I run a dilator program for women with rectal or anal cancer where I educate patients about the need for and correct use of vaginal dilators to mitigate the effects of radiation on the vaginal wall. Many women don’t understand the need for dilators after radiation for this cancer, so I always start with a description of the anatomy and …
A story of how small things really can make a big difference
It was that time of the year at the cancer center — with treats all around, chocolates, cookies and gingerbread houses, gifted from the patients to their doctors. Yes, it was the excess sugar holiday season. Most of these patients were follow-ups — the already established patients of the cancer center, expressing their gratitude in taking care of them in the tough times earlier in the year. Among all the …
Stop comparing cancer with diabetes
Curiosity and apprehension. I experience this tension as a young man ushers me through large daunting doors with “Authorized Personnel Only” posted in bold red letters. Inside, a massive machine dominates the room, and yet my focus turns to the patient lying on the table, face covered in a white mask holding his head still while the technician targets the malignant brain tumor.
“All right in there?” the specialist asks, and …
My father is no longer a practicing neurologist, but he is forever a doctor
I was confused. Perhaps, I needed another cup of coffee. The chart did not make sense. Ellen, who I was about to see because she was transferring her care, was receiving medication for cancer that was a simple pill; inexpensive, with few side effects. What confused me is that it was obvious the therapy would not work.
Baffled, I called the oncologist who had been treating Ellen for two years. A …
It’s often a bad idea when patients order treatment
I’m writing to you from the future — approximately ten years from where you are now. You’re a few months into your medical oncology residency, just beginning to assimilate to the flow of your daily responsibilities as a doctor committed to the diagnosis and treatment of cancer.
You hate living in upstate New York, and are dreading the upcoming winter and the associated endless piles of snow and sub-zero temperature nights …
A letter to myself as a first-year oncology resident
I enjoyed Agatha Christie’s Hercule Poirot. Not only did the ingenious Belgian solve the murder so artfully. But someone identifiable is killed, and someone identifiable is the killer.
Epidemiological studies are whodunits, too. Except you don’t know who has been killed, what the murder weapon is, or who the killer is. You only know that a murder may have happened.
A study found a higher incidence of breast cancer with …
The mystery of false positive mammograms and cancer risk
She had been a patient for several years, and I still remember meeting her that first time: Her breast cancer was stage IV at diagnosis, already established in her bones; she was scared; she was in pain. Surgery was taken off the table, and she was referred for medical therapy. We had discussed prognosis, the incurableness of her cancer, …
At the end of life, medicine truly becomes an art
There are times, as a healer, I feel helpless. These are not just the moments when cancer consumes. I understand that the dread disease has yet been conquered, and there is still terrible loss. This not when I refer a patient elsewhere; I know my limits. Rather, these are the times when I am trapped, ignored, and the result is needless suffering.
In his classic, often quoted, 1942 short story, Runaround, …
Doctors are not in control. Perhaps this is our greatest challenge.
“Don’t forget to bring that stool card back in, OK?”
As he walked out of the room, carrying his portable oxygen, he turned back, with the nasal cannula in his nose, and replied, “I’ll get it back to you soon. I’d hate to have colon cancer.”
At this point, I’d hate for him to have a positive occult blood card. I could really care less about colon cancer. Colon cancer isn’t going …
I’m not worried about colon cancer. I’m worried about the potential colonoscopy.
Three decades at cancer’s bedside has taught me about fear. I have seen denial postpone critical diagnosis. I have watched mistrust and anger yield poor choice. I have fought against terror that spreads malignancy by delaying treatment. I have shared fury and devastation as horrid growths rip apart bodies, destroy families and end life.
After so many thousands of patients, so many wasted lives, you would think I would have given …
Fear, anger, and loss should have burned me out. But it hasn’t.
Recently, the World Health Organization (WHO) released its report condemning processed meat as a group 1 human carcinogen — a classification that includes such notorious companions as tobacco smoking, smokeless tobacco, and second-hand smoke. This is not surprising considering that processed meat contains many of the same known or probable carcinogens as cigarette smoke, like heterocyclic amines and N-nitrosamines.
Red meat was labeled in the runner-up category as a …
How the meat industry is acting like big tobacco
There is only one correct, perfect, absolute approach to life and decisions near its end. This truth relieves the doctor of final decision. The right way lifts the burden of anxiety, confrontation or guilt. The perfect path makes giving care at a very hard time, much easier. That correct course, the only way to treat every patient and every family, is exactly what the patient and family say it is.
This …
For each cancer patient, there is one perfect path
The past year had been a tremendously exciting time to be an oncologist, and to be a lung cancer oncologist in particular. It seems we hardly have time to get used to one newly approved agent before another one becomes available. In 2015, we have seen gefitinib (don’t I know you from somewhere?), afatinib, nivolumab (twice), pembrolizumab, necitumumab, and osimertinib all …
This is why a computer algorithm cannot ever fully replace a doctor’s judgment
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When is an advocate not an advocate? When should a spouse step back and let the husband make a treatment decision? When should an adult child of a man with prostate cancer let their father decide what is best for him? These are questions that, fortunately, I don’t have to ask all that often. Most men I see for prostate cancer …
When an advocate goes too far in the exam room
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 65-year-old man is evaluated after a recent colonoscopy, which disclosed a 2.5-cm pedunculated polyp in the sigmoid colon. The polyp was removed in its entirety in a single piece. Biopsy results showed a well-differentiated adenocarcinoma confined to the submucosa without evidence of lymphovascular involvement and a 1-mm margin. There is no family history of …
MKSAP: 65-year-old man is evaluated after a recent colonoscopy
The American Cancer Society (ACS), an advocacy organization that has fairly recently (and very positively) taken a more appropriate, evidence-based approach to cancer screening, recently revised its mammography recommendations. While it still recommends more mammograms than the U.S. Preventive Services Task Force (which doesn’t recommend starting until age 50, and then screening only every other year), it has raised the starting age from 40 …
The problem of expert fallacy in cancer screening guidelines
To cope with loss, oncologists simply forget. Perhaps, “forget” is not the right word. “Compartmentalize,” “separate” or simply “contain,” may be better. We put all those wonderful people who have died, all that suffering, all those lives, in a corner closet of our minds, close the door and lock them away.
Perhaps. However, all those memories remain; they are part of me. Quietly, they change how I practice medicine, what I …
Advances in cancer treatment are built on those of have suffered in the past
We have all seen patients whose distress is off the charts, or off the Distress Thermometer (NCCN). They sit in our offices, dazed and seemingly so depressed that we ask the mandatory question: “Are you thinking of hurting yourself?” Some patients just shake their head, not making eye contact, and even though they say they aren’t going to hurt themselves, we …
Asking patients about suicide sometimes feels out of place
Recently, a group of researchers in the World Health Organization (WHO) released a study that caused a bit of a kerfuffle. The group, the International Agency for Research on Cancer (IARC), published a paper classifying processed meat as a carcinogen. What’s processed meat? According to the authors, it’s “meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavor or improve preservation.” That includes …
Processed meats and cancer: How much is too much?
A new study in JAMA Internal Medicine finds that two-thirds of cancer drugs considered by the U.S. Food and Drug Administration (FDA) over the past five years were approved without evidence that they improve health outcomes or length of life. (This study closely corroborates and acknowledges the findings published last year by John Fauber of the Milwaukee Journal Sentinel and Elbert Chu of MedPage Today.)
Follow-up …
The FDA’s epic regulatory failure
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