Think Like A Doctor

Examining Scars for Residual Disease

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Eat Those Fruits And Vegetables

What You Say

What Your Doctor is Thinking

Examining Scars for Residual Disease ____________ Eat Those Fruits And Vegetables	Everyone who has been a healthcare provider at some point has a wrenching story that makes the cancer-free among us glad to be alive. Here's mine. As a medical student, I worked for a while in the breast cancer clinic. The first patient I saw was - are you ready for this? - a man. Few people know it, but men, too, succumb to this cancer. After I had participated in a discussion about bone marrow transplantation and high-dose chemotherapy with the patient, his wife, and the attending physician, I thought I was ready for anything. That was until I met a woman, who I'll call Sandra. Only sixteen years old, Sandra had been diagnosed with bilateral breast cancer the year before. After her diagnosis, she elected to have both breasts removed. I talked with Sandra, took a history, and completed an exam. When I reported to the attending, he said, "Great job, but you forgot to tell me about the breast exam." I smiled - was he joking? - and replied, "She has no breasts, sir." He looked at me and did not smile. "Are you sure that the surgeons removed 100% of the breast tissue during the mastectomy? Are you sure that there was no local invasion of breast cancer into the chest wall prior to the surgery? Are you sure that there is no way that there could be any local recurrence?" If you ever go to medical school, here's a hint: if a physician asks you, "Are you sure?", the correct answer is always, "No." In this case, "No" meant that five minutes and several deep breaths later I was breast examining a bilaterally mastectomized sixteen-year-old. Did you see the popular magazine cover some years ago that pictured a woman with a mastectomy scar? If so, then you might have some sense of the experience that I had with Sandra. How can you avoid cancer? With breast cancer, the biggest risk is being female. The second biggest risk is if you have had breast cancer previously. Third, family history and several other relatively minor factors. Not much of that you have control over, though. So the best way to avoid cancer in general is to live a healthy life. For more on that, see the cardiovascular chapter. In a nutshell, study after study has demonstrated that a nutritious diet, plenty of exercise, and refraining from smoking dramatically increases the likelihood that you won't get cancer. Specifically, eat a high-fiber, low-fat, low-cholesterol diet with lots of fruits and vegetables; exercise by walking or by being in some other way physically active for half-an-hour or so several times per week; and don't smoke. For my litany on smoking, see the smoking chapter. All I'll say now is that far more people die from lung cancer, due to smoking, than any other cancer. There are other things that you can do to avoid cancer aside from the healthy life stuff. For example, wearing sunscreen and not excessively exposing yourself to ultraviolet radiation (i.e., "laying out") can help prevent skin cancer. Getting PAP smears, mammograms, and breast exams on a regular basis reduces cancer risk for women of certain ages. The same goes for men with the testicular exam. Self-examinations are important - ask your doctor to show you how. Contrary to what many believe, cancer does not always end in death. I can count several friends of mine as survivors of cancer, and there's plenty of reason to believe that you too can beat this disease. But the likelihood that you'll survive cancer depends on the type of cancer and the stage of the disease. As far as cancer types go, for instance, Hodgkin's Disease and testicular cancer are often very curable cancers, whereas lung cancer and melanoma usually are not. Cancer is described in terms of severity by stage. There are four stages, summarized in a very general way in the table below. Please remember, though, that the stages differ from cancer to cancer, and survival differs from person to person.

		IN THE NECK OF TIME The neck shown here is outlined by the trapezius muscle on the right, the collarbone (clavicle) on the bottom, and the throat on the left. Note the mole. Fast-growing moles with irregular borders and funny colors (such as red, white, or blue) should be checked by your doctor for cancer. Mole cancer, a form of skin cancer called melanoma, is a particularly aggressive cancer, often metastasizing to the brain, so it pays to keep an eye on moles.

Stage	Basic Meaning	General Percent Survival Five Years After Diagnosis
I	Small amount of local disease	100% - 75%
II	Large amount of local disease	75% - 50%
III	Local disease and local lymph nodes and/or invasion into another nearby tissue	50% - 25%
IV	Metastatic disease (spread of cancer into tissues distant from the tissue of origin)	25% - 0%

So if you have just been diagnosed with cancer, how you should approach the future depends on the type and stage of the cancer. Your doctor will tell you both.

