1. Harpham, Wendy S. MD, FACP

Article Content

The care of patients with metastatic breast cancer tests your skills in the art of medicine. You're expected to show compassion while expertly addressing complex medical issues. Since compassion begins with understanding what someone else is going through, I recommend you read In-Between Days, a memoir for patients. Illustrated short essays offer clinicians a fresh view of life with metastatic cancer that can open opportunities for healing words.

metastatic cancer; T... - Click to enlarge in new windowmetastatic cancer; Teva Harrison. metastatic cancer; Teva Harrison
Wendy S. Harpham, MD... - Click to enlarge in new windowWendy S. Harpham, MD, FACP. WENDY S. HARPHAM, MD, FACP, is an internist, cancer survivor, and author. Her books include

Author Teva Harrison was a 37-year-old graphic artist, recreational runner, and big-time director of marketing when diagnosed with breast cancer. The opening essay condenses into two pages the months-long saga between developing her first worrisome twinge and settling in to life with metastatic cancer. "I learned that my cancer was already stage IV-incurable-and that I would never be on the other side of it...."


The brevity of her medical history attests to this memoir being less about Teva than about shining light on "the hard stuff"-common issues often silenced by fears, awkwardness, or the inadequacy of words. She succeeds brilliantly, thanks to the combination of short essays and black-and-white art, mostly comics, but some clip-arty images. Page after page, as I read her eloquent prose that gave voice to so many familiar thoughts and feelings, I whispered, "Teva, you nailed it."


Even if you read only two-any two-of the 60-plus pieces, it will be worth your time and attention. To show you why, let's look at her 16-line essay, "On a Platter," in which she reflects on appropriate interventions that force patients into absurd positions, literally, if not figuratively. Teva describes her first radiation therapy session, where she's strapped into a personalized mold. After explaining why immobilization is serious business, Teva writes, "The process was so strange and new to me, I couldn't stop laughing." She asked the tech to grab her cell phone and take a picture, so her husband could see her "wrapped up like a tray of sushi."


The amusing vignette is a nice reminder to clinicians that routine procedures are not routine for patients, and that their jokes can go a long way in relieving tension. Teva's sushi story also reminds clinicians of something else. Nervous laughter, which the Association for Psychological Science describes as, "incongruous emotional displays like chuckling uncontrollably at a funeral....," modulates otherwise overwhelming emotions. Patients' uncontrolled laughter, whether triggered by their own calculated joke or arising spontaneously, may signal distress.


Hours after being diagnosed with my first recurrence, at the end of a serious conversation with a consultant, I cracked a joke-a terrible joke I thought was hysterical. The physician fake-smiled and then kept talking. I thought I detected a fleeting look of worry that I didn't grasp the seriousness of what was going on (or that I was losing it). Self-conscious, I justified my joking with the claim that silliness helped me regain a sense of control, even if at the price of looking silly.


Teva's sushi reference may have had to do with control, too. At the risk of projecting how I felt when tethered by a mask to a radiation table, Teva's sense of loss of control of her life may have been exacerbated by the physical sensations of immobilization. As for her uncontrolled laughter, I read it as a sign of distress. She couldn't escape the physical or psychic pain caused by her cancer. Along with the absurdity of feeling like a sushi tray was the absurdity of cancer taking away the career she loved and the future she'd imagined, one she'd planned on filling with children and growing old with her beloved husband.


"On a Platter" highlights how people whose private world has fallen apart have a different view of the high-tech miracles of modern medicine that empower us. Teva explains, "Everything about treatment would be so fascinating if it just weren't happening to me. It's as if I just wandered away from my life...into a surrealist dream sequence."


The sushi story opened my eyes to new opportunities for helping patients. If patients crack jokes, you can take their lead and applaud their humor, validating its healing power in stressful circumstances. To help patients awaiting their first radiation therapy, you can...


* Prepare them for emotions that might arise. ("At the first session, the machines can feel intimidating and the experience surreal.")


* Link the discomforts with the benefits. ("Holding still increases the safety and effectiveness of your treatment.")


* Reframe the control issue. ("Immobilization gives you control by keeping you in perfect position.")


* Encourage them to look for something humorous to help offset unpleasant thoughts. ("One patient gave everyone a laugh when she said she felt like a sushi tray.")


* Set the stage for hope. ("Optimizing your treatment gives you reason to hope for the best.")



In addition to Teva's attention to nervous laughter, she shines light on the impact of symptoms, from vomiting to vaginismus; the challenges of pain management; the many faces of anxiety; the threat to self-image; as well as the existential issues of life, death, and love. This book answers the cry of patients with metastatic cancer who feel abandoned by a culture of cure. In-Between Days is literary manna, satisfying their hunger for understanding and companionship.


Compassion begins with understanding what your patients with metastatic cancer are experiencing. The greater your understanding, the easier it is to figure out what they need. Teva speaks for many patients-including me-when she says, "it's the unspoken that is most frightening." I urge you to recommend In-Between Days to your patients and read it yourself, savoring one essay at a time. Then you can hope tomorrow brings better treatments while you help your patient today through healing conversations about the hard stuff.