When I told him he had a four-centimeter-diameter cancer in his right lung, his immediate reaction was, “I’m worried about my parents.”
“IT’S JUST A CASE OF MIDDLE-AGED HYPOCHONDRIA.”
“NO, IT ISN'T” WAS MY MIND’S BLUNT REPLY. AS I STARED AT THE NEATLY HANDWRITTEN WORDS. I FELT MY FACE GRIMACE IN RESPECTFUL ACKNOWLEDGMENT OF FATE’S TIMING. WHICH HAD BROUGHT ARLAN’S LETTER TO MY DESK JUST MOMENTS AFTER THE RADIOLOGIST HAD CALLED WITH THE RESULTS OF HIS CHEST X-RAY.
Arlan is 47 years old.
His tall, lanky frame, big nose, and self-effacing demeanor remind me of me. Two days previously, he had come into my office because he had lost more than 20 pounds in four months and did not know why. He otherwise felt fine and did not have any other symptoms. Over 25 years of cigarette smoking had given him a chronic morning cough, but this was not any worse than usual lately.
Our scales confirmed his weight loss, but I could not find anything else wrong on his physical examination. It was because he felt so well and I hadn’t yet made another diagnosis that he felt obligated, just after he left my office, to write me to denounce himself as a hypochondriac.
An evaluation for weight loss of unknown cause always leads to a discussion of cancer, and Arlan had responded with his characteristic candor. He feared the disease but had no difficulty talking about it, probably because he had spent so much of his life talking to psychiatrists.
Arlan has chronic undifferentiated schizophrenia, a condition that tends to isolate its victims because the disease distracts them from everyday, necessary tasks. Powerful thoughts, often including visual and auditory hallucinations, invade schizophrenics’ minds in a reckless, random fashion. The disease’s worst victims cannot separate reality from these intrusive thoughts and their consequent delusions. Thought processes become disorganized as an affected person tries to survive in a world where, for example, everyone can hear his thoughts over the radio, the FBI pursues him, Jesus Christ speaks to him, or a voice he doesn’t recognize keeps telling him to kill himself.
In most cases, symptoms start at about age 18, a time when society expects us to become independent. Performance in school and/or work declines as the unrelenting thoughts ruin the schizophrenic’s ability to concentrate and distract him from his basic needs, particularly self-care. One of the reasons most of us do not have many schizophrenic friends is because when they are ill, they do not conform to our grooming standards. They smell terrible because they do not bathe. Their hair is too long and splays out in all directions. They cannot “pull themselves together.” Disorder and chaos torture them, and before long many seek any kind of shelter from their hyperactive brains’ never-ending assaults. That’s when many schizophrenics discover cigarettes.
“I know they’re dangerous,” Arlan told me after I called him into my office. “It’s not like I didn’t know this could happen. But cigarettes allow me to focus, and I just can’t give that up."
As much as I detest cigarettes, I had to wonder if this wasn’t a common but seldom-acknowledged medicinal use. I thought of Gloria, who began smoking in her early teens. Sexually molested at age 3, a runaway at 11, and an intravenous drug user at 12, Gloria learned growing up on the streets of Oakland not to trust anyone. Add the hallucinations and delusions of chronic paranoid schizophrenia to that background, and you get a mess.
When I met Gloria in March 1993, her horrible luck was about to get worse: she had cancer, but neither of us knew it. During that first visit, she told me she had been losing weight for five years, but for the past few months had felt even worse than usual because of frequent nausea while eating. I examined her entire body and couldn’t find anything wrong with her, so I did a tuberculosis skin test and ordered a blood chemistry panel, blood count, syphilis test, thyroid test, and an HIV test. All were normal, and when she came back two weeks later, she had gained a pound, so I began to treat her for depression.
I didn’t hear from her again until October, when she called from Oakland's Summit Medical Center wanting me to come see her. She was in the hospital with hepatitis, and a gastroenterologist had just discovered the cause: an unusual cancer in her bile ducts. If something, most commonly a gallstone, blocks the biliary system, the pressure of the blocked bile behind the obstruction causes liver cells to inflame and die, resulting in the clinical illness of hepatitis. She had come to the hospital looking yellow and suffering from severe nausea. I noted that with her black face, yellow eyes, and ever-present scarf covering her hair, she had the frightened, vulnerable look of my cat staring into the headlights of an oncoming car. “I’ve been poisoned,” she insisted each day. With her counselor’s help, we got her through surgery and a stormy postoperative course. She still has no signs of cancer recurrence, but at every visit she tells me she has either been poisoned, infected with HIV, or infected with something else. She asks for antibiotics to clean herself because she always feels dirty. And she still smokes. At the close of every visit, she thanks me, gives me a hug (as a rule, I don’t hug my patients, but I make an exception for Gloria because I don't think anyone else in the world does), and changes the paper on the exam table because she doesn’t want to create extra work for Rhonda, our medical assistant. Behind all that fear and paranoia lies one of the sweetest personalities I’ve ever seen.
