Cancer Doesn't Care

Cancer does not care what you think or what you feel. It does whatever it wants.


Several months ago a young man came into our office with a strange looking lesion on his scalp. I was not sure what it was but I knew it wasn’t normal. It was big enough and weird enough that I referred him on to a specialist for the biopsy. My worst fears were confirmed when the pathology report came back as a very rare type of melanoma, the most deadly type of skin cancer. I referred the patient to a cancer specialist for ongoing treatment.

The cancer doctor immediately recommended that he see a plastic surgeon for a wider excision to make sure that none of the cancer was missed and to also biopsy a lymph node in the area to make sure the cancer had not started to spread. The patient didn’t want to go. He didn’t want the scar, didn’t want to deal with the recovery, didn't want to believe it was serious. He refused to listen to the oncologist’s warnings not to trust that all of the cancer had been removed in the initial incision. The patient refused the doctor's advise and decided to instead try herbs and holistic medicines.

The cancer wasn’t impressed with the patient’s interest in natural remedies, nor did it care that the patient believed he was cured. It spread anyway, and it spread everywhere. Lungs, liver, and bones all had tumors within a matter of months. The patient is in his early twenties and is too young to die. The cancer does not care. The odds for long term survival are not good. 

Cancer never cares what we want or think. It is a heartless killer. Colon cancer does not care that you are afraid of having a colonoscopy, is not moved by your embarrassment about having someone insert something into your rectum, or worry that you can't take the time off of work. It ignores all of our concerns and attacks who it wants when it wants. It will attack 1 in 20 Americans and do what cancer does. If not caught in time it will spread and it will kill.

Breast cancer does not care that mammograms can be uncomfortable or that you have sensitive breasts. It does not care that no one else in your family has had cancer, or how big or small your breasts are. It will attack 1 in 11 American women and do what cancer does.

Cancer can not be wished away or ignored into oblivion. It does not care how positive your thoughts are. It does not care how many children you have or about your retirement plans. It moves at its own pace on its own timetable. It does not discriminate. It does not care about the color of your skin, your religious faith or what you do for a living. For many cancers it does not care whether you or male or female. It does not care whether you or rich or poor. It can attack anyone and when it does it will try to do what cancer does. It will spread and it will kill.

So what can we do? Like any enemy it is best to attack when the opponent is weak and small. While early detection does not always guarantee victory there are cancers for which it truly matters, such as breast and colon cancer. Smart people get colonoscopies and mammograms done when they turn 50. Smokers can stop smoking, and those who have smoked too long and too much can get CT scans to look for cancer after age 50 as well. When diagnosed with cancer we can listen to our doctors and pursue aggressive treatments, and trust their opinions more than our feelings. We deny denial a chance to harm us. We can do these things because we care about ourselves and our families, even when cancer doesn’t.

- Bart

Thanks for reading and sharing. More importantly, thanks for getting your colonoscopies and mammograms!

A Dying Patient, Deceitful Doctors

He was dying. There was no cure for his pancreatic cancer, no way to halt the inevitable, so he lay in his hospital bed and waited, day after day after day. Every three days or so he received a blood transfusion. His initial surgery for the cancer, performed two years earlier, included the removal of a section of his small intestine. This was followed by radiation treatments that damaged the area where the intestines were sewn back together, causing a large, bleeding ulcer.

Under normal circumstances an ulcer like his would be treated with surgery. Terminal pancreatic cancer is not a normal circumstance so the decision was made to treat him with periodic transfusions, keeping him alive until the cancer killed him. In addition to bleeding the ulcer also prevented him from eating a normal diet. He was severely malnourished and his strength had faded away. His weakened condition made it difficult for him to walk and his need for repeated blood transfusions rendered him too sick to be discharged from the hospital. He was resigned to spending his remaining days in a hospital room, occasionally moving from his bed to a chair. It wasn’t much of a life but he didn’t have long to live anyway.

