The First Commandment of Oncology

Several years ago I saw a man who was referred to me for further evaluation of enlarged lymph nodes in his neck. They seemed suspicious on examination, so I ordered the simplest and least invasive type of biopsy available: a needle biopsy of the most prominent node, thus sparing the gentleman from an incision in his neck.

The pathology report returned a few days later and stated that the patient had a low-grade lymphoma. I made arrangements for him to undergo further testing, and prepared to refer him for radiation therapy to the neck.

Everything seemed to be copacetic, except for one tiny problem...

I couldn't shake off a lingering doubt about the diagnosis. The proper diagnosis of lymphoma includes identifying what grade it is, and this information could not be determined on the needle biopsy. I held the path report before me and asked myself the following (oncologists often perform interior monologues, just like Hamlet):

"Forsooth! Doth this diagnosis reflect all that is true? Say, why is this? wherefore? what should we do?"

Myself considered the situation and summoned up the courage to yodel back "I ain't so sure!" This was all I needed to yank on the brakes and stop this patient from rolling on into the radiation oncology station house. I called him up and made him see a surgeon for a formal excisional biopsy of the lymph node. The next pathology report was nothing but good news for him, for it revealed that he did not have lymphoma. His sigh of relief could be heard for miles until it crashed into an identical gale emanating from the building where my office was located.

The moral of this story could be chiseled onto a tablet as this First Commandment of Oncology:

Thou shalt make certain the diagnosis is the truth before thou terrifies the patient.

In order to ensure that a patient does indeed have a malignancy, and that the exact type of cancer is identified, medical oncologists, pathologists, surgeons and other specialists must work together. They must consider several maneuvers to pin down the correct diagnosis, such as staining the biopsy specimen for immunhistochemical markers specific for a type of cancer, or even using electron microscopy on the specimen. If no agreement can be made as to what this lesion represents, they should send it out to another experienced pathologist for an outside review.

Sometimes, such as in the case I presented above, the specimen is simply inadequate to establish a diagnosis. Then the lesion of interest must either be re-biopsed, or a lesion in a different location should be considered for biopsy. Patience is required by all parties when atttempting to come up with the proper diagnosis before proceeding with chemotherapy, surgery, or radiation therapy.

The best way in my opinion to ensure beyond any doubt that a patient will be diagnosed correctly is to consider the whole person before you. Each aspect of a patient's clinical presentation is a clue as to what the final diagnosis will be. Oncologists must place these pieces before them as if they were working a jigsaw puzzle, analyze all the different parts with the precison of a watchmaker, and then solve the puzzle as if it held the secret to immortality itself. We fulfill our commitment to our patients by taking each case as seriously as did that great detective with the deerstalker cap, whose most famous quotation is:

"When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth."

Guest-Blogging for Kevin, M.D.

The wise and eloquent psychiatrist Shrinkette and I are guest-blogging for Kevin, M.D. for a few days - check out both these blogs if you haven't had the opportunity to enjoy them.

In the meantime I'll be posting a piece on the number one priority of the medical oncologist - as soon as I write it! Look for it later today...

Death Comes for the Grasshopper

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.
Me only cruel immortality
Consumes: I wither slowly in thine arms,

Alfred, Lord Tennyson, Tithonus, 1860


I grabbed the chart from the plastic holder and paused, one hand on the door knob, quickly reviewing the latest information on the man waiting for me in the exam room. A date in the upper corner of the folder caught my eye. I glided into the room with a big grin and he looked up as I greeted him.

"Do you realize that this is the seventh anniversary of the day you were diagnosed?" I asked. "You have lived a long time - much longer than the average patient."

He bowed his head slightly before answering me and as we exchanged our congratulations I noticed his clavicles bulged from his tee shirt like two tent poles. I helped him to the table and recorded the findings of my examination with perfunctory precision - hard cervical lymph nodes, persistent left pleural effusion, colostomy in place. After shaking his hand I said I'd see him next month.

"Let me know if you run low on pain meds." He nodded to me as I opened the waiting room door for him. I then went back to my office to dictate my note. Outside my window a chickadee caroled me from a nearby branch: see-bee-see-bay. I put down the telephone and listened to its melody, and before I could regain my train of thought lines from a poem learned long ago rose into consciousness.

And though they could not end me, left me maimed
To dwell in presence of immortal youth,
Immortal age beside immortal youth,
And all I was, in ashes.

When oncologists evaluate the benefits of an anti-cancer medicine one of the most important statistics they consider is whether the treatment prolongs survival. Helping patients to live as long as they can is one of the great goals of modern cancer therapy. Those who are cured of cancer obviously receive the greatest reward, just as those who are cursed with tumor progression are fated to see their life end before the "half-opening buds / Of April" push through the earth next spring. What then becomes of those whose disease neither grows nor disappears? What does it mean to be given the gift of survival without remission? The image of my gaunt patient floated in the air as I considered the parallel between him and the title character of Tennyson's poem. According to the myth, Tithonus, the beloved of Aurora, goddess of the dawn, was granted eternal life but not eternal youth, and therefore becomes a withered skeleton, "a white-haired shadow roaming like a dream / The ever-silent spaces of the East." He comes to envy "happy men that have the power to die" and begs the goddess:

Let me go: take back thy gift:
Why should a man desire in any way
To vary from the kindly race of men,

It is this kind of irony that drives physicians mad - to work so hard to lengthen the lives of patients by turning cancer into a chronic disease, only to see them slowly decay.

