The Radiation Question

Maybe it's me, but meeting with doctors to get one's questions answered can be tricky. The information is complex, and sometimes physicians just don't understand what you really want to know. Should they dumb it down for you, or do you have enough background to make sense of the textbook answer.

The problem is two-fold. One, when we talk to our doctors, we're usually not displaying our best selves. The format of doctors' appointments, and the anxiety that accompanies them, prevent us from being on top of our game. As a result, doctors may not get a true sense of who we are, at least not initially. Two, doctors have a history of being a little superior. While the profession has worked to reduce the egotism and improve patient communication, evidence of doctors' loftiness is still apparent.

Consider the wardrobe problem. While having serious conversations with physicians, I'm often wearing an ugly hospital gown that is exposing my bare back. Not my best look. The doctor, however, is usually dressed professionally and sporting a bright white lab coat with his or her name embroidered on it. As patients, our forefathers must have been really ill to let this imbalance get established. Would you go to any other meeting only half-dressed and wearing a hideous shade of green or an unflattering hue of blue? I didn't think so.

Second, the doctor's name on the lab coat is always followed by the capital letters M.D. Since it's a pre-requisite for physicianship, I just assume that they graduated from medical school. Why do they need to wear their credentials on their coats? Others with advanced degrees don't wave them around so openly. I fully accept that doctors are better at science than I am. That's why they make the big bucks.

Given the considerable differences between us, maybe patients and doctors should spend a little time getting to know each other at the outset in order to establish a style of communication. I recently found myself talking to the radiation oncologist again, as I tried to get a treatment question answered. After a minute or so of conversation, my background as an investigator emerged and took over the questioning, because I just couldn't get the answer I wanted -- mostly because the doctor and I needed to get on the same page.

My question was this: Why does a patient still require radiation if she has already undergone surgery and chemotherapy and achieved clean margins? Here's how the conversation went:

Setting: Little exam room. Doctor has just completed a brief physical exam. I'm sitting on an examination table wearing faded blue, oversized hospital garb that keeps coming untied. Doctor is sitting straight and tall on a stool wearing a pressed dress shirt, tie, and a very clean white coat.

Doctor: Everything looks good. Do you have any questions about radiation?

Me: I do have a lingering question. I've had surgery, chemotherapy and a re-excision. Tell me why I need radiation, too?

Doctor: In the old days, every woman with breast cancer was given a radical mastectomy. This was very disfiguring, so doctors moved away from this practice. Now we try to remove just the diseased tissue and then treat the breast with radiation. Because you didn't have a mastectomy, you need radiation. It's the standard of care.

Me: I understand that it's the standard of care. But why?

(Doctor's cell phone rings. He fishes for the phone in his pocket. Doctor looks at caller ID, answers the phone, and says "I'll be right there." He turns his attention back to me.)

Doctor: We find that radiation reduces recurrences that occur at the site of the original cancer. Women who have had surgery and radiation do much better in the long-term than those who only had surgery.

Me: But if women have had chemo, why do they still need to be radiated. Why isn't chemo enough to kill any remaining cancer cells in the breast?

Doctor: Chemo is more effective at reducing metastasis in other parts of the body. Radiation kills the dividing cells in the breast.

Me: But why? Doesn't chemo work the same way as radiation-- by killing dividing cells.

Doctor: That's correct. Chemo and radiation work on the same principle. They both destroy dividing cells, but they attack them differently.

(Doctor's cell phone rings again. He answers it, saying with slight impatience, "I'll be right there." He again turns his attention back to me.)

Me: You need to go. I'm keeping you too long.

Doctor: No, they can wait. Do you understand what I'm saying?

Me: I understand the words that you're saying, and I know that radiation is the standard of care. But I'm still not clear on why chemo doesn't do the job. Why do we have to bring in the radioactive substances if I've already had four rounds of chemo?

Doctor (looking like he is out on a limb): Because surgery has changed the vascular structure of the breast, so chemo may not reach the cancer cells there.

Me (cartoon-type light bulb over my head illuminating): Oh!!! It's a highway construction problem. Maybe the chemo drugs can't get to the cancer cells in the breast because surgery has realigned some of the veins. Essentially, the roads may be bad.

Doctor: Yes. Also, there are lots of cancer cells at the actual disease site, so surgery may not remove them all and chemo may not kill them all off. Radiation provides extra protection and helps to prevent recurrence.

Me (appreciatively): Thank you. Now I get it.

Doctor (looking relieved): You're asking the types of questions that medical researchers ask. Scientists want to know why one treatment works better than another treatment or a combination of treatments. I'm going to download some information for you from the Internet.

Me: That would be great. Thank you.

To his credit, this doctor did not leave the room until I was satisfied with his answer. He could have used his ringing cell phone as an excuse to exit, but he didn't. And for that, I was grateful.