Good News; Bad News

Thoughts from an Unremarkable Patient

“Other than my brain cancer, I’m in really good health!”

My dad joke sensibilities find me repeating this line often. If you know me in real life, I’m sure you’ve heard me say this, followed by a twisted smile and a wink. Whitney, without a doubt, is the far funnier partner in this arrangement, but together our humor buoys us through occasional rough waters.¹

“You’re my favorite patient of the day.”

“Eh. It’s only 11:30am, there’s plenty of time for another one.”

This is what I replied to the clinician who administered my echocardiogram.

“Ooh, I love your tattoo!” she exclaimed when placing the IV. It’s an anatomical heart on my left forearm that balances the brain on the right. I held up my right arm, “head and heart.”

“This is cardiology, I’m partial to the heart.”

“Well, I’ve got brain cancer, so I think my care team is partial to this one.”

“I saw on your chart, when were you diagnosed?”

“2016.”

“Wow!”

It’s the usual reaction.

“I know, right? I just keep living. It’s sort of weird that I’m not dead yet.”

“Hush! Don't say that!” she snapped with a gentle smile.

“It’s fine, listen, seven plus years with brain cancer, pretty cynical to begin with, and my spouse is in healthcare, she works here, in fact, it’s a lot of dark humor with us.”

“Well, you’re right, lots of us in healthcare have some of the darkest humor. You should hear what me and my colleagues talk about”

“You’ll have to tell me about it next time.”

“Sorry to make you wait a few minutes for me to get over here,” the phlebotomist said who drew the blood for labs up on three by the green elevators after the cardiology exam.

“You’ve got to keep those productivity scores up!” I chuckle.

“Blood work’s gonna be super quick, I asked them to keep the IV in for labs after the echo,” I texted Whitney.

Tell me you’re a cancer patient without telling me you’re a cancer patient.

This quite obvious fact has irritated me all week: I am a cancer patient! Not because of the cancer part, but all the other hoop-jumping that I’ve been doing. If you’re new here, a routine MRI scan in November revealed a new tumor growing near my surgical cavity where the bulk of a primary brain tumor was removed in 2016; a really aggressive cancerous tumor. The tumor board, a convening of multi-disciplinary specialists that review patients (“cases”) to determine a recommended course of treatment has been of split opinion on what exactly to do about this new mass. A couple of tumor types have been suggested, someone said surgery, another said gamma knife, a few opinions suggested a watch and wait approach, and maybe my favorite response, during a neurosurgical consultation, one doc made it plain, “Hey, if you want me to go in there and get it out, I can definitely do it, just let me know.”

I’ve had conversations with plumbers with more hand wringing than that!

Someone at the tumor board wondered, “Maybe those two new spots [in addition to the one tumor that is definitely growing] are from a small stroke.”

“Well, I have a high grade glioma, couldn’t those new areas of contrast enhancement simply be malignant cells that are migrating through the white matter tracts in the brain and are now growing in this other spot?”

“That’s certainly a possibility,” my oncologist replied, “I really think we should rule out stroke.” My mind begins playing for a theater audience of one, “Were you listening to the dude’s story?” (foul language warning).

“If you had a small stroke…”

The stroke is not the issue here, dude.

“I think we should rule out stroke, and if you did have a small stroke … well, you’re at risk for a large stroke immediately following the smaller stroke. You should start taking aspirin, like now, today, and every day, until we know whether this was a stroke.”

If you read “Radiology After Hours,” then you know that I had a CT angiogram and venogram. Also, an echo, described in this post, and a lipid panel.

Turns out, friends, that if it weren’t for my brain cancer, I’m in really good health! The diagnostic results tell a good news, bad news story. Which do you want first? The good news is that I’m in surprisingly good health! As it goes with veins and arteries, no occlusion nor obstruction; with the heart, all appears pretty normal, save for a few mild abnormalities that seem not to concern the echocardiographer, and the lipid panel? Cholesterol, triglycerides, and whatever else, all within optimal ranges or very close to it. I’m the (radiographic) picture of health! And it is this good news that reinforces the bad: Having ruled out other possibilities on the differential, that brings us back to the tumor; and the new spots.

Cancer survivorship is full of good news, bad news stories. You have cancer, but you’re otherwise healthy; you have an aggressive high grade brain tumor, but you harbor a key mutation that responds well to therapy; you have some weird stuff in your brain, but you didn't have a stroke. I should say that I’m (rather too?) confidently ruling out stroke on my own, having read all the reports following the tests. I have not yet had an official follow up visit with my doc. I guess what I should say, with more epistemic humility, is that all the tests ordered to evaluate for stroke returned normal and/or unremarkable findings.

Navigating good news, bad news is not to passively receive whatever life has in store. I suggested in a post not too long ago that sometimes the only thing to be done with suffering is to bear witness to it, and the secret when facing suffering is, “To examine our attitudes and imagine their opposite.” I think we can apply the rule here, too.

I am in a celebratory mood. Truly. No bullshit. I am deeply grateful to read that from the veins in my brain, to the beating muscle in my chest, and the blood it is pumping, my physiology is physiologizing in unremarkable ways.

Yes, good news bad news, the bad news is that by ruling out one problem, the other problem becomes more likely. The hypothetical migrating malignant cells may be the case, and with the tumor growth confirmed on a scan a few weeks ago, recurrence of glioma presents us with a troubling path ahead. Slow down, we don’t have enough information to say much with confidence, and over the next few weeks we’ll have another MRI and a PET scan to gather more data. More data are always good.

So yes, I am in a celebratory mood, because, I think we could all agree, that not having a stroke is objectively good, regardless of the cancer, so why not slap a smile on my face and say let’s go get more data! And that’s what we’ll do. Good news, bad news is not what is happening to us, but what is happening, period, and the sense we make of it is either good or bad. That sense-making of things on our own is an exercise in agency, and agency helps us to feel a little more in control.

The good news can be bad news, the bad news may be good. It’s all about the sense we choose to make of things, and I’m doing my best with the agency I have to make the unremarkable the favorite patient of the day.

1. Apologies for that tortured metaphor