But thy strong Hours indignant worked their wills,
And beat me down and marred and wasted me,

Some cancers like chronic lymphocytic leukemia can be tolerated for many years without consuming the patient's vitality, but this is simply because of the natural history of the disease. Oncologists continue to search for treatments that will blunt the progression of horrid tumors such as melanoma or lung cancer. If researchers someday announce that a new medicine can stop the growth of cancer but not eradicate it, will this be a blessing or a bane? Are patients who experience a long life living with cancer lucky or unlucky? What would one choose if offered the gift from the goddess of the "rosy shadows", knowing that one's vigor would be sacrificed?

The song outside my window stopped and a gray bank of clouds drifted into view, darkening the office walls. I finished my dictation and stood to leave. Before turning, I peered briefly at the trees by the parking lot. Like a priest who held high the cup, their limbs were hanging in the late winter air, stippled with buds promising new life, a renewal repeated since the dawn of time.

Tithonus was eventually released from his living imprisonment, for the myth ends when Zeus, taking pity upon the aged lover, transforms him into a grasshopper. We who are mere mortals have nothing to fear, for no matter how long we live or how much we suffer we will never end up inside of a glass jar furiously rubbing our hind legs together. Our fate is the fate that Tithonus pleaded for yet was denied. One can imagine he sits outside our window even now, chirping his cry long into the night until the first light of his former lover bathes the distant hills:

Release me, and restore me to the ground;
Thou seest all things, thou wilt see my grave:
Thou wilt renew thy beauty morn by morn;
I earth in earth forget these empty courts,
And thee returning on thy silver wheels.

In Memorium: Hunter S. Thompson

Prologue: Hunter S. Thompson, who committed suicide this week, was one of my favorite writers for many reasons. His obnoxious, irreverant behavior was the center of his wild-eyed stories about crashing political and sporting events around the world. Thompson's writing style was a pure delight - it defies description and has to be read to be appreciated. The closest analogy I can think of is if Frankenstein's monster had kept a diary, this is how it would look.

What made Thompson's dispatches so entertaining to me was the fact that I was dying to live as he did - with total debauchery - but as a pre-med student, then medical student, et cetera, I couldn't. What would the dean say if I and my buddies showed up for anatomy lab plastered to the gills, with a suitcase full of hacksaws, ether and gila monsters? Like many other studious, goal-oriented preppies of my generation, I could only experience true madness vicariously through his writings. Back then I was ambitious and serious - in other words, boring. Hunter S. Thompson was a string of firecrackers thrown into a hot charcoal grill during a church picnic; he was a man in a gorilla suit running after an ICU attending with defibrillator paddles; he was the avatar (to use one of his pet words) of insubordination, mixed with just enough silliness and insanity to awe a milquetoast like me. He is the only character I have ever dressed up as on Hallowe'en since I left boyhood.

Tom Wolfe has just called Hunter S. Thompson "the century's greatest comic writer in the English language". (He's wrong, of course - that distinction belongs to P. G. Wodehouse). Nevertheless, in Doctor Gonzo's memory I offer the following parody, as a tribute to the man who once said:

"When the going gets weird, the weird turn pro."


FEAR AND LOATHING IN THE E. R.
(written in the manner of one Raoul Duke)

Why am I here? Who is this woman in a giant muu-muu, standing before me squeezing what appears to be a copperhead snake in her hands? She spoke to me in some strange language - obviously disrespectful of the country that took her in after a long canoe trip across the oceans. I thought of screaming "Back! Get Back!" but suddenly sat bolt upright and remembered:

I am a doctor...on call in the emergency room of the world's greatest hospital. My shoes were smeared with thick crusts of vomit and blood, as were my pants, except I wasn't wearing any. I must find them, I thought. The lights above my head burned into my skull like the first kiss of the electric chair. I reached for my pistol to shoot at them, but it, too, was missing. The situation was rapidly deteriorating. I began to sweat like a champagne fountain at a coal miner's wedding.

She continued to bark at me as I stood up and surveyed the room. I had been working since six o'clock the previous evening, and felt like I had been stomped by buffaloes. I desperately wanted to claw my eyes out, but instead hunched over the desk, searching for a pack of cigarettes. What was it - 12 hours of pure massacre, or had I been trapped in this reptile pit for weeks? No one seemed to hear me as I asked for matches and a can of kerosene...

"Yes, yes," I said to the nurse. "You're doing fine, doing a fine job for all of us here." She glared at me as if she had just seen Martin Bormann in an Argentinian health club. What did she want from me? She followed me across the floor as I attempted to break into the crash cart...a nice ampule of epinephrine ought to help, I thought - perks a man up to the point where he would not hesitate to offer his aunt a quick game of Russian roulette. I looked over my shoulder at the nurse. Maybe I should inject her first - give her just enough to get her to dance on the counter top, holding a gunny sack full of live rats. I laughed hysterically at this idea until a security officer tried to club me with a sap. He missed and accidentally whacked a pizza delivery man right in the pepperonies.

I quickly grabbed a clipboard and walked into the nearest exam room. "What is your problem, sir?" It was difficult to see him through the cheap Saigon sunglasses my attorney had given me.

