Why Get a Second Opinion?

It’s basically the difference between being a grateful user of public services and being a consumer. This is the second opinion in Canada vs. the U.S.

When I was diagnosed with breast cancer, I learned that second opinions aren’t really done in Canada, or at least not if you have confidence in your doctor(s). First I was diagnosed by my excellent family doctor, then sent to the breast care center for biopsies and further diagnosis, then to an oncologist at the local cancer program for more specific diagnosis and treatment.

As I understand it, it was a matter of the luck of the draw that I was paired with a medical oncologist (MO) who was caring, conscientious, and well-versed in the latest treatments. After all, I saw a lot of doctors (family doctor, surgeon, interventional radiologist, radiation oncologist, pathologist, etc), but it is the medical oncologist who is mainly responsible for my care and who has seen me often enough to likely be sick of me and the plaid flannel dress that I have come to favor, especially in cold hospital rooms.

An American friend who was treated for cancer locally many years ago explained, “Second opinions are not really a thing here. People will get squirrelly if you ask for one.”

And yet, all the Americans wanted to know if I was going to get a second opinion, as if not getting one would be irresponsible. “I’m pretty sure that the second opinion is that I still have breast cancer,” I noted.

But the fact is that only about 6-10% of breast cancer patients have metastatic breast cancer at the time of diagnosis (de novo). Being diagnosed at age 44 puts me well below the median age for breast cancer patients, an age where cancers are more likely to be aggressive, but patients are more likely to respond well to treatment. I read through the treatment guidelines and noted that they are the same for women with breast cancer, regardless of what age they are diagnosed or whether or not their cancer is de novo or a recurrence. It seemed to me that these variables introduced some wiggle room into the question of how to treat me.

In addition, we got convincing email from our American friends noting that for many American oncologists, a second opinion is a standard practice and a sign of having made a thoughtful choice when you do sign on for treatment with your oncologist. The principle of leaving no stone unturned as you think through what kind of diagnostic testing and treatment makes sense for you makes sense, even in the Canadian single-payer sensibility.

So we went to Toronto and met with a MO who has treated hundreds of patients like me, and she did not have anything new to suggest. We went full steam ahead with the standard chemotherapy treatment and, lo and behold, I did have a great response, even what is called “a complete response,” meaning that my cancer was undetectable. Until it wasn’t anymore, and I found out that I needed brain surgery.

Fortunately, my MO was supportive of getting a second opinion, something that a friend has suggested as generational. Under insistence from my parents and path smoothed by one of their friends, I scheduled an appointment with the excellent breast cancer team at Dana-Farber Cancer Institute in Boston for right after my brain surgery last November.

To cut to the chase, how did I process this question of whether or not to get a second opinion? And why does no one seem to talk about it, at least in Canada. Here are some of my thoughts.

REASONS NOT TO GET A SECOND OPINION

  1. Treatment will be the same. If treatment for your condition is well-covered by clinical guidelines, then a second opinion will probably yield more of the same plans and decisions. The same is true for the diagnosis, if it is not likely to change or if the original testing is complete and thorough.
  2. Your case is going through a tumor board. Yes, it’s actually called that, when a lot of different doctors in a cancer centre get together and review your case. They talk through the ambiguities and everyone gets the benefits of multiple minds focused on the case. This is an example of how medicine can be a very collegial and collective enterprise, and of how you can have several different clinicians’ problem-solving applied to a problem without ever leaving home.

REASONS TO SEEK A SECOND OPINION

  1. Your doctor is a quack. Thankfully, none of my doctors have been quacks, and the world “quack” amuses me plenty. However, I think the specter of the quack hangs over any patient who wants a second opinion, whose doctor has to think, “Does this person think I am a quack?” while the patient is also thinking, “Does this doctor think that I think that s/he is a quack?”
  2. You are part of a fast-changing field. Knowledge about cancer is changing every day, and new clinical trials pop up every day. In many cases, those who seek a second opinion feel like they need to find out what the state of knowledge is elsewhere and whether their case would be seen differently there.
  3. Your case is somehow different or special. For me, I was diagnosed at age 44 for a cancer in which the median age is much older. Should the fact is that I am able to tolerate more aggressive treatment be factored in to my treatment plan? Should the extremely aggressive nature of my cancer?

