"The Break Up" ?

******

Did you hear the one about the woman LIVING and WORKING with METS?

This Woman walks into her cardiologist's office...and they "break-up" with her? 





So...this Woman wanted to see the cardiologist, but he was otherwise occupied. So Woman's appointment is punted to the cardiologist's #1 PA.

Because Woman had a particularly rough weekend, health-wise, an EKG is done with a tech before said #1 PA comes in.

PA walks in, sad and compassionate look on her face.

Prior, Woman had removed herself from the exam table and is sitting, like a real "equal" person, on one of the room's chairs.

PA sits herself, with her sad and compassionate look, on the step-up to the exam table.

"Hi...I'm Brenda PA".

Hi, Brenda PA. I am Woman.

"What brings you in today?

Um, scheduled follow up; bad weekend; hoping that the EKG proves husband wrong - that I did not experience a heart attack.

"Yes, I know. Are you still not willing to pursue a treatment protocol of chemo?"

That has been declined, several times; and off-the-table, since September, 2011. Moot topic. Did I have a heart attack?

"Do you have children? How many? What are their ages?"

Yes, three. Did I have a heart attack?

How are they handling your disease? Are they in counseling?"

Living their lives. No, why? Did I have a heart attack?

"Do you have a DNR or DNI prepared?"

Yes, DNR. Don't know what a DNI is. Did I have a heart attack?

"Good. Good. No, you didn't not have a heart attack. I have reviewed and discussed your situation, including what you experienced on Saturday, with Dr. Cardio. He wanted me to talk with you about the "H-word".

The "H-word"?

"He thinks that this should be discussed."

Excuse me, what is the "H-word"?

"It is really a good idea."

E-x-c-u-s-e ... me, WHAT is the "H-word?"

"Hospice".

W-T-H - ????? WHY ????

"The pericarditis is just going to worsen because of your advanced cancer".

Yes, and so....................

"Well, we have to face the fact that your prognosis is not good, not good at all".

Oh, something to do with having metastatic cancer?

"(Small laugh)...pericarditis with advanced cancer...well, the prognosis is not good, the symptoms are going to get worse. We think that a referral to hospice would be smart."

 ****Interlude****

By this time I have my little friends sitting on opposing shoulders. My little "angel" and my not-so-little "devil".  "Devil" is urging me to rip Brenda-PA a new one. "Angel" is cautioning me to just smile & nod and see where Brenda-PA is going to end up with this dialogue. "After all, this could be really good fodder for bitching blogging!" Ah, yes. You are right, "angel"...who's the devil now?

I  am not feeling so smart. I don't have time for hospice. It won't fit in my schedule.

"What do you mean? What are you doing?" (You mean, besides LIVING?)

Everything that I have been doing for the last 18 years.

How are you still working?

How could I not be?

"Really? Wow! How are you able to continue? (Because the alternative is...?) You are so calm. Are you afraid of dying ... Are you ready to die?" (Oh my!)

Brenda-PA, I am not afraid of dying. It is an unavoidable consequence of living. But no, I am not ready to die. I am not planning to do so anytime soon. So, I think I will take a pass on "ready-ing" myself to at the moment, at least this week.

"(Another small laugh) Are you so calm because you are in the 'acceptance' phase?" (Obviously not, as I am NOT READY to engage hospice services this week, or next, or the ones thereafter!)

I don't think so. I am just  too busy...LIVING.

"May I give you the hospice information? They are a wonderful entity. They are not all about grim-reaper stuff (did she just say that?). If I did not work with Dr. Cardio, I would work with them in a heartbeat (oh Brenda-PA is puny). I will give you the card of the intake director and make the referral."


. . .

. . . Brenda-PA plucks herself off her lower perch and leaves the exam room to retrieve the information. She re-enters exam room and meaningfully squeezes Woman's arm while she hands over the card and information sheet. Brenda-PA walks Woman to the front desk and hands the charting information to the clerk. Clerk looks at the paper and looks at Woman and Brenda-PA and asks: "Are we scheduling a follow up visit?"

. . . Brenda-PA, not missing a beat says (with the sad and compassionate look plastered to her punim) "Oh no, there will be no need."  .... Badadum!

I walk out the door wondering, and wonder still, did that REALLY just happen? WHAT just happened? Did my cardiologist just "break-up" with me? Was Brenda-PA a REAL person? I have had heart-wrenching (pun intended) relationship break-ups that made more sense. Talk about turning the classic break-up scenario on its head!

