Tailoring your approach to how you interact with a patient can be beneficial.
Christopher Dittus, DO, MPH
Sharon was a 40-year-old female patient, and she did not want chemotherapy. As a first-year hematology-oncology fellow, it was my job to convince her otherwise. Sharon was initially diagnosed with early stage, estrogenreceptor— positive breast cancer 2 years before my first visit with her. At that time, she was advised to have surgery, as well as hormonal therapy and, possibly, chemotherapy. Surprisingly, Sharon refused surgery and all adjuvant treatment. After multiple failed attempts to convince her otherwise, she agreed to be followed very closely by her medical team with breast exams and mammograms. As expected, her cancer progressed. She was ultimately diagnosed with stage 3A breast cancer several months prior to my initial evaluation.
As I sat across from Sharon during our initial visit, I was first struck by her eyes. Penetrating and defiant, they seemed to reject my recommendations before I spoke. I then noticed that her mouth was fixed in a scowl, and it looked as though this was its normal position. Lastly, her sharp cheekbones were framed by straight, long, brown hair. Her face seemed to warn the world that she was formidable and anyone seeking to interact with her should be forewarned.
As I began to interact with her, I was careful not to dwell on the past. I did not want to appear accusatory and knew that, despite saying otherwise, she understood that her life was in jeopardy because of a poor decision she had made years earlier. Immediately, I realized that my initial impression was correct—she had a particularly guarded and defensive demeanor. Later, I learned that she was frightened and angry about her diagnosis. She was also vain and having had a mastectomy the month prior, she was particularly focused on her appearance.
Later in the encounter, I was able to delve deeper into why she had initially deferred therapy. Sharon had deeply held beliefs regarding her ability to “self-heal” and she was highly suspicious of the modern medical system.
To her, the intensive treatments we use in oncology were the worst of all. She felt that chemotherapy was poison, hormones would cause additional cancer, and surgery and radiation were horribly disfiguring.
Over the course of my interaction with Sharon, I found that she appreciated succinct, direct language. Knowing that her prognosis now depended on my ability to develop a meaningful rapport with her, I firmly, but sincerely, asked her if she wanted to live. At first she was surprised by my directness, but her scowl soon softened and she responded that, yes, she did want to live. I told her that I could not promise her a cure because of the extent of her disease, but that if she trusted me and the medical system, we would give her the best chance of cure. She replied that she was ready to listen.
Because Sharon already had a mastectomy, she would now need intensive chemotherapy to kill any remaining cancer cells. Many of her questions focused on practical issues. She wanted to know if she would lose her hair. I replied that, yes, she would most likely lose her hair, but we would arrange for her to wear a wig until it grew back. Feeling disfigured, she wondered if she could go to the beach after having had a mastectomy. Yes, I replied. I reassured her that we would order a post-mastectomy swimsuit for her to wear. Lastly, she had a new job as a dental hygienist and wondered if we could schedule her treatments around her schedule. I responded that, yes, we could arrange for her to arrive and leave early in the day.
After thinking about it overnight and asking several more questions, Sharon agreed to initiate dosedense doxorubicin and cyclophosphamide followed by weekly paclitaxel. Despite pretreatment anxiety and many work-related obligations, Sharon did well throughout her intensive chemotherapy regimen.
Toward the end of her treatments, I broached the topic of radiation therapy. Sharon’s major concern was that she would not be able to have breast reconstruction surgery afterward. This common misconception was dispelled after a visit to both the radiation oncologist and the breast surgeon.
When I returned to Sharon’s hospital after rotating at another hospital for 6 months, she had completed her radiation therapy. Her formerly long brown hair was in a short pixie-cut, further defining her angular cheekbones. Sharon told me she liked her hairstyle and would keep it short, at least for a while. After spending some time catching up, our discussion turned to the hormonal therapy that I knew she needed, but did not want. Anticipating resistance, I had printed out information from an online prognostic model. After reviewing the evidence in favor of hormonal therapy and taking it home to discuss with her family, Sharon ultimately agreed to take these important pills.
Despite her initial misgivings, Sharon has successfully completed surgery, chemotherapy, and radiation therapy. Additionally, she is adherent with her ongoing hormonal therapy. Sharon may not be cured, but she now has a second chance at life.