Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The ability to diagnose cancer is a necessary evil

Dominic Donato, DDS
Conditions
July 8, 2015
138 Shares
Share
Tweet
Share

shutterstock_148383902

I am in my twenties.

I am a student in dental school. My seven classmates and I have gathered, notebooks and pens in hand, for the first day of our ten-day rotation at the Veteran’s Hospital oncology department.

Dr. Steele, a published expert in oral cancer, instructs us to follow him to the outpatient clinic. Some of those he’ll examine are initial consultations; others are follow-up exams. All are U.S. veterans. Many are homeless alcoholics, whose lifestyle, we’re told, predisposes them to oral cancers.

“I want each of you to take a look at this lesion on the right lateral border ventral side of the tongue,” says Dr. Steele in resonant tones. We bob our heads to find the right line of vision. The lesion is nothing more than a small red spot. Dr. Steele applies dye to the spot, examines the patient’s head and neck lymph nodes, then dismisses him.

“Well, what do you think?” he asks.

We are silent.

“Does anyone here think at all? What if I told you that the dye was absorbed by the lesion, and that there’s a positive submaximal node on the right side?”

Everyone is thinking carcinoma, but maybe it’s a trick question. I’d rather be quiet than incorrect.

Dr. Steele stares at the floor, biting his lower lip thoughtfully. Then his head snaps up. He puts his hands on his hips and stares at us.

“Well, I’ll tell you what I think. The odds are only about fifty percent that this patient will be alive in five years.”

I frown, slumping slightly in disappointment. I knew it was cancer … Most likely squamous-cell carcinoma. Why didn’t I shout it out? Missed opportunity, I conclude.

***

I am now in my forties.

My office is busy today; the schedule is full. A patient calls to ask if I can see her elderly mother because her denture is painful. I consent, and she arrives later in the afternoon.

The patient, in her late eighties, provides a history of smoking two packs of cigarettes per day for most of her life. I examine her and see no denture irritation. I do, however, notice a swelling under the right posterior part of the tongue. It feels firm to the touch. I have serious doubts about whether her denture is the problem. Nevertheless, I relieve the denture pressure in that area and tell her to return in one week.

The following week, neither the swelling nor the pain has dissipated. I am nearly certain that there is a tumor in the floor of the mouth.

“Well, I’m referring you to a surgeon,” I say. My words strike me as hollow and solemn; moreover, they are not enough. Without more explanation, she may not understand how urgent it is that she go to see the surgeon. I search for the words that I don’t want to say.

I have found my first cancer — or perhaps it has found me. How should I tell the patient what I suspect? As I stand there, staring at the floor, she speaks softly and slowly.

“It’s OK. I know.”

Her eyes are fixed upon me, her body motionless, her words calm and deliberate. But it is her smile — forgiving, accepting — that I remember most. It conveys the philosophy and grace that old age sometimes brings.

She will die less than a year later.

It’s been only a few weeks since the elderly lady with the memorable smile was diagnosed with cancer. A friend of mine, a man in his early eighties, calls for an appointment because he’s having pain on the left side of his tongue.

The lesion looks like a laceration, but I cannot find the cause. It’s possible that he cut the underside of his tongue on his denture clasp, I reason. I send the prosthesis out to have the clasp repaired. I give it back to the patient and ask him to return in one week. He is a cigar smoker, and I pray.

My friend returns the following week, but the lesion persists. I phone the surgeon.

“Joe, I’m referring another patient to you for a biopsy. The lesion is on the right lateral ventral tongue. I believe it has a high probability of being a carcinoma.”

“Now you’re seeing them everywhere,” Joe chides. “That sometimes happens after your first cancer diagnosis; you get too cautious.”

“I hope you’re right,” I retort. “This guy is a friend of mine. I’ve known him all my life. I’d appreciate it if you would see him as soon as possible.”

“OK, have him call my office. I’ll get him in this week.”

The following week my receptionist says, “The surgeon is on the phone. Can you speak with him now?”

“Yes,” I reply. Leaving my current patient still supine, with cotton in his mouth, in my assistant’s care, I go to take Joe’s call.

“Well, it looks like you found another one,” he says. “I biopsied it. We’ll know for sure in about a week. I told them to rush it.”