Notice what is not on either of these lists is, “You have confidence in your doctor.” I assume that this is true either way, and I also assume that more than one good doctor might have different views on the same case.  I am assuming, in short, that the doctor is not a quack.

Vocabulary Lesson, Part 2

Building on my earlier Vocabulary Lesson post, I have some more advanced vocabulary here. It’s a little technical, but it helps to spread some knowledge around that better reflects the state of what cancer patients go through today.

Prognosis – this is the third rail of conversation with cancer patients. Conversationally, prognosis means what physicians predict what is going to happen to the patient, and when. However, physicians know that they are terrible at this, and good doctors will refuse to give prognoses all the time. I have heard a lot of cancer patients complaining that when (probably well-meaning) people ask about their prognosis, they feel like they are looking for the “expiration date” that must be stamped on them somewhere. You know, like the perfectly nice person I see in the grocery store who brightly says, “But your prognosis is good, right?” Or the hairstylist who says, after I explain why I lost all my hair, “But everything’s good now, right?” Or the other hairstylist … what is it with hairstylists?  Maybe I’ll write a whole other piece about this one, but the bottom line is that no one can predict what your prognosis is because surprise is always part of the picture. I can tell you what the median survival time is for patients with Stage IV breast cancer, but that won’t tell you much about my case.  I offer this as the only topic to be avoided with cancer patients.

First Line/Second Line Treatment – this was a new one to me, but it’s extremely important. The First Line Treatment in chemo is whatever your oncologist puts you on first, usually according to whatever the clinical guidelines tell him/her to do. When that appears to be not working anymore, because cancer finds a way around most treatments, s/he puts you on the second line treatment. In Ontario, the government funds two lines of treatment, so the decision to switch from one to the next takes on a lot of clinical significance.  If I’m reading the NCCN guidelines correctly, the largescale data says that there’s no additional benefit to treatment beyond 2 lines of therapy, so this is Ontario’s reasoning.  It also takes on emotional significance for the patient, who may be known to say things like, “I failed Ibrance after 8 months”! But never, “Ibrance failed me.” Discuss amongst yourselves.

Targeted Therapy – not all treatments are chemotherapy. Increasingly, cancer patients on targeted therapies that aim to interrupt specific traits in cancers, such as proteins or hormones, rather than attacking all cells, as chemotherapy (cytotoxic) drugs do. For example, for HER2-positive patients like me, who are between 15-20% of breast cancer patients, we are likely to get Herceptin and Perjeta, which are HER2-targeted drugs, at some point. These drugs are considered very good and have dramatically increased the prognosis of patients like me.

Second Opinion – this is also a funny one. A second opinion is when you go to another professional to find out how they see your case. I learned from experience that second opinions are often verboten in Canada because why would you imply that you weren’t already getting the best possible treatment in our amazing OHIP system? The tricky part is that I am American, and my family still resides in the U.S., where second opinions are basically required of everyone and if you don’t get one you might as well announce to anyone who will listen that you don’t care about your own health or the quality of your care. This is one of the many subtle differences between Canada and the U.S. that are very easy to overlook until you bump right up against them. Yeah, more on this one later, for sure.

Back in December, there was a lot riding on my laparoscopic surgery.  You see, I had this growth that was showing up in my pelvis, and no one could say for sure what it was unless we got a sample to the pathology lab. Was it cancer, showing that something new and dangerous was growing in my torso? Or was it just one of those things that grows in your pelvis? An attempt at an ultrasound-guided biopsy did not work out, but if it proved to be cancer, then we would have to move from a first-line treatment to a second-line treatment. So I had my ovaries removed — as one does — and learned that the growth was actually just regular benign fibroids, so I get to stay on my first-line targeted therapy, for now.  Woo-hoo.

What we read together

It’s not every evening, but as often as we can – maybe once a week and maybe several nights in a row – the four of us sit down together on our old beige couch to read a bedtime story. This usually happens around 7:30, when the kids are ready for bed.  The choosing of the stories is a pretty big deal, and once the novel is chosen, we all commit to it (to the extent that I have yet to complain much about the Rick Riordan one that we are currently making our way through). We read one or more chapter a night.

