said the caption on my patient’s hot pink socks, the words coming from the mouth of a little purple cat holding up its middle finger in defiance. My patient—let’s call her Kenzie--was in the therapy gym, electrical stimulation pads strategically placed on her lower leg muscles, sending currents to the nerves in sync with the movement of the automated biking machine. All in hopes her legs would recover some motor function and strength, which was taken away by the tumor in her brain. She told me that her best friend had bought these socks for her in an effort to make light of a dismal diagnosis. As soon as I saw the image, I started chuckling, which quickly led to tears, briefly of joy, then of quiet grief, knowing the disheartening long-term prognosis for the metastatic cancer in her brain. I had to look down to hide my moist eyes and face.
As her rehabilitation physician, I continued daily to offer words of hope and encouragement. Yes, she had brain surgery to remove the tumor, yet the cancer had already spread to other organs in her body. Yes, she had already had good recovery of the strength in her arm and leg, which were initially paralyzed. Soon she was going to start brain radiation and chemotherapy to improve her chances of survival, but she and I both knew the cancer would eventually win, it was just a matter of time. When I asked her if she had thought much about her future, she tearfully told me that she was unsure she would be alive in six months to see her children. She was quite aware of the deadly elephant in the room.
It was a bonanza week for brain cancer. I usually take care of patients who have had strokes, but this was a week in which I had three patients with different types of cancer in their brains. Two patients had metastatic cancer; one, breast; the other, melanoma. These renegade cells had morphed into invisible mobile cells that evaded the body’s immune system, traveled via the blood stream to other organs, and set up camp where they didn’t belong. One patient--let’s call her Sarah-- had survived breast cancer many years prior with a double mastectomy, chemotherapy, and radiation, only to have it return and invade her brain, bones, and liver. She had a tube surgically placed in her brain in order to remove pressure and allow brain fluid to empty into her abdominal cavity, in the hopes of preventing catastrophic swelling. She also had radiation to the metastatic tumors in her brain in an effort to slow down the growth of the cancer cells. Unlike my first patient, her tumors unfortunately were not in a location amenable to surgical resection.
Several days after her admission I met Sarah outside where she was sitting in the sunshine in her wheelchair, doing some easy leg exercises with her physical therapist guiding her. She didn’t have much energy or endurance to do much else. I asked her if she knew why she was in the rehabilitation hospital. She told me that she had surgery on her head, something put in there to help the “water on my brain.” Yes, I told her, you had a shunt placed to help relieve pressure. But she couldn’t answer why she had brain swelling in the first place. I told her that she had cancer in her brain, metastatic breast cancer. She looked incredulous. “You mean I have cancer in my brain?” Yes. “You mean that I’m dying?” Well…eventually yes, you will die from this cancer. “But I feel fine!” Yes, you are doing quite well right now. “Damn breast cancer” were her last words to me that day. She was transferred to a skilled nursing facility the following week and just yesterday I heard that she had died not long after I discharged her.
Many of these patients with cancer come to our rehabilitation unit without a definitive prognosis for survival, often because their diagnosis is new. Many have not yet started additional treatment as they have had brain surgery to eliminate tumor burden and first need to recover and get stronger for future chemotherapy and/or radiation treatments. I am not the right doctor to tell someone what the prognosis is for his/her cancer as I am not an oncologist. I have not studied the intricacies of each type of cancer, what treatments are available or effective, or the average length of life a patient can expect depending on how advanced the cancer is (because that is what the patient really wants to know – “Doc, how long do I have?). But I can at least guide the patient and family about what to expect in terms of recovery from brain surgery and possible side effects from the future treatments. The hardest part of providing rehabilitation for these cancer patients is that while they are recovering from whatever neurological deficits their cancer initially caused them, those relentless cancer cells continue to divide; so, the disease continues to progress. That means anything can happen, and progress is not always linear.
My third patient of the week—let’s call him David-- had a primary brain tumor, not a metastatic cancer that came from a cell type from a different part of the body. He had glioblastoma multiforme, a stage 4 (advanced) brain-cell cancer with a variable length of survival if patients are candidates for the standard treatments of radiation and chemotherapy. David had cognitive deficits due to the location of his tumors, including short-term memory impairments, difficulty paying attention as well as problem solving issues. Prior to rehab, he had surgery to remove some of the largest tumor, in order to decrease swelling and get a sample to confirm the pathological diagnosis. When I talked to David and his family about his disease, they were all in shock and denial, an appropriate response to a new diagnosis of advanced brain cancer. His family kept telling stories of how functional he was, how he had no symptoms until they noted his balance was slightly off, then his memory slightly diminished. They were not expecting the brain scan to show multiple tumors on both sides of his brain. Again, it was not my job to tell the patient and his family his poor prognosis, because I could not accurately tell them how many months he may have left. He was going to see the oncologist after leaving the rehab unit, to discuss starting treatment. My job was to improve his function, his general strength, balance, and cognition so that he could begin chemotherapy and radiation in the best shape possible. He unfortunately had a setback when his steroids, strong immunosuppressants that help with brain swelling, were decreased, which delayed his discharge. As the surgeon was not able to remove all the tumors, the cancer cells continued to divide and cause increased pressure in the brain. When he finally was discharged home after an extra week of therapy and an increase in steroids, I wondered how many months he would be lucky to get.
It’s challenging to take care of these patients because of the reality lurking in the background. The unspoken questions of whether the patient would still be alive the following months or years is always in the back of my mind. What I do know is that rehabilitation is giving the patient the best chance to improve the quality of any life they have left.
And yes, I agree with the purple cat. F*** cancer.