Ms. S. is a 39-year-old, single Caucasian female with no significant past psychiatric history and a past medical history of stage IIIC grade 3 serous ovarian cancer status-post debulking surgery and chemotherapy who presents for evaluation of low mood and anxiety. Ms. S.’s symptoms are in the context of her cancer diagnosis, resultant medical sequelae, and the high likelihood of recurrence within the next 2 years. Ms. S. notes that she has been having difficulty in learning how to live her life as before and in this current state of uncertainty. She notes that she has been having panic attacks, which she describes as periods of “intense fear something bad will happen to her” with concurrent palpitations that last for 15 minutes and are followed by bouts of severe sadness. She feels her panic attacks come on mostly at night when she is alone at home and not distracted by work or chores. She also has been having difficulty falling asleep and continues to feel lethargic since completing chemotherapy. Ms. S. notes that her family is supportive, but she does not want to overburden them with her emotions and fears during this time.
Ms. S. describes how much of a shock her diagnosis of ovarian cancer was, as she had only gone to the emergency department for abdominal pain. During a computerized tomography scan of her abdomen, two pelvic masses were discovered. After having the masses surgically removed by a gynecologic oncologist, she was diagnosed with ovarian cancer and began 18 weeks of chemotherapy. She developed a bowel obstruction due to some of the side effects of her chemotherapy, coupled with adhesions from her earlier surgery. Ms. S. subsequently had to have further abdominal surgeries and spent 5 weeks in the hospital. This was a very demoralizing time for Ms. S. She is currently in the surveillance stage after completing chemotherapy and is adjusting to life back at home. She continues to work as a sign language interpreter and has some sympathetic friends in the area.
Ms. S.’s mother and aunt both had different types of breast cancer, and Ms. S. is thinking about getting genetic testing soon as well. This makes Ms. S. feel very anxious, as she has two other sisters. Ms. S. has no family history of psychiatric disorders, other than alcohol use disorder, which was severe in her deceased father. Ms. S. had been sparring at a local gym and competing in amateur boxing matches when she was diagnosed and greatly misses this activity, as she is currently too weak and anxious about being hit in her abdomen (especially after her numerous surgeries) to participate. She continues to feel as though she cannot enjoy things or look forward to anything and also feels slow and low in energy. Her appetite remains minimal at best, but she feels this is mostly due to her fears of eating foods that may precipitate another bowel obstruction.
A Resident’s Perspective
“There’s an 80% chance my cancer will recur in 2 years; how am I supposed to live ‘in the now?’”
My patient asked this poignant question at her first session in my cancer survivorship clinic. This question was one I did not feel prepared for or qualified to answer, but it was one I would most certainly ask myself if I were in the same situation.
It was easy to relate to S., a 39-year-old in the surveillance stage of stage III ovarian cancer. She was funny, sweet, tough, and understandably scared. She had been referred by her primary care physician after having undergone complete resection of all gross cancer, a second surgery due to a bowel obstruction, and numerous cycles of chemotherapy. She came into my office tearful, angry, weak, and sad. She had not been sleeping, she was losing her “chemo buddy” to ovarian cancer, and she was worried about her dog’s health. She missed kick-boxing, she hated people’s insensitive comments about her lack of hair, and she wondered about dating in the future. Overall, she showed me that the medical system that treats cancer patients often misses addressing basic emotional needs, not only because of the lack of available services, but also due to the lack of knowledge about services needed. S. had access to a psychiatrist, but what was I supposed to do? How I was I supposed to help alleviate her suffering?
The literature was scarce. There was evidence for the use of supportive, cognitive-behavioral and existential therapies, but they did not necessarily help me address her immediate challenges. My psychodynamic supervision helped me deal with my countertransference in regard to her being relatable and likeable. But I still felt inept; I could not discern why her case was so difficult for me to address. And then, it struck me. All this time I was trying to find pathology in S., something I could treat. However, what distressed S. was not pathological; it was actually a very normal response to a very unfortunate event. I realized my issue was that I had been restrained by a system tailored to “pathologize” and to “symptomatize.” Such a system simply missed the big picture with patients like S.
And so, S. helped me see the current limitations of our medical system and to look for ways to tailor my practice with her in mind. I realized that along with her team of specialists, I had a very important role to play, one which may not yet be well articulated. In trying to actualize my role, I tried to see what tools I had to use. From the get-go, the two things I had to my advantage was a relative mastery of psychopharmacology and the ability to be a “present” therapist. I began by using these in my work with S.
S. had been trialed on sertraline in the recent past for treatment of hot flashes. However, she could not tolerate the side effects (which were mostly gastrointenstinal) and was wary of being trialed on any further psychotropic agents. By taking a thorough history and discovering that she had been started on moderate-sized doses and titrated quickly, I explained that we could go much slower and at lower dosages to help decrease the probabilities of having similar side effects again. I also reviewed in detail what the possible side effects could be day by day and week by week, so that she would be aware of what could and could not be due to the medication. This reduced some of her concerns, and she was willing to re-try the same medication for her anxiety and mild depressive symptoms. S. came back to my office after the titration, stating “Day 3 of the nausea was terrible, but you were right—that was the worst day and then it started to get better.” She said she would not have otherwise continued the medication had she not known about the timeline of the sequelae, which she had not been aware of before.
Similarly, S. had difficulty sharing her feelings and worries with family members and loved ones due to a fear of burdening them. She recognized it was her own perception, but she nonetheless felt she “had to put on a happy face” for others or would “only continue to hurt them.” By providing a stoic and tolerant presence for S. where she could feel comfortable and not fearful of inflicting harm on others, she was able to explore her emotions in a meaningful way. She often times mentioned that she specifically looked forward to our sessions and would “save up things to say in here” because she believed there was no one else she could be open with in the same way. It was reassuring to her that I viewed her as a person and not as a particular disease or a sick individual. Even though this principle was something I had been taught before, I never truly understood it until working with S.
I know these examples may seem in-significant, but the insight I gained from them in conceptualizing cancer patients and their needs was tremendous. Additionally, I learned my value in their care and where I could cultivate my niche when working in partnership with other providers. In S.’s case, I was able to assist her in dealing with her distress and plan for her immediate future. I was also able to correspond with her many specialists and attend some of their outpatient clinics. It was a truly joyous experience to work within a team with this demographic known to conjure up many emotions for both providers and patients alike. Finding my place in this arena and discovering my strong suits helped me gain confidence and deliver tailored care to complicated patients. As I prepare to complete residency, and eventual termination of care with S., I leave knowing I made a difference and provided something intangible for her during very trying times.