Our first family novel was probably The Mysterious Benedict Societ by Trenton Lee Stewart. At the time, I thought that The Prophet was too young to understand the novel — he used to need a small toy to fidget with during story time — but he would periodically pipe up to remind us of the key facts from previous chapters that we may have forgotten. I can’t count Charlotte’s Web as our first family story because it was only 3 of us reading, even if it did cause La Neige to become vegetarian for the rest of her life, and even if it was one of very few books that caused The Historian to cry when reading the last chapter.

Speaking of crying, my favorite book of storytime, perhaps of all time, is The Graveyard Book, by Neil Gaiman. It’s based on Rudyard Kipling’s The Jungle Book.  To those who have read the source material — that would be The Historian and La Neige — Gaiman’s version is a huge improvement. It’s about a boy whose family is murdered by The Man Jack, so he toddles into a nearby graveyard and is adopted by a family of ghosts. Over the years, he learns to turn himself invisible, yearns and fails to make friends with normal living kids his age, wards off demons, participates in a highly memorable danse macabre, and eventually walks away from the graveyard. The last few pages were so moving that we had to pass the book over to La Neige or we couldn’t have finished it.  Gaiman’s writing is extremely vivid without being showy, and he has a devastating eye for detail. I was not prepared for how much this book affected me.

At some point, it became clear that family story time was “our thing,” and I started collecting the books that we read on one shelf in our living room. I’m not quite sure of the order, since the presence of series’ will tend to mix everything up, but I think that we’ve read:

  • The Mysterious Benedict Society series by Trenton Lee Stewart
  • The Incorrigible Children of Ashton Place series by Mary Rose Wood
  • How to Train Your Dragon by Cressida Cowell
  • The Graveyard Book by Neil Gaiman
  • The Girl who Circumnavigated Fairyland in a Ship of her own Making and The Girll who Fell beneath Fairyland and Led the Revels There by Catherynne Valente
  • Watership Down by Richard Adams
  • Magnus Chase and the Gods of Asgard by Rick Riordan
  • and, of course, Harry Potter by J.K. Rowling

In the olden days, I think families gathered around to read together. It takes something that my nerdy family loves, which is READING, and makes it a social activity. We have giggled together at the antics of Lady Constance of Ashton Place; and we have debated around the dinner table the fitness of Stewart’s mind games or Harry’s character as the Chosen One. La Neige has decreed that since we started reading Harry Potter when both she and Harry were in First Year, we read one book a year. This means that we still have the last one to go. We may break with tradition and read two Harry Potter books in one year. This would demonstrate how extremely flexible and fair-minded we are.

For a while, The Historian and I would trade the reader role back and forth, but then I got too sick and tired and he did all the reading. Good thing he’s a great reader and has an excellent Hagrid-Scottish accent. I have been known to fall asleep during story time and had to go back and reread the end of Harry Potter and the Half-Blood Prince, but miraculously, the four of us still fit on our compact beige couch.

A Vocabulary Lesson, part 1

From the always-wise Susan Gubar:

For most people with cancer, life has conventional stages that I can sum up with acronyms: B.C. (before cancer), A.D. (at diagnosis), S.S.N. (some surgical nightmare), RATS (radiation therapies), ICH (in chemotherapy), followed by IRS (in a remission of some number).

Like a growing number of patients today, I inhabit a less familiar state: maintenance. This new phase presents a viable alternative to remission which, I sometimes feel, is not everything it is cracked up to be.

recent article in the New York Times chronicled quite vividly the author’s experience of trying to communicate with people about living with stage IV colon cancer. This article got a tremendous response from people, and it made me realize how lost we all are when it comes to talking about cancer, or about any chronic illness really. We live in a culture where it’s not okay to be ill in public, but at the same time we have this amazing growing ability to diagnose people as chronically ill when they might have previously looked “normal”. And we have a growing disabilities rights movement that is all about making sure that everyone is accommodated in public. So we have sick people walking around looking well, which probably isn’t a new thing at all, and no one knows what the right thing to say is.

The bottom line is that there is no right thing to say. The ability to let go of the need to say the right thing is a wonderful gift, I’ve discovered, as is my tolerance for awkwardness. I am so grateful for the many people who have braved being awkward or inappropriate when they did not have the ‘right thing’ to say was but did not let that stop them from reaching out to me or being with me or my family.  And, luckily, once I threw away any semblance of propriety I opened myself up to hearing what was on people’s minds. If you’re looking for a way to do this, it’s always helpful to acknowledge that some things are terrible, that you’re sorry that your friend is going through this, that you feel sad or anxious, etc.

