By Dr. Bruce Campbell
Mrs. Jordan, a withered leaf of a
woman, sits crumpled in the clinic
exam chair. I introduce myself to
everyone. Her husband, sister, and
daughter are serious, substantial
people who shake my hand firmly.
The woman’s grip barely registers.
She has been through much over
the past year. After her surgery, she
received a combination of radiation
therapy and chemotherapy for her
aggressive tongue cancer. She tells
me that she quit smoking, improved
her diet, attempted to go for a daily
walk, endeavored to be positive,
enlisted prayer partners, and practiced
self-care for the first time in years.
“I have been trying very hard.”
“That is great,” I respond. “So,
how can I help you?” I know that she
is visiting other centers after having
learned that her cancer has recurred.
Her prior surgeon has said that she is
not a candidate for another operation.
They want to see if surgery might still
be an option to rid her of her disease.
“The doctors back home have her
on chemo,” her husband tells me.
“We’re in a holding pattern.” He looks
at her and she nods back. “She wants
to keep fighting.”
“I can see that she has been
working very hard,” I say. The daughter
picks up her pen. There are several
questions written on her notepad and
she fills in the blank spaces as we
talk. They ask about the cancer and
its treatment. What might we offer?
What are the risks, given that she is so
weak? How urgent is it? Her husband
leans forward, attentive to every word,
raising his eyebrows whenever I pause
to frame my responses.
“Before I make any recommenda-
tions,” I say, “let me examine you.”
I put on a headlight and wash
my hands, then roll across the floor
toward her on the examination chair.
She winces as I feel inside her mouth.
“That’s okay, Doc. Do what you gotta
do.” The mass is hard and fixed to the
jaw. There are enlarged, firm lymph
nodes in the upper neck. Her tongue
does not move well. I look at her voice
box with a mirror and can see that the
cancer is creeping down the wall on
the inside of her throat.
As I work through the exam, I am
increasingly concerned about her
cancer and what I would need to do
in the operating room. The mass is
large but could be removed. It would
be a difficult, long procedure and
the reconstruction would be complex. Healing might be a problem
given her overall condition. She is,
indeed, a poor candidate for surgery
although it might still offer a slim
chance for a cure.
“The physicians at the other hospital
ordered some new scans a couple of
days ago,” the sister says. “Have you
“No. Let’s pull them up and see
what they can tell us.”
I log into the computer and pull up
the images. The neck scan confirms
what I already know. This is a large can-
cer but surgery is – barely – an option.
Next, I pull up the CT scan of the
chest and review the report. “Oh, oh.”
I turn the screen toward the patient
and her family. “These are her lungs
on the scan. Unfortunately, there are
several masses in the lungs that the
radiologist believes are new and grow-
ing. These are a sign that the cancer
has spread. I wish I had different news
for you but when these cancers spread
to other parts of the body, they are
very dangerous. Surgery would not be
helpful to her.”
The daughter puts down her pen.
“What do you mean?” she asks.
“Even with an operation, the cancer
will continue to grow in these new
places. We need an approach that
addresses the rest of the body, not
just the mouth.”
Surgeon Atul Gawande in his
book “Being Mortal” offers guidance
to physicians and families on how to
navigate these difficult discussions.
For years, my approach for patients
with recurrent, non-resectable cancer
was to send them off to the medical
oncologist with an optimistic but noncommittal “perhaps chemotherapy will
slow down or knock out the rest of
the cancer.” I have told people about
the occasional patient who has had
an amazing response – wondrous,
miraculous cures – with chemotherapy. I cling to these cases because
they have been so delightful and
“When there’s no
place for the scalpel,
words are the
surgeon’s only tool.”
Paul Kalanithi, When
Breath Becomes Air