He was in a VA hospital, transferred there after he reached the lifetime maximum on his private insurance plan. He went from the personal care of a private hospital to the impersonal care of the Veterans Administration. At the VA inpatients did not have a personal physician. They were cared for by a team of doctors in training. The team consisted of a third year Internal Medicine resident, two Internal Medicine interns and two medical students, all supervised by an attending physician. On the first of every month the team changed and the patient was introduced to a new group of doctors, all of whom were new to him, none of whom had ever read his chart. As he was a chronic patient his chart was several inches thick and contained over a year’s worth of his medical information. It was so thick that no one bothered to read it.

I took over his care in January 1989, my final year of medical school. After hearing his story form the other doctors on the team I expected him to be the stereotypical grumpy vet. He was anything but. He was kind, appreciative and gracious. He had accepted his fate and come to terms with his condition. He expected little from the care team and was grateful for any conversation. I genuinely liked him.

One night when I was on call I decided to be the first person to read his entire medical record. It was a slow night so I poured myself a cup of coffee and started flipping pages. I reviewed the records of blood transfusions, lab results and the portion of physician notes that were legible. As I thumbed through the pages I came across a pathology report from the Mayo clinic.  As I reviewed the report my jaw dropped and my heart skipped a beat.

He didn’t have cancer. The pathology report from the Mayo clinic was a second opinion on the specimen from his original cancer surgery. The expert review stated that the correct diagnosis was chronic pancreatitis, not pancreatic cancer. He did not have a terminal disease, he had not needed the surgery, nor the radiation. He had been completely misdiagnosed. Even more troubling was the date on the report. It was over 2 years old.

I sat back in my chair and wondered what to do. All of the treatment decisions and recommendations for the last two years had been based on a lie. He had been told he was incurable so he had never been offered curative treatment. He had wasted away from a bleeding ulcer because he was told he would soon be dead from cancer. He didn’t have cancer, which meant that if he regained his strength he could have surgery to treat the ulcer. If the ulcer could be treated, he would no longer need blood transfusions. If he no longer needed blood transfusions, he could go home.

I called my senior resident and showed him the report. “We have to tell him,” I said, “this changes everything!”

His response stunned me, “You can’t tell him,” he said firmly. He explained that the decision would be up to the attending physician as he was the one who would be held responsible and liable for the information and its consequences. The resident was concerned about malpractice liability, afraid that the patient might be angry when he learned of the misdiagnosis. He did not want anyone mad at him for informing the patient and he did not want me to inform the patient either.

I was not at all happy with his response. It seemed to me that the patient had a right to know the truth and that we had an obligation to tell it to him. In my mind there was nothing to discuss or debate. I shared these feelings with the attending physician at rounds the next morning. He was as unconvinced at my argument as the resident had been. He felt that the patient had potentially reached the point where he was not going to survive, with or without cancer, so there was nothing to be gained by telling the truth.

I refused to accept his answer. I knew they felt that it was not a medical student’s place to challenge the opinions of superiors but I felt responsible to the patient. I pushed for additional review from the hospital ethics committee. My persistence paid off. An ethics consult was requested.

Later that evening I found myself with 7 physicians crowded into a room that comfortably held 5 people. I was the least experienced person present but I was the one presenting the patient’s case to the ethics committee of the VA hospital. They listened attentively to all I had to say as I presented the patient’s case to them and as they listened to the concerns of my resident and attending. It did not take them long to reach their decision. The patient had a right to know everything about his care and diagnosis.

The next morning I told the patient his correct diagnosis. I told him that he did not have cancer and that if he regained his strength he might be a candidate for surgery to cure his ulcer. He was appreciative and gracious. I ordered a nutrition consult to see what we could do to improve his overall health.

It was too late. The patient died a few days later.

Although my efforts did not change the course of the patient’s treatment or the ultimate outcome my experience with him did have value. It changed me forever. I made myself a promise that what had happened to him would never happen to a patient under my care. I vowed to be thorough, to be complete and to be diligent. No chart would be too thick, no history too exhaustive, no patient too complicated to ignore or dismiss. I realized that there would be patients for whom quality care would require uncompensated hours of chart review and I promised myself that when those patients came to me for care I would invest those hours.