Any discussion of cancer should include end-of-life issues. Cancer is a disease that is relatively slow at causing death compared to a sudden heart attack or stroke. But, many times, it is fairly clear at the time of diagnosis that a patient could die from cancer. A key with deadly aggressive cancers, like pancreatic cancer, or metastatic (spread) cancers, is to understand that, unless your oncologist firmly believes otherwise, death is often imminent. In my experience, patients who have accepted the severity of their disease are generally far happier in the long run than those patients who do not. I was rounding in the hospital once and there was a fifty-year-old pancreatic cancer patient who said, "Just keep me alive until two weeks from Tuesday. I need to sign some papers, and then I'm ready to go." We adjusted his morphine, he signed his papers, and then he went. He did it right. And by every measure I know, he went happily. Contrast this to patients who fight the inevitable and make themselves as well as everyone else around them miserable in doing so. Accepting certain death is undeniably tough, but the alternative is tougher. Easy for me to say, I guess.

An important point concerning end-of-life issues, and throughout most other topics as well, is the need to trust your doctor. Oncologists have seen hundreds of people die. For this reason, they can somewhat reliably predict when you are going to die if you have late-stage cancer. Likewise, neurologists can somewhat reliably predict when you are going to die if you have a severe stroke, cardiologists can generally predict end-of-life issues for heart failure or severe heart attack patients, and intensive care docs can often tell you who's going to walk out of the intensive care unit and who's not. I've found that end-of-life issues are much harder on the family than on the patient. That's why I favor living wills and do not resuscitate (DNR) orders. You should leave your relative's life/death decisions up to him or her, unless he or she is mentally incompetent or unconscious. If your doctor suggests that signing a DNR or a Do Not Intubate (DNI) or a withdrawal of support order is the humane thing to do, then it almost certainly is the most humane thing to do. In other words, your doctor is telling you that prolonging the life of your loved one would be inhumane. If your mom or dad or husband or wife or son or daughter is in a coma and moves when you speak or smiles one day, then that often means absolutely nothing. The best advice I can give you is follow your doctor's advice, given that she knows infinitely more about patient care and end-of-life issues than we do.

But back to cancer. I think that it's important to know how typical cancer drugs work, so that you can decide along with your doctor if you really want to take them. The first thing to know is that cancer drugs, called chemotherapy, are toxic as hell. Cancer cells are your own cells, so it is very difficult to kill your cancer cells without killing you as well. Chemotherapy works by killing cells that divide rapidly, which include your cancer, along with the cells that make your hair, the cells that line your gut, the cells that make white and red blood cells. That is why people taking chemotherapy lose their hair, vomit a lot of the time, and develop infections. Radiation works the same way and has similar effects. The point here is that treating cancer is debilitating in many cases. Consider the toxicity of chemotherapy, then, when your doctor says that there is only a small chance that you'll be cured.

STUDY THAT BLOOD

Your doctor will want to check your blood every once in a while to make sure that things like your cell counts aren't out of whack. Low red blood cells, or anemia, could mean too little iron or blood loss. High levels of white blood cells could mean infection or may suggest blood cancers such as lymphoma, leukemia, or multiple myeloma. At any rate, such routine studies are a good reason to see your doc on a regular basis.

What You Say	What Your Doctor is Thinking
I know mom has stage IV breast cancer that has spread to her lungs and brain, but I want the most aggressive treatment there is to try and save her.	Is that what your mom really wants? If she doesn't die from the toxicity of the treatment, she will likely die from the cancer anyway.
If Lance Armstrong survived metastatic cancer, so can I. I want to do everything I can to beat this lung cancer.	Testicular cancer is an exceptionally curable cancer. Lance was an exceptional athlete.
Dad smoked 2 packs of cigarettes a day for sixty years and never got lung cancer.	He probably died of heart disease, which was accelerated due to cigarette smoking. If you smoke like that, odds are that you will get lung cancer.
I'm not feeling well and I have had a pain in my tummy for the past two days. I think that I might have cancer.	Unlikely. Let's rule out other, more common causes, like gastritis or viral disease.

• To avoid breast cancer

• Cancer and the risk of death

• The stages of cancer

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What's this?! Play the Diagnosis Game and test your clinical skill.

• Giving up or battling on

• How chemo really works

• All this and more below ...

TIPS: Somking, diet, exercise, Pap smears, breast exams, when to fight, how to deal with chemo ...