In the spirit of helping, I put together a list of the some of the terms that are important to cancer patients but where we don’t seem to be working from a common definition.

Cancer – I gave myself an easy one to start with. Cancer is the growth of abnormal cells, mutated from the patient’s own cells. There are many – perhaps countless – types of cancers, so when I was diagnosed with breast cancer, I learned that it has both types and stages, which change how you might treat it. Everyone can have their own theory of what causes cancer, but it’s still pretty mysterious. For example, the majority of breast cancer patients, like me, do not have any ‘risk factors’ in their history such as smoking or having a family member with breast cancer.

Guidelines (also Medical Guidelines, Clinical Guidelines) – this is a really important one. During the past few decades, there has been a movement towards Evidence-Based Medicine (EBM) that analyzes published research in different fields to come out with guiding statements about how patients should be diagnosed and treated.  They are often pointed to as the “gold standard” in knowledge of a particular condition. In the case of cancer, my understanding is that doctors tend to follow the guidelines set out by the National Comprehensive Cancer Network. This means that there is something in writing that should conform to the empirical evidence of as many cases as possible. In my case, Ontario tends to adopt the recommendations of NCCN, resulting in top-quality care available to patients like me. The downside is that guidelines devolve from large-scale research, so they may not address key variables in your specific case (like, for example, the fact that I was diagnosed before the age of 45 with stage IV breast cancer). Also, guidelines lag behind the actual research, so in some cases guidelines may be behind the latest treatments for your particular case.

NED/NEAD/No Evidence of Active Disease – this is a key term for people with stage IV cancer because for most oncologists there is no ‘remission’ for us. Instead, the goal is to get to a state where medical science has beaten back any evidence of disease. For many patients this is Holy Grail of cancer treatment because NEAD status means that everything is working. But achieving NED status does not mean that cancer is gone, as Beth Caldwell wrote: Hope is like a rope that kind people who just don’t get what metster life is like will throw down to you and say, ‘Here, climb this.’ But the problem is, the higher you climb, the harder you fall. And you WILL fall. NED doesn’t mean cured. The cancer is still in there, trying to figure out how to overcome the drug I’m on and start growing again.

Stability – much like NED, this is seen as a good thing. When scans show that tumor(s) have not progressed, then a patient is regarded as being in a state of stability. For most oncologists, like mine, this is seen as a sign that treatments are successful because the cancer is in check.

Progression – this is when cancer is growing where it is or is detected in a new spot. This is generally seen as cause for different action because previous treatments were not totally working.  I’ve come to think of progression as being the thing that is around the next corner. You never know what it’s going to be. I never thought it would be brain tumors, but for me it was brain tumors.

Last fall, I went from a state of NED to progression very quickly when tumors were detected in my brain. Then I had successful surgery and radiation followed by a period of recovery, which is where I still am. Since the beginning of this year, I’m back on maintainance therapy, getting an infusion at the chemo clinic every 3 weeks because the guidelines say that that is the right thing to do. Apparently, there is this thing called the blood-brain barrier that means that drugs that are working from the neck down don’t work the same in your brain. Previously, researchers thought that the brain contained a barrier that keeps the chemo drugs out. Now, they’re not so sure why it is that the brain will grow tumors that they body won’t. The latest crop of cancer drugs have been controlling the growth of cancer well enough in the body that we are, apparently, seeing more and more brain tumors because these drugs just don’t work as well in the brain. When I was diagnosed with breast cancer I read that I had less than a 1-in-5 chance of brain tumors, now it’s looking more like 1-in-2.

 

Yoga and the death of a pig

I sank into a chair and sat still for a few minutes to think about my troubles, and then I got up and went to the barn, catching up on some odds and ends that needed tending to. Unconsciously I held off, for an hour, the deed by which I would officially recognize the collapse of the performance of raising a pig; I wanted no interruption in the regularity of feeding, the steadiness of growth, the even succession of days. I wanted no interruption, wanted no oil, no deviation. I just wanted to keep on raising a pig, full meal after full meal, spring into summer into fall.EB White, “Death of a Pig”

Yesterday I tried to go to a regular yoga class at noon. It was the kind of hot yoga class that I used to go to every day without much of a second thought, you know, in the BC (Before Cancer) days. I should have expected that the class would be full of beautiful, fit university students. the instructor was like, “Okay, you’re in a plank. Can you raise your left foot? Now can you raise your left hand? Side plank time!” Then there was a sequence that involved going from chair pose to eagle to toppling tree to crescent moon to standing splits. At this point, it’s worth mentioning that I hate crescent moon more than anything, and it took me decades to even attempt it because, even at my most fit, I thought it was a cruel joke. Now I will attempt a standing split with the knowledge that it will never be pretty.

