The following is feedback received for this blog:

Another great post! - rl bates http://rlbatesmd.blogspot.com/ I hope that your patient's taste sensation comes back all the way. I guess it's hard to prognosticate - are there any positive signs that would sway you one way or the other? In spinal cord injury medicine we wait 3 months before discussing likely functional outcomes. Do you have any milestones that you look for - like return of taste sensation within X weeks - to help with prognosis? A curious colleague... :) - Val Jones www.revolutionhealth.com/blogs/valjonesmd Thanks for the comment and the suggestion to write about this. ... The functional return after radiation and/or surgery is very unpredictable. Taste sensation and salivary flow are both affected permanently and some people get very little return while others have great recovery. I tell people not to give up since the time course can show improvement over a couple of years. I really do not know what leads to the improvement, though - it isn't really analogous to the resolution of nerve compression. Thanks again! -Bruce

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The Oncology Clinic waiting room chairs are full, the television replays yesterday’s events, and the conversation is quiet. Further down the hall, the laboratory draws blood samples from other cancer patients, guiding therapy and checking treatment progress.  

Ambulatory patients and family members weave around me as I pass through the waiting room heading to my own clinic duties. The people, individually and in pairs, slow and turn at the reception area. A patient who has completed checking in drops heavily into an open seat. As I walk on,  I am sensitive to the privacy of those assembled here, yet I glance up to see if I recognize any of my own patients’ faces.  

The door to the clinic hallway opens and a staff member emerges. She scans the room and calls out. “Constance? Constance? Oh, there you are! You brought company today! Come on in. Bring everyone along!”    

I pause as a wheelchair changes lanes in front of me. Constance looks up, smiles briefly, grits her teeth, and repositions her body — deliberately preparing to stand. She presses down firmly on the arms of the chair. Her companions, hands at her elbows, rise with her and together they move toward the doorway.  

Poet Laureate and cancer survivor Ted Kooser, in a poem titled, “At the Cancer Clinic,” captures the moment cleanly. As those of us in the waiting room note the woman's measured steps…    


“…There is no restlessness or impatience
or anger anywhere in sight. Grace
fills the clean mold of this moment
and all the shuffling magazines grow still.”  

(from Delights & Shadows, Copper Canyon Press, Port Townsend, WA 2004)  


We watch the patient and her companions move toward the door. We nervously scan the floor in front of them, looking for obstacles. We ache and hope and breathe along with them. We lean forward and care and dread, imagining their thoughts. 

Constance disappears down the hallway where she will learn what she is to learn.