We first met about two years ago when she came to see me in my clinic as a new patient. I glanced through her chart and reviewed her scans and pathology reports. She had one of the worst possible kinds of lung cancers, called small cell lung cancer, that had spread to both of her lungs. Her disease was incurable, but I could give her chemotherapy to improve her symptoms and to hopefully buy her a few more months of life.

I walked into the room and found a pleasant and poised 68-year-old woman sitting nervously with an admixture of fear and hope in her eyes. She was a beautiful woman who was nicely dressed, and there was an air of elegance and calm about her that reminded me of my mother. I instantaneously had a feeling of affection towards her. We spoke for about an hour, and I explained everything to her in simple language, avoiding medical jargon trying to give her the right balance of hope and realistic expectations. She listened intently and asked the usual questions to which my answers were well-rehearsed.

She then asked the ultimate question, “How long do I have doctor?” I replied, “Most people in your situation will have another year or two to live.” She kept a straight face and blinked her eyes carefully to suppress the tears. She reached for the tissue that I offered her trying to stifle the tremors of her hands but kept her composure. “It is what it is!” She responded and headed to the check-out desk to make her chemotherapy appointments. I moved on to my next patient.

She tolerated chemotherapy very well and enjoyed a good quality of life for two years. She had a few symptoms here and there, but mostly she was able to live close to a normal life. Her first scan after a few months showed dramatic shrinkage of her tumor. Scan after scan continued to look good, with her disease becoming very quiet, not showing any signs of progression. Eventually, I stopped her chemotherapy and placed her on a less toxic medication regimen to keep the cancer at bay. She also underwent preventative radiation to the brain, which affected her mental sharpness slightly but without any major decline in her cognitive capabilities.

Last week she came for a follow-up visit. She had already outlived the grim prognosis that I gave her at the outset. Her latest scans were still not showing any sign of disease progression. I walked into the room excitedly and shared the good news with her. I was expecting a joyful moment of celebration, but to my surprise, she started crying. With a puzzled look on my face, I asked her why she was upset when the cancer was under such good control. She responded, “Look at me, doctor, I feel so ugly. I have never looked this ugly in my entire life!” I froze in my chair.  Up until this moment, I felt that having gone through so many years of training, I had a proposed solution for all of the symptoms that my patients complained of. But nowhere was I ever taught what to do about a patient who feels that they look ugly. I could have moved on to talk about something else, but I took it upon myself to help her overcome this symptom.

My natural initial response to her was to say, “I don’t think you look ugly. You look perfectly fine to me.” She faked a smile in return, but I could see in her eyes that this run-of-the-mill consolation did nothing for her. Wanting to penetrate her mind, I took a deep look at her. She had lost her hair initially due to chemotherapy, but it had started to grow back. Her hair was gray, and she was wearing a baseball hat to hide it. Her face had become swollen from all the steroids she had received. She had gained weight and was wearing loosely fitted clothes without any care for matching or color co-ordination.

“Before you had the cancer, I remember you had such nice and dark hair. Have you kept it gray now on purpose?” I found myself giving hair advice to a patient my mother’s age, not knowing how she would respond.

“The nurses told me I could not dye my hair while I’m going through chemotherapy, and also, I just don’t care for my hair anymore.” She explained.

“As your oncologist, I would like to overrule my nurses’ well-intentioned recommendation and ask you to go ahead and dye your hair, not worrying about any interaction with chemotherapy.” I thundered. “Style your hair just the way you want and stop wearing the baseball hat to hide it.”

As a man, not very well versed in different ways how a woman can groom herself, I wanted to come up with more suggestions but felt helpless and eventually found myself saying to her, “I don’t care how you do it Jody, but get your game back on!”

I was a bit nervous about how she would perceive my advice. She could find it inappropriate and report me for making personal remarks. But I believe she sensed the sincerity in my words and appeared invigorated, uplifted, and excited. She was smiling now and exclaimed, “Doctor, you will see now how I get my game on!” She asked me when her next scans would be, and I told her, “First, you make an appointment at the hair salon, and I will schedule your next scans after that.” We struck a deal, and her body language changed. She jumped out of her chair and walked out of the room like a woman on a mission. A mission to look good. A mission to not feel ugly.

I don’t know how much longer she has to live. She may have another two months or another two years. I will be ready to treat any symptom she gets from cancer, but I will also make sure that we do everything for her to feel beautiful. Just like she actually is.

The patient’s name and some details have been changed to protect patient identity. Permission has also been obtained from the patient before writing this article.

Farhan S. Imran is a hematology-oncology physician who blogs at Did I Ask?

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