"My chest hurts and I can't breathe so good" he said. My God! His left arm suddenly fell off and he grabbed it and flung it at me! Another damn zombie in the emergency room - how they sneak past the metal detectors is beyond me. I rushed the gurney and toppled it over, sending the fiend crashing into an EKG machine. Musn't panic, I thought - just walk nonchalantly out of the room and down the hall to the lounge. Poor bastards... they'll find out soon enough what the living dead can do to a man's aorta with their teeth. Better let Security handle this, or better yet an armored company of Camp Pendleton's finest.

As I reached the lounge I realized that the sun was shining, meaning my hell-night was about over. All that was left to do was clean up the forty or so charts that I had tossed behind the soda machine, locate the rest of my clothes, sign in to the intern relieving me and slip out through the window in the men's room. Before leaving I decided to eat - after all, being a servant of the needy gives one an appetite like a crazed Samoan wrestler. My forged I.D. card was good for at least one more trip through the outlet store for the local waste dump, also known as the hospital cafeteria.

My surgical colleague sat next to me as I sliced up grapefruit with a stiletto. "Man, you sure had a rough night, didn't you? Last I saw of you, you were standing on a trash can during that code, screaming 'Somebody get me a chainsaw!' How long have you been on E. R. call?"

I turned my head to reply, but gasped - scorpions were crawling out of his eyes! He grinned at me like a Jolly Roger as I sprang from the table. I tossed my glass of ice water at him as he tried to grab my arm. I could hear him bleating like a goat caught in a vise as I ran through the glass doors and out to my car. I jumped into my 1971 red Cadillac convertible and sped off, playing "Mr. Tambourine Man" at full volume. I looked at my watch.

My next shift in the emergency room would start in just 23 hours and 14 minutes.

Epilogue: If any readers are unfamiliar with Thompson's bizarro world, a word of caution is advisable: his books are filled with unhealthy and illegal behavior. Take it all as a fantasy, like a trip through a haunted house - and remember, as they say on television: don't try this at home!

Twelve Strokes of the Clock

The "Red Death" had long devastated the country. No pestilence had ever been so fatal, or so hideous.

*****************

But the Prince Prospero was happy and dauntless and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends...and with these retired to the deep seclusion of one of his castellated abbeys.

*****************

A strong and lofty wall girdled it in. This wall had gates of iron. ...With such precautions the courtiers might bid defiance to the contagion. The external world could take care of itself. In the meantime it was folly to grieve, or to think.

E. A. Poe, The Masque of the Red Death, 1842

Those of you who are familiar with Poe's magnificent gothic tale know how the Prince's elaborate masque ends as the "gigantic clock of ebony" in the last apartment strikes midnight. The ghastly fate the revelers meet is appalling, yet after the initial frisson of the massacre, some readers might conclude that the selfish Prince and his frivolous friends got what they deserved for trying to cheat the Grim Reaper. They found out the hard way that one cannot wall out death; it is a part of all living things, and cannot be escaped.

Given the gruesome nature of the Red Death, however, who can blame them for trying? Who among us would refuse the invitation to leave the foul, decaying countryside for the safety of the barricaded abbey?

Modern consumers of health care in some ways are like the arabesque figures imprisoned within Poe's story. They learn about good health from the moment they can read and then are bombarded with helpful information about how to prevent one affliction or another. By the time they reach adulthood many of their actions are influenced by their impact on health. They feel guilty if they do not take every precaution to keep themselves safe from the plagues that punish in this age, such as cancer, heart disease and diabetes.

We all therefore devote much of our time trying to wall out illness. We toil at building a fortress to deny the invader who in the tale "dropped the revellers in the blood-bedewed halls of their revel". The stones we cut to construct our walls are plentiful and easy to quarry: exercise, healthy diet, screening tests, abstention from tobacco, moderation in alcohol use, medications and supplements. With reasonable alterations in lifestyle choices we can someday stand in the tower of a massive citadel, protected from the "Darkness and Decay" of the epidemics around us.

This is an admirable goal. I follow it faithfully, as do millions of conscientious men and women around the world. Our commitment to preventing illness will allows the gala called our healthy life to continue. We shall dance on - or as Poe would describe it:

And now again the music swells, and the dreams live, and writhe to and fro more merrily than ever...

I commend all those who have made the often difficult choice to embrace the habits that strengthen our bodies and eschew those that expose it to the dismaying and monstrous withering of preventable disease. May those who struggle to build this wall find the insight and courage to persevere.

Lest we forget though, remember that good health can be defined as dying at the slowest possible rate. The wisest person in the world is the one who enjoys the delights of the soiree while keeping an eye on the clock, for whether one is blessed with good health or poor, when "the last echoes of the last chime" sound, the masked spectre will "come like a thief in the night". Even the strongest walls cannot deny his entry. Let us stand tall before him at the hour of his arrival, and as he takes our hand, smile and look backward upon our life with pride.

Waiting for Tomorrow

Last night I had a dream that I was getting dressed to go to see the doctor. I knew I was sick, but the nature of this illness was hidden. I walked into the bathroom, glanced at the mirror and saw my reflection not where I stood, but behind me in the shower. When the fogged door opened there I was, dripping wet and sitting on a plastic chair. I did not get up, but instead called out a name.

I sat there, strands of white hair spilling over my ears, my chest sunken, my bony knees protruding like the roots of a cypress tree.

Gazing into the mirror, I saw myself as an old man.