Arlan also has one of those sweet personalities. When I told him he had a four-centimeter-diameter cancer in his right lung, his immediate reaction was, “I’m worried about my parents.” They are in their 80s and had just sold the house in which they had lived for decades. Arlan had promised to help them move in a couple of months, and he did not want to add to the trauma of their moving. We talked over his situation for a while and decided it would be best to finish “staging” (determining where it had spread) his cancer before he told his parents so they would know whether he would undergo surgery.
The process of diagnosing and staging cancers still scares me, because the results allow us to predict whether the patient is going to die from the cancer or have a decent shot at living long enough to die of something else. Arlan is the same age as Jerry, my last lung-cancer patient. A stocky, barrel-chested, bespectacled engineer and also a great guy, Jerry came into my office as a new patient two years ago, having quit smoking one month prior to meeting me. He complained of gradually worsening cough and shortness of breath. Listening with my stethoscope to the breath sounds in his chest, I heard wheezes, indicating mucus obstructing the small airways toward the periphery of the bronchial tree, and rales (rhymes with “tales” or “pals,” depending on whom you ask), the crackling tissue-paper sounds caused by that fluid in the lung tissue at the end of those small airways. I treated him with antibiotics and two types of inhaled medication, and when I saw him one week later, he was somewhat better. Three weeks later, though, he wasn’t better, so I ordered a chest X-ray.
“Jim, you will not believe this guy’s X-ray,” the radiologist informed me over the phone the next day. “He has something awful going on in his chest, probably cancer, maybe infection, maybe both. You have to see this.” After finishing with that morning’s patients I walked the two blocks to the radiology department to see the ugly picture. Three quarters of Jerry’s chest was white; only his right upper chest showed the dark-gray translucency of normal lung tissue. I had never seen anything like this in a patient who was not severely ill in the hospital; Jerry was still walking around and not even breathing hard, at least not at rest.
I sent Jerry to see Jim, a Berkeley pulmonologist whom I met while I was a medical student at UCSD and he was doing his internal medicine residency. Jim had Jerry cough a sputum sample into a cup and sent it to the pathology lab. That turned out to be all the staging Jerry needed.
“I’ve got horrible news.” It was Jim on the phone three days later. “He has terminal bronchioalveolar carcinoma (terminal referred not to Jerry’s present condition but to the terminal bronchioles, the smallest airways at the end of the bronchial tree). The pathologist called it from the sputum. You literally cough this cancer from a part of your lung to everywhere else.”
I knew the answer, but I had to ask: “Is there anything we can do?"
“Call the priest” was Jim’s honest answer. “He doesn’t have much time.” He died three months later.
The appearance of Arlan’s X-ray, showing the single abnormality without any surrounding tissue changes nor any evidence of enlarged hilar (in the center of the chest) lymph nodes, meant that we bad a much better chance at a good outcome, and I was able to convey to him some of that optimism. I ordered a chest CT scan to get a better look at the cancer and lymph nodes, and once again the result was encouraging: possibly one enlarged central ipsilateral (on the same side as the cancer) lymph node was involved, but other than the primary tumor, there were no other abnormalities. I sent him to another Jim, this time a chest surgeon. He took Arlan to the operating table and removed the lower and middle lobes of Arlan’s right lung, along with six lymph nodes, two of which contained cancer. As is true of most of our organs, we have more lung tissue than we need, and if Arlan can abstain from cigarettes, he won’t miss the lung tissue he lost to cancer.
I haven’t seen Arlan since he left the hospital. I often don’t see my cancer patients for a few months after they begin cancer treatment because they have so many other appointments with other doctors: the surgeon to make sure they heal; the medical oncologist for chemotherapy treatments; the radiation oncologist for radiation therapy. Arlan has seen all of these doctors and sought second opinions from other radiation and medical oncologists, but he did keep his appointment with my colleague Valerie while I was away on paternity leave. As of that visit, he had stayed away from cigarettes for 39 days.
Four weeks after Arlan left the hospital, my wife had our baby, and about a week after that, Arlan sent me a gift: a tape of an album he recorded, along with a bound typewritten volume containing the lyrics. He wrote the songs and played all of the instruments, and it’s a perfect self-portrait. The awkward rhythms, clumsy and sometimes dissonant harmonies, and bitter social commentaries interspersed with gentler sentiments of love and compassion are without question Arlan’s. Those of us who know him can listen and smile upon his recognizance; those who do not know him would never buy the tape. Arlan is reaching the age where schizophrenia often burns out, so if he can survive his cancer, he might produce a happier album next time. Perhaps if she lives long enough, Gloria could help him.