Just the day before I was at the downtown Y doing “chair yoga” in a dim room in the basement, where I was the youngest person by at least 20 years. And I won’t tell you that it was easy. “I think that chair yoga is as intense as the real thing,” Sue, my bright-eyed fellow-cancer sufferer told me chipperly in the Y locker room, “I love it!” So I went to chair yoga, and got to take a load off of my left foot, which is sprained for reasons that I need not go into here, but gives me a new appreciation for all the work that is done by the tiny muscles and bones in your foot.

It’s probably a good measurement of where my body is at. I go to acupuncture twice a week, as per one of my New Year’s resolutions, to deal with the peripheral neuropathy and the nerve pain in my right hip. I used to be a regular at adult fitness classes – yoga, weights, etc. – and now I’m looking forward to Tai Chi at the local community school tomorrow night. I used to climb 5.10s at the rock-climbing gym and hope (unsuccessfully) to pass the lead climb test. Now I take the kids to the climbing gym and cheer them from the sidelines. Sure, cancer takes its toll, but I’m aging at the same time, so maybe this is the season of life when I’m supposed to call it quits?

Or maybe I was too fit to begin with. I spent decades getting to be able to hold a tree pose, and now I’m just too wobbly. So today I went back to chair yoga, where I can still do tree pose but get to grab onto a chair if I wobble. But Sue was not there to cheer me on. In fact, I learned that Sue died unexpectedly on Saturday. The last time that we talked, we said a quick and partial good-bye in the Y locker room. “I’m sure I’ll see you again before your surgery next week!” and she quickly agreed. She was deep in conversation with someone else when I left because she knew everyone in that room. I was grateful to her for knowing just when to seek me out and share her experiences, as she always had her little walker to keep her mobile, her baggy lululemon pants and her leg wraps so that she could work out. “I wasn’t feeling great this morning, but then I realized that if I don’t come here, then my day will get even worse!” she reported. And then we made plans to go to chair yoga.

The news of the death of my pig traveled fast and far, and I received many expressions of sympathy from friends and neighbors, for no one took the event lightly and the premature expiration of a pig is, I soon discovered, a departure which the community marks solemnly on its calendar, a sorrow in which it feels fully involved. I have written this account in penitence and in grief, as a man who failed to raise his pig, and to explain my deviation from the classic course of so many raised pigs. The grave in the woods is unmarked, but Fred can direct the mourner to it unerringly and with immense good will, and I know he and I shall often revisit it, singly and together, in seasons of reflection and despair, on flagless memorial days of our own choosing.  –EB White, “Death of a Pig”

“Who is your audience?”

When you are in our forties, it’s probably normal to spend your birthday thinking about death. But when I think about death, I really think about death, and then I think about how that’s just not comfortable for most people I know. In fact, thinking about feelings is not very comfortable for most people.

“Who is your audience?” asked my husband and most thoughtful reader recently.  The question made me think. The audience is, of course, you, if you are reading this. My goal is to ask the questions, “What does it mean to live well with illness? What does it mean to live meaningfully and critically with illness?”  So I guess that my audience is the people who care about the answer to these questions.

Plus, I’m a social scientist at heart, so my answers to these questions are grounded in the real things that we do every day, in how they make me feel, and in what they do to our larger politicized worlds. So if you’re still reading this, then you are my audience. You might be like me, someone who is living with and thinking about illness. Or you might be like the many people in my life who are helping someone they love deal with illness and are curious about what that involves. Or maybe you are both, or somewhere in between.