After what seemed to be a tedious wait, a young woman came in and helped me out of the shower. She brought me a towel and a walker and I shuffled off, carefully eyeing the tiled floor in front of me. My name was written on the towel in black magic marker. The walker had yellow tennis balls stuck on the bottom of its metal legs. Neither she nor I spoke a word.

I then left the vision in the mirror and walked downstairs and out to the garage, where I climbed into my car and backed out into the driveway. Just as I started out I braked and looked into the rear-view mirror. I could see the oak tree in my back yard. Sunshine dropped through the shadows of the immense branches and formed a patchwork on the grass, and the leaves fussed from the breeze.

There were people walking all over the lawn.

I saw my son tossing a ball to a little boy in shorts, while two older girls sat gossiping under the tree. They called out "Father!" and he turned. He looked the same age as I am now, his hair dappled with gray. My wife and daugher stood nearby talking. My little girl was tall and tanned, and as she spoke my wife handed her a feisty-looking baby.

I peered into the small rectangle for several minutes, but never did catch a glimpse of anyone who looked like me. The last thing I remember before awakening was driving off down the road, unable to release even a sigh. The streets passed by silently, and I encountered no other cars on the desolate road.

What does the future hold for us? Will we cheat death for so long that we outlive the life we begged for, or will we instead be harvested early, spared from any further rendezvous with the lash? Such thoughts are but fantasies found in dreams - except for those living with cancer. For them speculation is not a phantasm. It is a daily reality thrust upon them, like an uninvited guest at the table. We who live without such a burden can honor those who do by remembering that unless one respects the future as the gift it is, waiting for it is pointless; it is worthless; it is absurd.

High in the Sunlit Silence

When I was a teenager I loved to watch the television comedy M*A*S*H, which may have subconsciously spurred an interest in medicine. Part of my fascination with the show was the realistic portrayal of how the doctors dealt with the stress of working in a chaotic war zone. It seemed that the hospital was the destination for an endless caravan of wounded soldiers, all desperately in need of the unique blend of surgery and fatherly advice the show's characters dispensed. The surgeon's shifts were long and grueling, yet they never failed once to complete their duties. Nothing could disrupt their devotion to patching up the young patients - the operating room survived blackouts, bombings, belligerent patients, snipers and supply shortages. It was the paradigm of grace under pressure.

There was one event, however, that rocked the surgical suite more than any other crisis ever broadcast on the show, and like most viewers on that day I was shocked by the tragedy. Part of the reason why the moment was so dramatic was that it consisted merely of an item of news delivered to the operating room staff by the company clerk.

The news was that Colonel Henry Blake, the freshly discharged commander of M*A*S*H 4077 had been killed in an airplane crash on his way back to the states.

I will never forget the looks on the surgeon's faces as they absorbed this devastating shock of the loss of their likeable leader. Because the doctors remained silent after hearing the news, the effect was stunning. They took this blow as stoically as Caesar took the dagger of Brutus, pausing briefly to stare at nothing and no one, then leaning over the open wound to carry on. This was an inspiring show of fortitude, but at the time I also thought it was unrealistic - how could anyone remain quiet in such a time of grief? Are doctors so obsessed with their work that they avoid showing any signs of human frailty? Could this reaction eventually lead to what our psychologist colleagues call repression?

The years passed, and by some miracle not seen since the parting of the Red Sea I was accepted into medical school, and furthermore, mirabile dictu, matched at a reputable internal medicine residency. I now viewed the bustling world not as a layperson, but through the goggles of an authentic physician, albeit a greenhorn. I slowly learned how to survive the hospital's routine, which apparently was modeled after the Hanoi Hilton's. After months of exhausting service comparable to the barbarity suffered by the good surgeons of the 4077th, we residents became inured to the bellyaching of patients, fellow physicians, spouses and pets. Our work was an addiction. The outside world faded from our sights as quickly as if we were rocketing away from Mother Earth.

On January 28, 1986, while on morning rounds in the intensive care unit, the space ride came to an abrupt, awful end. The universe awakened and stomped our little hideaway into an unrecognizable heap, and we realized that we were still citizens in a massive living thing called America. The question I posed all those years before - does the news of a tragedy stop a doctor in his tracks - was answered that day.

When the space shuttle Challenger exploded shortly after takeoff we not only stopped, we forgot why we were in the hospital in the first place.

Residents, attendings, nurses and anyone else close by on that day huddled around the nearest television as the drama unfolded. We watched the horrific moment again and again. The event staggered us so much that it transcended sadness and became baffling - we simply could not fathom what our eyes had just witnessed. We suspended our work that morning because we had just been shown a parallel universe, previously unknown to inexperienced minds - a strange world where a song of triumph disappears while it is being sung, a world where certitude is but a wisp of floating silk waiting to be swept away by the pitiless wind.

Like the rest of America, I experienced this heartbreak once more on September 11th, 2001. Again doctors stood in disbelief before the television, unfocused and afraid. We sank with despair on that day and hated ourselves for returning to the exam room - but return we did. We could have cancelled our clinics, but instead we went back to work on one of the worst days in the history of our country. I understand more clearly now why the doctors on M*A*S*H kept working on that fateful day. After catching their breath they looked down at their hands and saw them move; they opened their mouth and heard their voice. The surgeons searched within themselves and concluded that their only usefulness, their only worth in the world was if they kept the promise they made to another human in need. That promise is what fuels the doctor's engine for the magnificent journey called his career. It is the only thing that can lift him high enough to slip the surly bonds of earth and touch the face of God.