This time it was definitely "more about me" than it was about "them"! And where this relationship was going...well, let's just say I was not thrilled with the punch line!

Post Script:  In less than 5 minutes after posting the above, the hospice intake social worker called me on my personal cell phone. I repeat, with more vehemence...W-T-H???? "I would like to schedule a time for one of our hospice nurses to come out and do an intake. Would you like to set that up?"  No, I would not, but thank you very much! ~~Click~~

“The more you know . . .,"

******

“The more you know, the more you know you don't know and the more you know that you don't know.”     

― David Byrne, The New Sins

I did not know.
I thought I had a handle on what to expect.
How dumb. How very dumb.
I thought that the path I chose would save me from the foreseen.
How wrong. How absolutely wrong.
I thought that bullets could be dodged, if I opted to weave.
Sometimes an aim is too sure.
Sometimes fate has other things in mind.
You can never be sure. No sure thing.
Not today.

Today, I learned something I didn't know.
Knowledge can be dear.

Pericardial effusion is extra fluid around the heart.
 

Pericardial effusion is extra fluid inside the sac that surrounds the heart. The extra fluid causes pressure on the heart, which stops it from pumping blood normally. Lymph vessels may also be blocked, which often causes bacterial or viral infections. If fluid builds up quickly, a condition called cardiac tamponade may occur. In cardiac tamponade, the heart cannot pump enough blood to the rest of the body. This is life-threatening and must be treated right away.

Pericardial effusion may be caused by cancer or other conditions.

A pericardial effusion may be malignant (caused by cancer) or nonmalignant (caused by a condition that is not cancer). A malignant effusion is common in certain types of cancer. Lung cancer, BREAST CANCER, melanoma, lymphoma, and leukemia cause most malignant effusions. An effusion also may be caused by cancer treatment, such as radiation therapy or chemotherapy.

Possible signs of pericardial effusion include anxiety and dyspnea (shortness of breath).

At first, a pericardial effusion may not cause any symptoms. These and other symptoms may be caused by a pericardial effusion or by other conditions. Check with your doctor if you have any of the following problems:

• Dyspnea (shortness of breath).  √
• Cough. √
• Trouble breathing while lying flat. √
• Chest pain. √
• Fast heart beat or breathing.
• Feeling faint. Sometimes
• Swelling in the upper abdomen.
• Extreme tiredness or weakness. √
• Being anxious.

Pericardial effusion usually occurs in advanced cancer or in the last few weeks of life. During these times, it may be more important to relieve the symptoms than to diagnose the condition. However, in some cases, the following tests and procedures may be used to diagnose pericardial effusion:

• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.   √
• Echocardiography: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs of the chest. The echoes form a picture of the heart's position, motion of the walls, and internal parts such as the valves.
• Electrocardiogram (EKG or ECG): A line graph recording of the heart's electrical activity to check its rate and rhythm. A number of electrodes (small pads) are placed on the patient’s chest, arms, and legs. The electrodes are connected by wires to the EKG machine. Heart activity is then recorded on paper. Electrical activity that is faster or slower than normal may be a sign of heart problems.   √
• Pericardiocentesis: A procedure to remove fluid from the pericardium using a needle inserted through the chest wall. The doctor may use echocardiography to watch the movement of the heart and needle inside the chest. The fluid is viewed under a microscope by a pathologist to check for cancer cells or signs of infection. This procedure can also be used to treat pericardial effusion. Removing the fluid reduces pressure on the heart.

 

Domino Effect

******

Last night the pressure in my chest was disquieting. Not that I am complaining, screaming, groaning or kvetching!

It was followed up with heartburn. Who knew plain baked sweet-potatoes could cause such burn?

Then the dry cough starts. Irritating.

This triggers a broad ache through the upper chest wall that traverses the clavicle and tracheal areas.                   Every inch of me wants in the fun.

This then starts a deeper, but still dry, cough. Lung, anyone?

The "cherry" is, what can only be described, as a splintering pain in my chest wall.
                             Think, stomping onto a glass figurine with a lumberjack boot.

The cycle is topped off with stabbing pain up underneath my right rib cage. Because as the song goes...it is all connected.

Sigh....some days are indeed better than others. Today was not that day.

 

Cancer: Sometimes it's a Shell Game

******

I have been chasing the ellusive pea in a shell game, and I am growing cross-eyed!

