Smoke, Smoke, Smoke that You-Know-What

Medical oncologists are often asked to see patients who have abnormal physical findings or x-ray results but have not yet been diagnosed with a particular type of cancer. Sometimes when a malignancy presents in multiple locations it is difficult to determine where it originated. If the source of the cancer can be found then the treatment can be better tailored for that specific type. Since doctors love to show off their powers of deduction and intuition they usually rise to this challenge and begin to hunt for the clue that will solve this mystery. The denouement can be surprising and sometimes change a patient's prognosis for the better. For example, I remember a patient who had to undergo exploratory surgery for a pancreatic mass after a needle biopsy was unrevealing. He was found to have pancreatic lymphoma, not the typical devastating diagnosis of carcinoma. He achieved a complete remission with relative ease.

Before recommending scans or operations though oncologists must conduct the ancient and hallowed rite called the taking of the history. During this crucial interview they seat themselves before the patient, nodding in a rhythmical cadence while they listen as if wearing a Roman collar. Crucial information about the patient's symptoms and medical past are recorded and then a key question is asked which brings a pause, like a penitent admitting a mortal sin in the dark-curtained booth. The confessor's response can frequently portend both the final diagnosis and the prognosis. The question is, "Do you smoke cigarettes?"

Patients who answer yes can be considered to have lung cancer until proven otherwise.

I happened to meet such a patient recently who had multiple lung nodules on chest x-ray. The source of these nodules was not apparent and I considered several possiblities, but as we reached that point in the interview and he replied that he had smoked for over thirty years I realized it would be foolish to consider any other type of cancer - he just looked like someone with lung cancer.

"Doc, I haven't been sick my entire life but for the last couple of weeks I've been coughing and getting short of breath," he said, "and my right hand is cramping up on me." On exam his right hand had more than muscle spasms - it was nearly paralyzed. Within a day he was diagnosed with non-small cell lung cancer. The remainder of his life could now be seen as clearly as a mountain appearing out of the misty clouds, a coffin resting on its peak.

How did this man end up sitting in my office rubbing his claw-like hand, waiting for me to schedule a CT scan of his brain to confirm what I almost assuredly knew? Would he have chosen to smoke all those decades ago if he knew he would die from lung cancer? It seems unlikely that any sane person would but one forgets the stranglehold myopia has on the young, who are essentially incapable of visualizing themselves as old let alone dying.

Those who take up smoking in their teenage years may know it is unhealthy, but can they actually perceive how awful the consequences will be if they contract a tobacco-related malignancy?

I imagined my patient as a young man just out of school and starting his adult life, buying his first pack of cigarettes after work and unwittingly taking the first step toward a ghastly and ignoble death. An allegory about cigarette smoking suddenly appeared before me:

Deciding to smoke is like standing before the road that represents one's life, admiring two giant limosines parked side by side. A chauffeur stands beside each open door, beckoning riders to enter. One vehicle is marked No Smoking and the other has a sign on it that says Smoking Allowed. Some people choose the former car and others enter the latter and light up as the limos take off. Both cars speed down the road of life which wanders through hills and valleys, curves and straightaways, all signifying the major events of life - the highs and lows, the difficult times and periods when life was easy. The cars climb up higher and higher - the road becomes narrower. Up ahead the riders see a nasty hairpin curve. It is marked with a huge sign consisting of one letter only - "C". As the limosine full of nonsmokers hits the curve it squeals, fishtailing across lanes before finally regaining control and continuing to hum on down the highway.

The other vehicle flies off the cliff like a condor soaring over a valley, then tumbles down the mountainside, disintegrating as it rolls. Muffled screams echo briefly across the canyon before falling silent.

Not all smokers die of cancer, of course, and not all cancer victims are smokers. But those who decide to become addicted to the "coffin nail" should take a moment to ask themselves:

"Is it too late to change cars?"

Medical oncologists are like homicide detectives. We can find out how a death occured and why it occured. We just can't bring the deceased back.