Woman Finishing Cancer Treatment Who Wants to Go Back to Work — Free SCA Practice Case

Character Overview: You are Priscilla Hartnett, a 48 year old geography teacher at a large secondary school, where you have taught for 19 years and also run a Year 9 form group. You live with your husband Marcus, a hospital pharmacy technician, and your daughter Elin, who is 16 and doing her GCSEs this year. Seven months ago you had surgery for a breast cancer, then six cycles of chemotherapy, then radiotherapy, and you started tamoxifen three weeks ago. You have been off work throughout. You are organised, warm and used to coping, and you hate being the person who needs looking after. You are determined to prove you are back to normal, and you feel guilty that colleagues have been covering your classes. You have seen that the school is advertising a temporary cover post for your Year 9 form group, and you are afraid that if you are not back by the start of term you will lose it. You do not raise this yourself, but it comes out if you are asked about work or what is worrying you. You speak quickly and brightly, then your voice wobbles when you admit how tired you are.

Opening Sentence: "Hello, doctor. I finished chemo two months ago and the radiotherapy a few weeks back, and I'm still absolutely shattered. My head teacher has emailed asking for a firm date for my return, and I'd like to tell him I'll be back full time on the first day of the new term, which is in about six weeks. Can you write me a note saying that?"

History if Asked (Data Gathering Phase)

• ●The tiredness: "It isn't normal tiredness. I'm fine for about two hours in the morning, then it's like a plug has been pulled. By early afternoon I have to lie down and I sleep for an hour or two. It doesn't feel any better for resting."
• ●What it limits: "A twenty minute walk is fine. If I do half an hour, I'm flat out the next day. Cooking tea some days is too much, and Marcus has taken over most of it."
• ●Concentration: "My head is foggy. I read a page and it doesn't go in, and I lose words mid sentence. That frightens me more than the tiredness, because I can't teach like that."
• ●Time course: "I thought I'd be myself by now. It's about the same as a month ago, maybe slightly better on good days. The radiotherapy made it worse for a couple of weeks."
• ●Sleep: "Poor. Since the tamoxifen I wake two or three times a night drenched in sweat with hot flushes. Then I'm awake in the early hours with my mind racing."
• ●Hands: "Tingling in my fingertips since the chemo. It's mild and doesn't stop me writing."
• ●Appetite and weight: "Normal, and my weight has been steady for a few months."
• ●Mood: "Up and down. I cry in the car park some days and I can't say why. I worry about every ache. But I'm not hopeless, I enjoy things when I have the energy, and I've never thought of harming myself."
• ●Treatment and follow up: "Wide local excision on the left, lymph nodes clear, then six cycles of chemo, then three weeks of radiotherapy. Tamoxifen for years. My breast care nurse is lovely and I see the oncologist again in three months. Blood tests at the clinic were all normal."

Ideas, Concerns, Expectations

Gating note: Priscilla does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks, what is worrying her, or what she was hoping for.

• ●Ideas: She believes the tiredness should be over by now and that she is somehow failing at recovering. She assumes that a fit note must say either "not fit" or "fit", and that "may be fit for work" would mean full duties. She has never heard of a phased return. "Surely I should be better by now. People say they were back at work in a couple of months."
• ●Concerns: She fears she will collapse or lose her words in front of a class and be seen as incompetent. She is afraid the school will start a capability process or push her out if she asks for anything less than full time. The school is advertising a temporary cover post for her Year 9 form group, and she fears losing that pastoral role if she is not back by the start of term. She is quietly frightened that the cancer will return. "If I can't do the job properly, they'll say I'm not up to it. And they've advertised a temporary post to cover my form group. If I'm not back by the start of term, I'm frightened it won't be mine to come back to."
• ●Expectations: She came for a note that gives a full time return date so the head teacher will stop asking. She does not expect to be offered anything else, and she is surprised when she is. "I just need something to show him so he'll leave me alone."

If Asked: Medical History and Medications

Gating note: Priscilla answers each of these plainly when the doctor asks.