I remember when I was first diagnosed with breast cancer, one of my first questions was, “What is this thing, and how do I live with it?” I could not bear to look at the websites for breast cancer-related organizations and support services because they did not seem to understand who I was. For one thing, they most often featured photographs of breast cancer patients as happy, attractive, white, thin, affluent women who were facing illness with a sense of positivity and uplift. Recently I attended a lecture by a PhD student who had done a critical discourse analysis of several breast cancer survivorship-related sources. She noted how prevalent images were of women with their families, as if these pictures say, “Women are important because they have families.” Not, mind you, because they are people. Maybe this is one of the things that I was responding to.

The few organizations that were different were like a breath of fresh air, and I responded to them immediately. These were organizations like ReThink Breast Cancer and The Underbelly and the Metastatic Breast Cancer Network, organizations that have a stated mission that includes serving women like me with Stage IV breast cancer and who understand the breast cancer experience as one that is complicated, scary, and never-ending. It’s an experience that my brain seems to be always processing, whether I want it to or not.

I also discovered the blogs, memoirs and discussion boards of breast cancer patients. This was a source of bracing honesty, speculation and meaning-making. One of the first blogs that I came across, for better or for worse, was Lisa Bonchek Adams’ account of her own experience with breast cancer, which ended with her death in 2015. Lisa was a great writer and a very woke patient who also had training and experience as a social worker, so her blog reflected the concerns of someone who knew what other patients worried about. In Reading and Writing Cancer, Susan Gubar has written about the influence of Adams and her blog as an important service to patients, so no need to retread here. I have already noted that chronicles like hers have helped me to understand that there are so many ways that this disease can go, and there are so many ways that we can respond to it, and they are all legitimate. The web of stories that we offer up to each other is a way of sharing our experiences and acknowledging the commonalities in our very different predicaments. I am eternally grateful to all of the people who make their experiences public to increase the visibility  of this experience. Thank you, Beth Caldwell, Teva Harrison, Nina Riggs, Ann Silberman, and many anonymous others.

Last winter there was a CBC documentary called Cracking Cancer that followed the work of the POG clinic at UBC. For the documentary, several stage IV cancer patients allowed themselves to be recorded and interviewed at some very vulnerable moments so that members of the public like me could watch them and say, “So this is what it looks like to lives with a very bad cancer diagnosis as it progresses.” My mother watched the documentary at my urging, and said, “Look at how this normalizes the experience!” even though watching it was not easy and was not meant to be easy.

On a personal level, a few of the women I know have shared their own intimate experiences of illness with me. I won’t expose them here, but I just want to say how much it has meant to me when they have shared what it is like to live with a body that is somehow marked as weak or defective or non-obedient. Their experiences are with me always as I think about what it means to live with illness. Within the circle of my acquaintances, I have friends who have led by example as they have coped with chronic conditions that include: arthritis, diabetes, cancer of various types, asthma, COPD, heart disease, IBS, celiac disease, infertility, various complications of pregnancy, and who knows what else.

The need to keep the image of living with illness or disability a dark and shameful secret is one of the things that drives me. After processing my own illness, I came to realize that I have not done anything wrong, that being ill and dying are just part of the human experience, and if I try to keep them secret I’m stigmatizing myself. So I put my own embarassing or unattractive or unstandardized experiences out there to try to widen the circle of what kinds of experiences are out there. I’m hardly the first, but more stories have to be visible to normalize what is actually a very normal experience. Thank you again, Renee Lansley, for introducting me to the work of Rosemarie Garland-Thomson, who draws out connections between feminism and disability. She offers the Misfit as an image of the person whose body does not conform to the rational, male ideal, which, make no mistake about it, is a feminist mission.

And, of course, many disabled people write outside of the standard journals because they lack the institutional capital that makes them academic feminists. More recently and more colloquially, my attention was drawn to a New York Times series on living with disability. This recent article by Elliot Kukla has a lot of good things to say, but I picked this to share:

Like many people, I had once measured my worth by my capacity to produce things and experiences: to be productive at work, share responsibilities at home, “show up” equally in my friendships and rack up achievements. Being sick has been a long, slow detox from capitalist culture and its mandate that we never rest. Slowly, I found a deeper value in relationship beyond reciprocity: an unconditional love and care based in justice, and a belief that all humans deserve relationship, regardless of whether we can offer anything measurable back. In these discoveries, I’ve been led by other sick and disabled people, whose value had always been apparent to me. Amid the brilliant diversity of power wheelchairs, service dogs, canes and ice packs, it’s easy to see that we matter just as we are.