Once, as a dental student, I preferred to be silent rather than incorrect. Now, being incorrect would suit me just fine. But the lesion indeed turns out to be malignant, and my friend, who was gregarious and outgoing, becomes sullen and despondent. He passes away nine months later.

His ordeal and death affect all who knew him. For his loved ones, the world is now a different place. At his widow’s request, I arrange the funeral and even choose the casket.

Yes, my differential diagnosis was correct. Dr. Steele would have been proud, I’m sure. But I feel no sense of vindication.

***

I am now in my sixties.

Dr. Steele taught me to examine lesions carefully and to look closely for even the smallest signs. But years of practice have taught me to observe more broadly as well. As a consequence, I’ve learned some things that apply to all malignancies; namely, that they are always attached to someone, and that, interestingly–and contrary to what I was told as a student–they are contagious. I have seen them sicken not only my patients but also the lives of their loved ones.

I no longer see the ability to diagnose cancer as an opportunity for self-congratulation. It has become a necessary evil.

And now when I see a suspicious lesion, my first thought is, How many lives will this change?

Dominic Donato is a retired general dentist. This article was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

Image credit: Shutterstock.com

Prev

Dr. Robert Wachter: In defense of the ABIM

July 8, 2015 Kevin 47
…
Next

There are only 3 ways to allocate health care resources

July 8, 2015 Kevin 13
…

Tagged as: Oncology/Hematology

Post navigation

< Previous Post
Dr. Robert Wachter: In defense of the ABIM
Next Post >
There are only 3 ways to allocate health care resources

More in Conditions

  • The beauty of a patient’s gratitude

    Dr. Damane Zehra
  • From clocking in to clocking out: the transition to retirement

    Debbie Moore-Black, RN
  • Overcoming Parkinson’s: a journey of laughter and resilience

    Cynthia Poire Mathews, FNP
  • The untold struggles patients face with resident doctors

    Denise Reich
  • Maximize sleep efficiency with stimulus control

    Pedram Navab, DO
  • The endless waves of chronic illness

    Michele Luckenbaugh
  • Most Popular

  • Past Week

    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician
    • From clocking in to clocking out: the transition to retirement

      Debbie Moore-Black, RN | Conditions
    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
  • Recent Posts

    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Maximizing physician potential: How coaching can aid in conflict resolution, enhance health care leadership and build stronger teams

      Asha Padmanabhan, MD | Physician
    • The future of education: AI empowerment, YouTube college credits, and the impact on traditional colleges

      Harvey Castro, MD, MBA | Tech
    • The beauty of a patient’s gratitude

      Dr. Damane Zehra | Conditions
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Moderna's Steep COVID Vaccine Price: Corporate Greed or Capitalism?
  • House Republican Argues Against FDA Budget Increase
  • Prescriptions for Stimulants Jumped During the Pandemic
  • Federal Judge Strikes Down ACA's Preventive Care Coverage Requirements
  • Pandemic Jump in ED Visits for Firearm Injuries Continued Into 2022

Meeting Coverage

  • VTE Risk in Recurrent Ovarian Cancer Increases With More Lines of Chemotherapy
  • Obesity's Impact on Uterine Cancer Risk Greater in Younger Age Groups
  • Oral Roflumilast Effective in the Treatment of Plaque Psoriasis
  • Phase III Trials 'Hit a Home Run' in Advanced Endometrial Cancer
  • Cannabis Use Common in Post-Surgery Patients on Opioid Tapering
  • Most Popular

  • Past Week

    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • The untold struggles patients face with resident doctors

      Denise Reich | Conditions
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician
    • From clocking in to clocking out: the transition to retirement

      Debbie Moore-Black, RN | Conditions
    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
  • Recent Posts

    • Lessons from an orthopedic surgery journey [PODCAST]

      The Podcast by KevinMD | Podcast
    • Beyond pizza and pens: National Doctors’ Day should be about saving lives

      James Young, MD | Physician
    • Maximizing physician potential: How coaching can aid in conflict resolution, enhance health care leadership and build stronger teams

      Asha Padmanabhan, MD | Physician
    • The future of education: AI empowerment, YouTube college credits, and the impact on traditional colleges

      Harvey Castro, MD, MBA | Tech
    • The beauty of a patient’s gratitude

      Dr. Damane Zehra | Conditions
    • Physicians are a finite resource we need to protect

      Jack Resneck, Jr., MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The ability to diagnose cancer is a necessary evil
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...