The Last Call

The high points of a doctor's post-graduate training are so few in number they can generally be recalled in the same amount of time and with the same enthusiasm it takes to flush a toilet. There is one event, however, that stands like a sequoia in the vast forest of memories preserved within the young doctor's mind - the night of his last call. Every doctor remembers the final time he entered the healing palace as the resident on-call. He drifts about the halls that night like a specter under the fluorescent lights, exploring the wards he once haunted. Like most nights on-call though it is a time for survival, not reminiscence. The goal is to live through the night without losing one's temper, mind or car keys.

It was with true dread that I stared at the doors of the hospital all those years ago on the last day of my three years of servitude. The season was glorious spring, when flowering crabapple trees delighted the weary eye and a young doctor's thoughts turned to shouting a hearty sayonara to the apprenticeship and hightailing it to fellowship or private practice. My sights though were only on the imposing brick building rising before me, for when it came to lucky omens I had just been handed the Monkey's Paw. Some residents spend their final hours grooming little old ladies on the geriatric service. My last supper was to take place within a more ominous painting. I walked into the lobby and gazed at the portrait of the President hanging above a collection of flags, releasing a sigh as I trudged upstairs.

According to the schedule, my last night on call was to be at the Veteran's Hospital.

Those doctors who have trained at the VA hospital know what it means to roam the halls where any minute one expects to encounter a human head bouncing down the stairs or see flames shooting from the oxygen mask of a surreptitious smoker. I therefore swept all bad thoughts away, steeled myself and went about the business of the day which consisted mainly of tracking down the reasons why exactly the old soldiers were there in the first place. The afternoon chugged by without incident, although our medical student was nearly asphyxiated when he walked into a lounge hosting the weekly bingo-game-and-cigarette-exchange. The only casuality before sundown was a jug of urine. One of my patients had diligently carried it from home to the hospital but had forgotten to give the specimen to me.

"What did you do with your 24-hour urine sample?" I asked. I needed to know if it contained any abnormal protein, which could indicate the presence of multiple myeloma.

"I gave it to the lab technician. Thought that would be faster than trying to find you."

Like an Olympic skier leaning into the final turn, I slalomed down the stairs to the laboratory in an attempt to rescue the precious carafe, but to no avail. By the time I crashed through the doors it was already lost. I argued with the staff in an attempt to get them to find the cursed bottle but they just gave me a look like a police officer about to conduct a sobriety test. The hospital once again held illimitable dominion over all. I furled the flag and crawled back to the floor.

Evening fell, and I soon collapsed into the recesses of the beastly place. I lay fully dressed on my on-call cot, two beepers clipped to my belt, which made me look rather like a tot carrying a pair of six-shooters. Even the VA settles a bit at night and before long my eyes were dead to the world. Unfortunately at the same time the eyes of one grizzled trooper also decided to shutter permanently, and a nurse who noticed the apparent lack of respiration dialed the operator to send in the Marines - or in other words "call a code".

I had just reached that part of a dream when after several frustrating attempts, one has convinced oneself that he can soar off into space by flapping the arms. Suddenly a horrific wailing pierced the skull and cut short my maiden flight. My red beeper was shrieking, signaling a cardiac arrest somewhere in the hospital. The operator called out the location over the tiny speaker but the sound was so bad it seemed as if she was reading back an order from a drive-through restaurant. I sped down the hallway. When I arrived at the emergency no one was there but the nurse and the veteran playing the non-speaking role. I of course had to do all the work that night - intubating the patient, starting his I.V., giving him the juice - both liquid and electrical, until the Three Fates made their final decision. Hours later I staggered into the nurses' station and according to witnesses downed a two-week-old can of soda that had been left behind the copy machine.

The following morning after a brief search my medical student found me lying supine on the floor of the conference room, humming "Don't Sit Under the Apple Tree". He gently shook me awake and we waddled off to breakfast. The last I heard of him he was running a Botox clinic in Honolulu.

Thus ended my last night of call. As I was helped out to my car I swiveled for one last look at the object of my detention. The stony facade seemed to fix me in its gaze, as in The Fall of the House of Usher. It was almost twenty years before I laid eyes on it again, and as I drove by the barren landscape, I could swear the old relic winked at me. I smiled back and realized that like two old prize fighters sitting in a diner we could now laugh about the punches we threw back then. The forecast was once again balmy, for our scars no longer ached - we were at peace.

The Living Canvas

Last summer while driving through the farmlands of Missouri we plowed into a thunderstorm spawned from towers of clouds that lined the late afternoon horizon. We drove steadily on through the storm and soon the dark wall receded. I peered with anticipation through the wet sunshine and saw a giant arc of color off in the distance. "Look at the rainbow!" I called out. My children, always on the alert for an opportunity to confirm their suspicions about my childish behavior, ignored me. Not to be daunted, I increased the volume and resumed the science lecture. One could sense they were silently laughing.

"Over there on the right - can you see it?" I asked. Remnants of youthful innocence stored within them must have awakened, for they slowly turned to the window and scanned the sky. "We don't see anything," they replied. I tapped the windshield and said "There! Over there!", but they still were blinded. Finally they identified the radiant bands sweeping across distant clouds. I marveled at their obtuseness, but forgave them and motored on. As the rainbow vanished I considered how a keen sense of perception adds so much more to the enjoyment of life. How many other delights, such as the meadowlark's song, or the cotton-candy scent of honeysuckle, languish as we limp through another day? Consider the world I work in - cancer medicine. Would refined skills of observation make one a better physician?

