With cancer, sometimes there is no right answer

Medically speaking, what’s a guy to do when there is no right answer?  My patient’s solution is often to ask me what I would do given his particular circumstance.  He isn’t happy when I respond with, “I truthfully don’t know.”

In reality, I always know what I would do.  I’d gather knowledge, see consultants, and explore every possible option to its fullest.  Then, most probably, I would still not be sure what I would do unless I was in the situation myself.  “What’s a man to do?” is a very personal question with many, nonscientific factors to be taken into account.

Case in point.  I’ve counseled many patients with prostate cancer.  I know all the treatments available and the pluses and minuses of each approach.  The common options include “watchful waiting”, some form of radiation, surgery, or a combination of the latter two.

What’s a guy to do if he has prostate cancer?  This is one disease where the answer is difficult and the stakes high.  Several years ago, I had an elevated PSA (screening test for prostate cancer) and an abnormal prostate exam.  While waiting for my biopsy results, I got a chance to look at all the options from a patient’s point of view.  I now know what I would do if my biopsy was positive but my decision-making process was unique to my life and what I feel is important.

Today, I counseled a patient with a precancerous lesion of his colon.  A routine screening colonoscopy revealed a polyp (tubular adenoma) that could not be fully removed by the gastroenterologist and has the potential to become a cancer.  Again, his options were watchful waiting with careful follow-up versus a surgical resection of part of his colon.

What’s a man to do?  Watchful waiting means yearly colonoscopies and biopsies.  In my early days as a doc, I saw a young lady with a slightly abnormal mole on her back.  I started to advise a watchful waiting approach when I realized that I was watching to see if she might develop a malignancy.  After I explained my reasoning, I removed the lesion.  The pathology report came back as an early stage of melanoma, a particularly nasty cancer.  Since then, I have not been a fan of watchful waiting.  Luckily for my patients, I surround myself with conservative surgeons who provide a nice balance to my aggressive surgical leanings.

Colon resection is no picnic, either.  To have a colon resection for a lesion that may never turn cancerous carries its own risks and expense.  What’s a guy to do?

In the business world, its called “due diligence.”  According to BussinessDictionary.com, due diligence is a “measure of prudence, responsibility, and diligence that is expected from, and ordinarily exercised by, a reasonable and prudent person under the circumstances.”  A reasonable and prudent patient, when presented with a disease that does not have a clear cut treatment option, needs to collect all the information he can to define his options, the risks and benefits of those options, and the costs; then he has to make a decision and live with its consequences.

Life’s a bitch sometimes.  Making decisions is hard work and you know you’ll win some and some you’ll lose.  What’s important is being able to live with the results of the ones you lose.  If you did your best to answer all the questions, to weigh all the choices, you’ll be able to live with your losses.  If your decisions were ill-informed and hasty, not only will you have to live with your losses, you will have to live with regret, as well.

Until they invent a “retrospectoscope,” a man has to work hard to understand his situation, to know in his heart that what he chooses to do is right at the time, and to accept his account, whatever it is.

I’ve always said that, if you can make something good come from something bad, the bad wasn’t so bad after all.  Somebody once said, “man plans and God laughs.”  At least I’ve given God some good laughs over the years.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • http://twitter.com/LymphomaJourney Andrew

    I really enjoyed this article and how it captured the decision-making process for patients (see http://www.lymphomajourney.wordpress.com for my own process which largely followed the same path). Also really good observation that the author was aware of his own ‘bias’ for treatment and thus balanced this with colleagues with different perspectives, a really good approach.

  • Anonymous

    Stewart, I am especially respectful of the very honest account of your dilemma.  I have stage 4 cancer myself and do not look at it as a desperate, do anything and everything situation.  To me one must recognize “I am not my body.”  Rather “I am the pilot of my body” and I am spirit, soul, or whatever you may believe.

    I recognize a life-shortening disease to be an important time of life.  One in which there can be great strides in learning what is truly important… and what is not important.  This is a spiritual learning , not an intellectual one.  (If there’s transparency others can learn also by simply watching and reflecting.)  And, it is me the patient who has all the answers somewhere within (another lesson of mine).  Following is an real example of using Questions for the self… a request & response to a friend who is asking for help.
    Dear Dyck …I am
    about to go to Hammersmith Hospital in London to remove a cancer problem in my
    right upper lobe ( lung ) they operate tomorrow so please share yourpowerful
    thoughts for a quick healing power so I can get on with my lovely life on this
    jumping green sphere. Went to Winchester Hill yesterday in glorious
    sunshine, the hill was alive with the famous chalk blue butterflies in their
    thousands. Have good times with your friends.. Be here now.. 
    Dear M,  This is the first I’ve seen of your poetic self.  It becomes you as I sense
    in your words a fresh wisdom and confidence. 


    As I turn inward to think of you, picture you… thinking of your face, how
    you walk, your thumb nail, your attitude towards money, your voice tone, your
    innocence, how I felt being around you… I’m getting a somewhat fuzzy,
    smokey picture as its been several years.  


    After a few moments, and coming into Now I’m beginning to sense the
    affection I had and still have for you… how all these years I’ve wanted to
    hear you play your guitar for me… how I sense a deeper, spiritual self in you
    that has always wanted to- and is coming out… how I find myself wanting to
    know more, have more, of the true M B


    I sense in you questions.  Perhaps one is, “What is there to learn from
    this experience?”


    For me, everything I’m learning is coming from having questions.., left
    open- active, pulling my attention to them over and over, allowing themselves to
    gather information & even allowing me to change them.  They seem to want to
    pull me up into them– not to be pulled down to fit my quick answers.  They keep
    me alive.


    My energy is gathering like a big rain cloud for your strength and
    wisdom.  Dyck~

  • http://musicsparks.wordpress.com/ JoAnn Jordan

    We as patients need to inform ourselves by asking questions and doing research as to the pros and cons of treatment. I was diagnosed with papillary thyroid cancer about the time new guidelines for treatment were released. Spending the time reading them & asking questions allowed me to make a decision that was best for me. 

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