Column Olijfblad #4 2016

“There she was. In the middle of life, between her mother and her boyfriend. Her mother sweet and caring, her boyfriend big, tough and caring.

She laughed a lot and sincerely, but not with abandon. What a joy it would be to see her smile with devotion. But that didn’t work. After a short laugh or after speaking 3 sentences full of conviction, she had to catch her breath. Catching her breath because that terrible lymph node cancer literally took her breath away. Fortunately, there was a treatment plan and it had every chance of success. Every chance of recovery. But the treatment would also undoubtedly result in damage to the ovaries and perhaps infertility. And that’s why she sat in front of me: whether I wanted to freeze an ovary so that her 3-year-old daughter could still have a brother or sister in due course.

There she sat. Handled setback after setback with her sons. Referred from another hospital in good spirits to remove her cancer through keyhole surgery. But first it turned out that our radiologist did see abnormalities on the CT scan that could be metastases. And then it turned out during the operation that there were indeed metastases. But the biggest setback was that the cancer, contrary to what was thought after the biopsy, was much more aggressive than hoped. And much less sensitive to chemotherapy. And that’s why she sat in front of me: if I wanted to tell her about the opportunities, risks and possibilities of chemotherapy.

There she sat. With her partner and children. Not so long ago had very successful surgery for cancer. In the meantime, however, increasingly dependent for daily care and, especially because of her great overweight, completely dependent on her wheelchair. She had no complaints. But a scan had seen abnormalities that were thought to be the cancer back, and perhaps a 2nd type of cancer. And that’s why she sat in front of me: whether I wanted to try keyhole surgery to find out what was going on, whether the cancer had really come back.

It was 3 long conversations in which we listed everything step by step. Nothing was concealed, everything was said. Also the black edges, also the annoying consequences and also the bad scenarios. Don’t worry: the optimistic side also received time and attention. But the dilemmas were put into sharp focus, substantiated by the limited numbers. But we mainly looked at the value for the patient: what would the fulfillment of the request add to value, what would the patient benefit from and how relevant would that be in the context of that value? And what would be the consequences of the somewhat less optimistic, but very likely, scenarios on that value? Weigh, weigh, add, subtract and line up again. Looking for additional arguments. Hesitating and silently contemplating everything.

There she went, in her wheelchair. Determined not to have surgery. The risk of abdominal surgery and a stoma was so great that the consequences would be incalculable: worthless!

There she went, supported by the children. Determined not to do chemotherapy. The chance of side effects compared to the chance of effect was the deciding factor: worthless!

There she went, quickly back to her daughter. Determined not to freeze an ovary. Of course she didn’t want to take any chances that freezing would delay the treatment of the tumor in her lungs: worthless!

Instead of doing what is possible in the default, doing what the guideline prescribes, doing to do, we went looking for the value for the patient. What would the treatment add to value? What would the treatment detract from the value? Looking for the true value together: very valuable!”