I am not sure that success depends entirely upon a doctor's power of perception and insight, but I do know one thing - it makes his job a lot easier. A physician gains a special benefit by remaining vigilant, and that benefit is this:

The doctor who sees the clues contained within an illness also sees into the future, therefore, one who perceives the future can prepare for the tribulations it contains. The hints a patient reveals in the course of a visit can predict what direction his illness is turning. For example, last week I entered an exam room to see my patient sitting in a chair with a cane by his side. I smiled at him, because it was the first time since he had started treatment that he was not in a wheelchair. X-rays confirmed that his lung cancer was shrinking rapidly, and he made plans to travel this spring. While examining a different patient I noticed that her bulky abdominal mass was markedly smaller just one week after receiving treatment for chronic lymphocytic leukemia. This response, while welcomed by all, seemed unusually rapid to me. I checked her blood chemistries, and her potassium, uric acid and creatinine were all high - consistent with the complication called tumor lysis syndrome. By suspecting this problem I was able to prepare to relieve it.

Other clues foreshadow distress in the times ahead - I recall the patient who told me he had stopped balancing his checkbook because it was too difficult to complete the task; he was soon diagnosed with brain metastases.

A patient constantly exhibits signs of the state of his illness - signs that if read correctly, can be useful in planning future care. He is like a distant rainbow or a magnificent painting, an extraordinary composition to study if only noticed. A skillful doctor, like a master artist, develops a keen eye for the details arranged in the living canvas before him. He studies the patient as thoroughly as he would scrutinize the Mona Lisa, looking for clues as to what truths lie within such an awesome work of art. His work is tiring, but like a long walk through the Louvre, it is a source of endless satisfaction.

Moving the Chains

One of the goals of modern cancer therapy is to pound away at a tumor with different tools in an attempt to prolong life - to turn cancer into a chronic disease. Ironically, this exposes the patient to a Hobson's choice of suffering from the effects of treatment, or from the cancer if its growth is not thwarted. The fine line between helping and harming a patient is one of the oldest dilemmas in cancer care and must be considered in every move the doctor makes in the contest against a clever foe. A good oncologist must become a strategist, an expert at seeing the playing field before him, a master interpreter of the opponent's plans and a genius in calling the best play, so to speak, to ensure victory.

That's right - an oncologist is basically a football coach in a lab coat.

The fight against cancer is obviously not taken as sport, but like the clashes that occur on cool, sunny afternoons in October it is a match between two adversaries. Similar to the fall pastime, each head coach has his game plan before him and rallies his team with shouts of inspiration, asking his players to give their all for the cause. Unlike a football game, though, when the coach says "Now go out there and kill 'em!" he really means it. Playing against cancer is the ultimate death match.

With a little imagination one can envision how the game develops:

First, think of the oncologist as the coach whose team has the football on the 20 yard line in overtime. The distant end zone, where victory lies, represents either cure of the patient or at least prolongation of life. The team has only four downs to go the required 80 yards, otherwise possession changes, and cancer has never failed to score when given the ball. The four downs allotted the Crab Busters represent the four stages in a patient's plan of therapy. Each down can be described as follows:

First down - this is the time to call the best play in the book, for some initial treatments can wipe out cancer like a fullback plowing through the crowd at a garden party. Some tumors, like testis cancer or Hodgkin disease, are so susceptible to chemotherapy one can call a quarterback sneak and still reach the end zone. Many others, though, require a more complicated strategy involving fake handoffs and long passes. The goal on first down is to gain as much of the necessary yardage as possible.

Second down - if the team doesn't score with the preferred treatment, the oncologist must now take a hard look at his clipboard and pick the second best therapy he has. No two patients are alike, and therefore salvage treatments do vary. The coach must take into consideration such factors as the patient's overall condition before sending in the play. Some second down plays are simply straight forward rushes, such as single-agent chemotherapy; others such as stem-cell transplantation for relapsed lymphoma, are works of subterfuge and precision as beautiful as a successful flea-flicker.

Third down - by now if the tumor has not been outplayed the chance of fans joyously tearing down the goalposts dwindles. Although some cancers such as ovarian carcinoma respond to many different kinds of chemotherapy and can be subdued for years, most others, like an enemy coach who decodes the other team's signals, become resistant. This is the down where experimental therapy should be considered. The playbook has been exhausted - it is now time to innovate, such as drawing a saber from the folds of the uniform, or setting the field on fire.

Fourth down - as sad as it seems, there comes a time when the oncologist must realize that he can no longer prevent a tumor from achieving its perverted goal of committing suicide by killing its host. In many cases there is nothing more to be gained by exposing the patient to the side effects of a futile Hail Mary pass. A more humane move would be to refer the patient for hospice care and begin to concentrate on providing quality of life, rather than obsess over its length. A few patients will not accept this advice and will seek out unproven cancer therapies. While an oncologist should respect the wishes of his patients, he is not required to advocate any treatment not supported by medical evidence.

A skilled oncologist, like a hard-nosed football coach, knows when to play it conservative and when to go for broke. He plots his strategy against the enemy and then stands on the sideline as the drama unfolds, hoping for the best, but unable to enter the playing field. The patient alone must carry the ball, and his doctor must always remember that the greatest coach is the one who embraces his players in victory or defeat and says "You did your best."

