A glimpse past a wheelchair found my next patient sitting in the ENT office examination chair, bedroom slippers in place. The woman appeared to be in her early 70s, sagging jowls pulling her face into a sad expression, puffy eyelids, pale, markedly thinned white hair combed back simply, concave temples, hands resting quietly on the chair arms. Through the open neck of a markedly faded short-sleeved blue dress that buttoned down the front, radiation burns glared out from the left chest. The dress was full on the right, flat on the left, one breast obviously missing.
She looked tired. "Was she tired of waiting for the doctor?" I thought defensively. Two serious-faced, middle-aged women sat with her, her daughters, I presumed.
Her chief complaint was "imbalance." A bit uneasy, I smiled, introduced myself, shook hands, and sat down. The elderly woman's face seemed tired as she described progressively worsening balance and loss of hearing in the left ear over the previous five months, leaving behind only annoyingly intrusive ear ringing.
As she spoke about all the other doctor visits, the internist, the oncologist, the neurologist, the ENT doctor, the CAT scan, the MRI, the EEGs, the hearing tests, the left side of her face moved almost imperceptibly less well than the right. "They said that the imbalance might be from a slight stroke," she scowled. Again, careful observation confirmed that the left facial weakness was unmistakable, though subtle.
Her insistent voice and animated face contemptibly and forcefully rejected the notion that the imbalance was from a stroke. No one in her family had had strokes before. The balance had gotten slowly worse, had not started suddenly and then improved. The hearing in her left ear had grown slowly worse, not suddenly worse. The ringing had slowly become loud and intrusive.
"It happened too gradually," I heard her say.
"Smart lady," I thought. "Does she know?"
Glancing down, I read the balance assessment notes: She was unable to stand or walk without assistance. More complex tests of balance were deferred as unsafe. On examination, her voice was clear, speech distinct, and her only other significant physical findings beyond the obviously absent left breast were the deafness in the left ear and the subtle left facial weakness.
The sticker on her chart indicated that her MRI films were ready for review. I invited the daughters into the hall to view the films, suggesting to the woman that I wouldn't trouble her to come along since the effort to walk was difficult. She didn't object, and I really only wanted to talk to the daughters at that point. About 4 months old, the MRI images were grainy, with unclear images of her brain and skull base. They showed no definite pathology, but with the clinical information, I thought perhaps a subtle soft tumor filled the left internal ear canal. That was the only spot that her clinical findings pointed to, meaning that the problem had to be there.
Turning to the daughters, I reviewed the salient findings, the only way that they could be connected, and then asked if they understood that this was quite likely metastatic breast cancer that had spread to the brain cavity and the internal ear canal. Both pairs of eyes opened widely for a moment but gave no guidance.
"I will need another MRI, but I do need to address the cancer issue. What should I tell her?" I asked.
"Tell her what she needs to know," one said.
As we returned to the room, the trepidation on my face probably spoke as loudly as the daughters' grim faces. The woman's experienced eyes watched, squinting, fixed on my face, but she sat without other expression.
Eye to eye, watching her carefully, I struggled to inform her that, although perhaps a virus or Lyme disease could cause this picture, this could also be a recurrence of the breast cancer. At that point she glanced briefly at her daughters and turned her head back for more. I continued, "We need another MRI to try to sort this out, and I would like to get it done today if possible." Though it was already well into the lunch hour, the arrangements were made. The MRI completed, she was back in the office by midafternoon.
As she wheeled into the room, she seemed more chipper, more animated, more energetic, dipping her hand into a bag of red licorice. One daughter handed me the MRI films. I smiled and joked while gesturing to the licorice, "Where's mine?" She laughed and kidded right back, a mischievous smile on her face, "Because you sent me for that MRI, I didn't get any lunch and I had to have something." Grinning back outwardly while burdened internally, I excused myself and invited the daughters to review the films with me. The elderly lady scooted her wheelchair over to the sink, reaching for a paper towel.
The MRI films were worse than I had expected: Not only did a tumor fill the left internal ear canal, but two other areas suggested widespread brain metastases. Breast cancer was back on a menacingly inexorable march. After pointing out the abnormalities to the daughters, I asked again how to address their mother.
"Tell her what she needs to know."
Shaken by the severity of the problem, I re-entered the room and sat, my right knee next to her right knee. Her bag of licorice lay open on her lap. She swallowed a mouthful, as if a lump in the throat. I began to speak, my hand on her arm.
"This does confirm that the tumor is back," I intoned, watching a more serious face and waiting for her response.
Same expression, same squinted but attentive eyes, not a flinch or a twitch, not a whimper or a tear.
"I do think this can be partially treated, but the hearing and balance function will not likely return."
Arm still; her stoic face did not change.
"Treatment would likely involve chemotherapy and radiotherapy."
At this, she turned almost reflexively to her daughters and frowned. Then one daughter interpreted the unspoken, "She won't likely go for that again."
Now more worn-looking, she seemed in agreement, apparently remembering unrepeatable discomfort.
After what seemed an eternity, I offered to call the oncologist for them. He agreed to see her in two days, and I encouraged them to follow up with him. Finally, one daughter asked the question I most wanted to avoid, "How long does she have?"
The elderly woman leaned forward intently, her gaze piercing my face. With a big deep breath and a most uncomfortable sigh, I equivocated, "I can only guess, but perhaps a few weeks to months, not long, but, then again, it could be quite a while."
Now, a bit more relaxed, the brave lady looked at her daughters, tension easing from her shoulders.
With that, I had nothing more to say and felt drained, and without closure. This was not the kind of news I wanted to bear. Awkwardly, I said, "Well, if there is anything else I can do, please do let me know." I stood up and handed them the chart, indicating that it should go to the front desk. Then one of the daughters exclaimed, "Thank you for sorting this out for her." With that, the elderly lady smiled from ear to ear with the largest grin, reached up with a paper towel full of licorice, and invited, "Doc, here, have some. I know you missed your lunch too." I watched as they approached the desk, no tears, no heaviness in their steps, but my heart was weighed down.
About two weeks later, a phone call informed us that the lady had passed away. Sitting pensively at my desk with the phone message, my eyes misted as I sorted through the images and impressions, back to a courageous woman who knew but desperately wanted officially to know that her illness was terminal.
From her friends, I later learned that this lady had always been a gracious hostess who loved having friends over for desserts and fellowship. Literally, from the day of her last office visit until the day before she passed on, a steady stream of folks came to share her favorite brownies and wish her well. Her faith was strong and outgoing. Although she was weak, she thoroughly enjoyed those last two weeks. Finally freed by knowing, this gracious lady was at liberty to invite family and friends to share her last journey. Knowing had allowed her to slip away in peace, embraced by those she loved.
- Loren J. Bartels, M.D., is a specialist focusing on hearing and balance disorders.