Those who share my shoes blanche at the usual cancer tropes. My newest personal visualization is not original, but it sums up my fall season.  Monitoring my health has not been a game of medical skill, but of chance and opportunity. With all such slight-of-hands, if you stay focused you can get lucky and track the path of the disease. Take your eyes off the trajectory for a second and the forces will push the "pea" to unexpected destinations. The gamer, as always, is unscrupulous.

June 2011 - "Evolving lymphatic metastasis" / "hypermetabolic focus also seen in the anterior abdominal wall near the base of the umbilicus...soft tissue metastasis cannot be excluded"

...I then started on an aggressive regimen of supplements; bi-weekly high dose IV vitamin C; and weekly ozone infusion treatments...

November 2011 - "July 2011, core biopsy sampling of left axillary lymph node demonstrated metastatic invasive lobular cancer [but at this time] no suspicious abnormalities are identified...may represent positive response to treatment."

...I then tapper off aggressive regimen and opted to do a modified maintenance program of supplements only...veins can only take so much sticking.

August 2012 - Concurrent pneumonia and shingles. Both controlled with broad-based antibiotics.

September 2012 - Sharp intermittent chest pains and shortness of breath unresolved. PCP orders EKG and Chest CT, and refers to pulmonologist and cardiologist.

October  2012 - "Subpleural nodule in the left lower lobe" / "metabolic activity in left axillary"

November 2012 - "Shadow present on right lung...recheck in 2 months with follow up chest CT with contrast"

...Weight loss of 6 lbs over the course of a two plus weeks...Chest pains are now accompanied with nausea and heart burn. Falling asleep curled up in weeble position, propped up because laying on back increases pain. Laying on side makes rib cage feel like its splintering. Not much recuperative sleep happening. Sucks!

November 2012 - "Chronic pericarditis secondary to invasive lobular carcinoma...recheck in 2 months with follow up echocardiagram"

...Restart ozone infusion treatments. Start pounding "Meriva (aka Curcumin") like "skittles" (to challenge the inflammation).  Scheduling IV vitamin C treatments. The game plays on.

 

I am part of the 8%. Lucky me.

******

Original Article

Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence

Archie Bleyer, M.D., and H. Gilbert Welch, M.D., M.P.H.

N Engl J Med 2012; 367:1998-2005November 22, 2012DOI: 10.1056/NEJMoa1206809

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Background

To reduce mortality, screening must detect life-threatening disease at an earlier, more curable stage. Effective cancer-screening programs therefore both increase the incidence of cancer detected at an early stage and decrease the incidence of cancer presenting at a late stage.

Methods

We used Surveillance, Epidemiology, and End Results data to examine trends from 1976 through 2008 in the incidence of early-stage breast cancer (ductal carcinoma in situ and localized disease) and late-stage breast cancer (regional and distant disease) among women 40 years of age or older.

Results

The introduction of screening mammography in the United States has been associated with a doubling in the number of cases of early-stage breast cancer that are detected each year, from 112 to 234 cases per 100,000 women — an absolute increase of 122 cases per 100,000 women. Concomitantly, the rate at which women present with late-stage cancer has decreased by 8%, from 102 to 94 cases per 100,000 women — an absolute decrease of 8 cases per 100,000 women. With the assumption of a constant underlying disease burden, only 8 of the 122 additional early-stage cancers diagnosed were expected to progress to advanced disease. After excluding the transient excess incidence associated with hormone-replacement therapy and adjusting for trends in the incidence of breast cancer among women younger than 40 years of age, we estimated that breast cancer was overdiagnosed (i.e., tumors were detected on screening that would never have led to clinical symptoms) in 1.3 million U.S. women in the past 30 years. We estimated that in 2008, breast cancer was overdiagnosed in more than 70,000 women; this accounted for 31% of all breast cancers diagnosed.

Conclusions

Despite substantial increases in the number of cases of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with advanced cancer. Although it is not certain which women have been affected, the imbalance suggests that there is substantial overdiagnosis, accounting for nearly a third of all newly diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate of death from breast cancer.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
We thank Lynn Ries, M.S., of the Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, for her help in analyzing Surveillance, Epidemiology, and End Results data.

Source Information

From the Quality Department, St. Charles Health System, Central Oregon, and the Department of Radiation Medicine, Oregon Health and Science University, Portland (A.B.); the University of Texas Medical School at Houston, Houston (A.B.); and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH (H.G.W.).
Address reprint requests to Dr. Bleyer at 2500 NE Neff Rd., Bend, OR 97701, or at ableyer@gmail.com.