Deciding to be Undecided

Time for you and time for me,
And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

T. S. Eliot, The Love Song of J. Alfred Prufrock, 1919



I frowned as I stared at the jumble of golf clubs peeking out from my bag, pondering which weapon to use on what looked to be a spine-tingling second shot over a pond the size of Lake Michigan. As I made the necessary mental calculations involving distance, wind, and more importantly, my famous slice, I heard the voice of one of our foursome cry "C'mon and make up your mind!" Ignoring the rube, I let several more ticks of the clock pass before selecting a club. I then approached the ball like Pharoah lording over the prostrate Moses and with one swing launched a perfect parabola that peaked near the heavens but ended where only minnows and frogs are happy. I wondered if I had made up my mind too hastily.

While waiting for the laughter around me to die down I thought about the problem of indecision and how it applies to my own vocation. It should come as no surprise that the cancer specialist is asked to make tough decisions every day. He must weigh the benefits of treatment against its risks and then determine if this therapy is safe to give to his patient. There is the possibility that treatment may lead to severe side effects, or even death. It is no wonder then that medical oncologists are often found slumped in their office with chin on hand, as deep in concentration as any man dreamed of by Rodin. They are truly under enormous pressure, and not just because a nearby statue has toppled.

Could there be a species of oncologist, however, that lacks the nerve to press the launch button and send a volley toward some hostile tumor threatening dear old grandmother? As I addressed the fiendish ball (a new one, since his twin now slept with the fishes), I recalled a man sent to my office last week for a second opinion. He was recovering from a successful operation to remove an early stage rectal cancer, and had seen a medical oncologist for advice on whether or not to take several months of adjuvant chemotherapy and radiation therapy. Since this visit was to receive a second opinion, I asked him what conclusions were advanced during the first.

"Oh, he didn't really say anything," he replied. "He said I could take chemotherapy if I wanted to, but that it was up to me."

Had a paparazzo surreptitiously snapped my face at that moment he could have sold it for a pretty sum (if I was a star), for I gave the patient a look like a fellow who has just seen a parking attendant back his Ferrari into a hot dog stand. Delving deep into the manual on tact and diplomacy, I was able to politely ascertain that his erstwhile doctor had taken no stand on the situation on the table - that is, should this gentleman endure six months of mementos such as diarrhea in order to improve his already favorable prognosis? The answer to this dilemma was clear to me: the current data on his stage of rectal cancer were encouraging enough to obviate the need for any adjuvant therapy.

No church bells pealed, however, when I revealed my impression to the man since he still had to live with the small chance that the malignancy could return, but in general he was satisfied with our time together. All that was left to do was dissect the reasons why my rival had vacillated at the moment of decision. I began to formulate hypotheses as I stepped onto the green, my scorecard blackened with strokes and penalties. At last an easy decision awaited me - I yanked my putter out of the bag and prepared to send the traitorous sphere into the pit with one sweep of the pendulum.

Assuming cowardice is not the flaw when an oncologist fails to deliver an opinion, what then makes a highly trained specialist tongue-tied when a plan of action (or no action in this case) is desperately called for? I worried about certain defects known to appear in the physician if his career careens, such as passive-aggressiveness, or indifference. No oncologist could maintain his practice for long if he sank into this kind of wickedness, and I doubted that my competitor was actually deranged. Rather, I suspected he had floated up into the seductive cloud of indecisiveness that tempts all physicians. High above the laboring crowd, a doctor who asks his patients to choose their care can rest easy, knowing that if the outcome is unfavorable he cannot be blamed. He lives without fear of making a mistake, and therefore is technically immune from any retribution. Such an oncologist is agreeable at all times to all people, for he is but a messenger - an attendant lord in the royal court, his head safe from the chopping block. There are many ways to decribe a "no opinion" oncologist, and Eliot did it best:

Deferential, glad to be of use,
Politic, cautious, and meticulous;
Full of high sentence, but a bit obtuse;
At times, indeed, almost ridiculous--
Almost, at times, the Fool.

Decisions in cancer care are often agonizing for the oncologist, patient and family, but they must be rendered. In the kingdoms of old no great battle was ever won by a declaration from the Fool. A wise doctor will recognize this and summon up the courage to give his opinion and then stand by it - perhaps not with regal splendor, but with enough dignity to warrant a cheer from the brigade of warriors massing around him.

A Soft Answer Turneth Away Wrath

"Speak when you are angry and you will make the best speech you will ever regret."

-Ambrose Bierce

Once upon a time a fire broke out in a house, and as the fire chief arrived he could see many people hanging out of the windows upstairs, hollering for help. He quickly drew up a plan and his team of firefighters went to work with ladders and hoses. There were more people to be rescued than rescuers, and some victims had to wait their turn. Some residents became irritated and insulted their saviors, calling them slow, or clumsy. As the blaze was extinguished, a crowd gathered around the chief and bitterly criticized his leadership. When he defended his plan they accused him of being rude and unsympathetic. The chief tossed his helmet to the ground and lashed back at the residents. He blistered their ears, calling them ungrateful.

