I was asked to see an elderly lady in her nineties with a locally invasive parotid gland malignancy. She had a high grade cancer in the salivary gland. It is never easy to manage cancer, and it is even harder when you consider the context of that cancer in an elderly patient. A senior surgeon reviewed the patient and discussed her case in a multidisciplinary meeting with the expert input of oncologists and radiation oncologists. As a multidisciplinary team, we elected to offer her the option of surgery with curative intent.
What shocked me was what happened after that.
Butchery. The medical team looking after her essentially said, “How could you surgeons butcher a ninety-something year old?” The patient advocate was called in by the medical team, to protect this lady from the butchers’ knives.
As a doctor working with a Head and Neck Cancer unit, I see some truly deforming tumours. Cancer anywhere in the body is bad but to have cancer visibly growing around the Head and Neck is very confronting to the patient and the family. Patients talk about the embarrassment of losing their hair after chemo. Think about what patients feel when they have a fungating tumour growing on their face or neck. Head and neck cancers kill by erosion of the airway (they suffocate and die), erosion of the food pipe (they can’t swallow), erosion of the blood vessels (massive bleed), erosion of soft tissue and bones (horrible facial deformities). Patients and their families are visually reminded of this. The lasting image of their dying parents is that of a face deformed by tumour.
Oftentimes, when head and neck cancer have progressed so badly around the face, patients beg us to cut it out of their face, so they can be rid of the fungating lesion, putrid tumour, and excruciating pain each time they smile, speak or swallow.
The medical teams do not see the horrible effects of a head and neck cancer left alone to run it’s (un)natural course. Doubling time of tumour biology teaches us that a cancer will exponentially grow in size given enough time. Patients will wake up every morning and see with their own eyes the growth of this tumour. Imagine seeing your face being slowly eaten by cancer.
I discussed the options of surgery, radiotherapy and no treatment to the patient and the family. This ninety something year old with a sharp mind smiled and said, “Thank you. I know what I want now.”
The medical team thinks they are being a patient advocate by trying to protect her from the butchers’ knives. The surgeons think that they are being an advocate by offering the patient a surgical option.
The patient advocate asked me this rhetoric question which I absolutely abhor because it is a stupid question, “What would you do if this was your grandmother?”, in essence trying to place guilt upon me for even suggesting the surgical option.
I replied, “I would not change anything because I TREAT EVERY PATIENT AS IF THEY WERE MY FAMILY MEMBERS. I will discuss at MDM, offer them the options and let them chose what is best for them. Don’t you do that?”
Throughout my training I see surgeons agonising over decisions to take patients to theatre. Sometimes, we hate doing it, but it has got to be done, because not operating on them is against the patient wishes and will result in a more horrible outcome. Head and neck operations also carry a different physiological effects on a patient as opposed to an intrathoracic, intracranial or intraabdominal surgeries. One cannot assume that all operations are the same.
There are no 2 patients alike, no 2 diseases alike and no 2 operations alike. To make a decision based on age alone is unfair to the patient. Head and Neck cancer carry a heavier burden of physical appearance, form and function. They affect a patient’s identity: their face, look, smile, voice, speech, swallow, breathing. The patients need to know this too, way ahead of time.
I would never suggest to a medical team when they should chose metoprolol or bisoprolol on their patients. So they should never tell a surgeon when they should or shouldn’t operate. To think that surgeons are butchering their patients is unprofessional and discourteous.
As doctors, we need to serve our patients better by doing what they and their family think is best for them, not what WE THINK is best for them.