• ●Other health problems: "Nothing else. I had migraines in my twenties and they stopped. I haven't had a period since the chemo."
• ●Medicines: "Just the tamoxifen, one a day. I take paracetamol occasionally for headaches. I haven't taken any herbal remedies, though a friend suggested St John's wort for the flushes."
• ●Allergies: "None."
• ●Alcohol and smoking: "I don't smoke. I've stopped drinking since the diagnosis."

Social History and Lifestyle Impact

• ●Work: Priscilla teaches five lessons a day on her feet, runs a Year 9 form group, does a lunchtime playground duty twice a week and has a Year 11 class she taught from the start and desperately wants to see through. She usually spends one to two hours a night marking and planning. If asked about adjustments, she says nobody at school has mentioned any, and she has not asked in case it looks like weakness. Her head teacher is Mr Fenner, who has been kind but is under pressure to plan staffing. The school has an occupational health service but nobody has referred her.
• ●Form group: "I saw the advert for a temporary cover post for my Year 9 form. I know they need someone for the children, but I'm frightened it won't be mine to come back to."
• ●Home: Marcus has cut his overtime to help. Elin has been a star but is stressed with exams. Priscilla feels guilty about the strain on them.
• ●Support: Her sister rings most days. She has not tried any cancer support group because she says she is fine compared with others.
• ●Current fit note: The most recent one says not fit for work and ends in ten days.
• ●Availability to be seen: Not needed. She can attend the surgery if asked.

If Asked: Associated Symptoms

Gating note: Priscilla answers these only when asked. Every one is negative unless stated.

• ●If asked about new lumps in the breast, armpit or neck: "No, nothing. The scar is healing well."
• ●If asked about bone pain, back pain or pain that wakes her: "Just aches in my joints after sitting, nothing that stays."
• ●If asked about cough, breathlessness or chest pain: "No. I'm tired walking uphill but I'm not breathless at rest."
• ●If asked about headaches, vision changes, weakness or confusion: "No. The fogginess is just slow thinking."
• ●If asked about weight loss, poor appetite, fevers or sweats apart from the flushes: "No."
• ●If asked about calf pain or swelling, or vaginal bleeding: "No."
• ●If asked about dizziness, palpitations or looking pale: "No. Marcus says I look better than I did."

Responses to Management (The Negotiation Phase)

• ●If the doctor says a full time return from the first day is unlikely to be realistic, or suggests a phased return:
  • ●Reaction: Taken aback and a little tearful. "But I can't go back part time, they'll think I've given up. And I want to be there for my Year 11s." She softens if the doctor explains that building up gradually is what makes a return last: "So I could start with a few days and build up? I didn't know that was allowed." She asks, "What would that actually look like?"
• ●If the doctor talks about a fit note saying she may be fit for work with adjustments, or about not giving a firm date:
  • ●Reaction: Worried that no date means losing her form group. "But Mr Fenner wants a date." Once told the note can describe what she can do and the school can plan around it, with a review before term: "So I could give him a target and say we'll confirm it nearer the time? That's more honest, actually." She is happy for the note to say what helps without naming the cancer.
• ●If the doctor explains workplace adjustments, occupational health or her legal protection:
  • ●Reaction: Surprised. "I'm classed as disabled? I've never thought of myself like that." Reassured once told it protects her and the school must consider reasonable changes. She asks, "What sort of changes can I ask for?", "Will you write to them if I ask?" and "Can they just give my form group to whoever they hire?" She agrees to ask for the occupational health referral.
• ●If the doctor discusses managing the fatigue, exercise, sleep or hot flushes:
  • ●Reaction: Doubtful. "Isn't exercise the opposite of resting? I'm exhausted." She accepts gradual walking and pacing once it is explained, and asks for a diary. She asks if St John's wort is safe for the flushes. If told to avoid it with tamoxifen: "Oh. Good thing I asked. What else is there?"
• ●If the doctor offers support, a review, or safety nets:
  • ●Reaction: Willing but wants specifics. "How will I know if it's just tiredness or something coming back?" She repeats back clear advice about symptoms to report. She welcomes a review before the new term and is glad to hear about Macmillan or a rehabilitation course: "Maybe I should talk to someone who has been through it."