Some patients, like the sooty patrons of the house in this fable, have limited insight into the work involved in trying to save a life. They may be rude, demanding or unappreciative of their doctor's efforts. They might even be so blind as to fail to see that they have just been pulled from the consuming flames. How the doctor reacts to the cavils of the very same people he is sworn to help can determine both the success and the length of his career. No doctor enjoys caring for an obnoxious patient, no matter how infrequently this creature is found. If, however, a physician gives in to the temptation to humble the insolent, he places his calling in peril, and not just because of the possibility of being denounced to the State Board (cf. Blair, Eric Arthur 1903-1950). More importantly, once a doctor blows his stack he now has two adversaries competing for his attention - disease and anger.

All doctors experience "one of those days" when they cannot seem to please a patient or family member, or when they run into someone whose cup runneth over with churlishness. Since doctors tend to be self-centered and overrate their social skills, they interpret a negative reaction as an affront. They become incensed that anyone would dare to question their judgment or compassion - why some kingpins would even go so far as to call it lese-majeste'. Although it is acceptable as it is unavoidable that some hackle-raising will occur at this time, the doctor must quash anger before it bursts through the cracks. Anger is not only unprofessional, it is like smashing The Portland Vase in a fit of rage - one feels a savage sense of satisfaction at first, but then try to leave the museum without the guards noticing. A doctor who erupts at a patient will have to face the consequences sooner or later. His most precious commodity - his reputation - will sink like a torpedoed freighter if he fails to control his temper.

What then, could our beleaguered fire chief have done to soothe the irate crowd short of submitting his resignation? Well, for starters he could have summoned up what seems to be a rapidly disappearing attribute in these days of reality television - self-discipline. It takes only a moment of deep-breathing to delay the wrathful response, and by then hopefully another helpful concept, like a record plopping on the old jukebox, will begin to play in his mind - perspective. Keeping everything in perspective should be a constant goal of the doctor as he counsels, so that those in need understand that treatments such as chemotherapy, with all their distressing side effects, are necessary to achieve the prime goal of remission.

If these techniques are still ineffective in getting the villagers to drop their scythes and torches, try my personal favorite defense - humor. The use of humor in oncology has been neglected and is just now being recognized as an effective way to help patients cope with their illness. When applied appropriately it is a great way to raise spirits and give hope - especially if the boss tries a little self-deprecating jesting.

Finally, the doctor's last defense in a midst of a potential confrontation is this, as best relayed by the character Sgt. Barnes in the movie Platoon:

"Take the pain! Take it!"

In other words: shut up, Doc, and let the rant burn out on its own. Remember, this too shall pass, and the head will rest easier on the pillow tonight knowing that once again anger tried to take command of an emotional situation, and once again it failed like the miserable chump it is.

The Conundrum of Remission

One of the basic tasks a medical oncologist must perform is to determine whether a patient's cancer has responded to treatment. This evaluation is usually made by measuring the size of a tumor on physical examination or x-rays, and if the lesion is at least half its previous size a partial remission is said to have occurred, which is an encouraging result. Even better, if the mass is gone then the remission is labeled as complete. Patients whose tumors shrink less than half, remain the same size, or increase in size are formally deemed nonresponders, and using this system of reckoning, thought to face a grim future. For many years formal clinical trials of chemotherapy reported repsonses in this objective manner, as a way to predict which patients have the best chance to extend their lives. Once a tumor is measured on an imaging study, the answer to the question "Did the treatment work?" must be communicated to the patient and family.

I am the doctor who walks into an examining room and delivers this news.

Obviously my job is easy if the report is reassuring, but what if the cancer has not responded to therapy? When an x-ray reveals a meager response, how does an oncologist share this information without delivering a crushing blow to the hopes of his patient? The truth is, the manner in which I counsel a patient is one of the little-known quirks of the field of cancer care. Depending upon my facial expression, my body language or my demeanor in general, my answer - even if it contains discouraging news - may still calm the anxious face in front of me. Like an actor I may choose the role I wish to play that day - rescuer or villain, optimist or cynic. I can attach my own personal slant to the interpretation of the x-rays that may cause the patient to vow to fight on, or simply give up.

On this day - strange but true - I am the ultimate spin doctor.

There is a problem, however, in using the response rate to predict survival. Many new treatments available in the battle against cancer, such as monoclonal antibodies or growth factor inhibitors, nicknamed targeted therapy, can aid a patient without significantly reducing the size of a tumor. Cancer growth can sometimes be arrested, leading to a noticeable improvement in the patient's symptoms. This outcome has been enthusiastically described as "turning cancer into a chronic disease". In this setting it matters less that the tumor has shrunk but that it is no longer growing out of control.

If a patient can actually co-exist with cancer, then the significance of the response on x-ray lessens. Now, living with cancer no longer becomes an all-or-nothing game, where only those who rid themselves of the disease completely have any chance for a future. Even if an x-ray shows no signs of remission, if a patient feels better after receiving treatment my job is to provide encouragement and hope.

The treatment of cancer is changing - from a game of pure chance to a game of skill - a long campaign, with many battles, retreats when necessary, and an ever-shifting strategy against a faceless enemy.

Cancer therapy is not like playing the lottery, won by only a handful. To me it is like a long run to the top of a mountain called Cure. Some patients travel only a short distance before they drop from exhaustion. Others can sprint for miles, barely visible to the eye as they climb upward into the furrows and ledges. Some even reach the summit. All who attempt this ascent, whether it ends close to the base or on the bright peak, deserve to be called the bravest of the brave.