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.
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