Almost 20 years have passed but I have not forgotten my promise. Two weeks ago a new patient came to see me for the first time. He brought with him a list diagnoses that included congested heart failure, diabetes, hypertension and chronic pain along with an extensive list of medications. In keeping with my promise, I scheduled him for an hour long appointment. During that appointment I logged into the hospital system and reviewed his lengthy history. Halfway through my review I came across an echocardiogram report. The report described a perfectly functioning heart. The diagnosis of heart failure, one that he had carried with him for 8 years, was incorrect. The diagnosis had been handed down from one doctor to the next, unquestioned, for all of that time. I did not hesitate to tell him what I had found.

I ordered additional testing and referrals so we could plan a new course of treatment. As I filled out the referral request and entered the medications into his chart I was again reminded of the patient from the VA, and I was grateful for the lessons he taught me. Good medicine takes time. Good doctors invest as much time as is needed.


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A Cancer Diagnosis- Missed

It was cancer and I missed it. I not only missed it, I missed it badly. The thought of malignancy never entered my mind. He had come in a few months earlier complaining of pain along the lateral aspect of his thigh. He was tender over the iliotibial band so I diagnosed him with iliotibial band syndrome and sent him to a physical therapist. When he came in a few weeks later reporting improvement I was confident I had made the right call.

The improvement did not last and within the month he told me the pain had worsened. Perplexed, I referred him to an orthopedic surgeon. The orthopedist ordered an MRI of the area and the accurate diagnosis was made. He had a tumor in the muscle of his thigh and it was malignant.

I never saw the patient again. Our final contact was over the phone. He had called me to tell me he was firing me as his doctor and would be seeking care elsewhere. He was convinced that it was my fault the diagnosis had been delayed.

I told him I understood his anger and frustration and that I wished I had thought to order the MRI sooner. I explained that he was the first patient with muscle cancer I had ever encountered and that the diagnosis was rare. Because it was rare, muscle cancer was not something high on my list of possible causes. I told him that doctors typically start with common diagnoses and then move down the list, that if doctors began every course of treatment searching for the extremely rare serious condition they would not be good doctors. He was not satisfied with my explanation.

He was not the only patient to leave my practice over his diagnosis. His wife and a family friend joined in the exodus, convinced that I was a “bad” doctor. I grieved at their decision and wondered what I could have done differently.

The truth is there was nothing I could have done. I am a human being with all of the imperfections that come with it. Medicine is to broad and the body too complex for any one doctor to master it all. Perfection is impossible.

In spite of my years of education and hard work, each day I find myself facing the reality that I will miss things. I hate this reality and it is a source of intense fear and anxiety but it is inescapable. I will occasionally make mistakes. Like every working person in the world my only option is to do the best I can every day and hope for the best. When my best is not good enough I have not choice but to accept the outcome and rely on the grace of others. More importantly, I need to extend the same grace to others when they fall short. 


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The Loneliness that Cancer Brings

Two young children and a husband with cancer. It was impossible not to worry. She tried to be positive and supportive, but the fears were inescapable. What if the cancer spread? How many years did they have left? If her worst fears materialized, how would she make it?

Her husband either did not share or fears or did a much better job of suppressing them. Like so many cancer patients I have seen he decided that talking and worrying didn’t change anything, so he focused on getting back to work and a sense of normalcy. He kept the details of his Illness a secret to his friends and his extended family, preferring to avoid the questions and the scrutiny.

While this modified form of denial seemed to work well for him it was difficult for her. Unable to share the secret she often felt alone in her grief and worry. She longed to be able to tell others, shed tears, and receive hugs and prayers.

Theirs is not an uncommon tale. A cancer diagnosis is typically more difficult for family members than it is for the patient. The patient focuses on treatments and recovery, the family just worries.

The stress of family members illustrates another common aspect of our society, isolation and lack of community. Deep friendships and meaningful relationships are increasingly rare. People focus on work and family with little time for anything else. Acquaintances are made with other parents through youth sports and activities but there is little opportunity for serious conversations at soccer games and pizza parties. When difficult times come people often have no where to turn.

Years ago I heard a pastor bring this point home by asking the question, “If your husband or wife was in the ICU facing death, who would you want sitting by your side?” Most people struggled to come up with more than a handful of names.

The pastor’s question and the young mother’s struggles serve as a powerful reminder of how important it is to develop friendships and invest in the lives of others. We never know when we may need encouragement and support or when others may need us.

- Bart

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