The Cancer Card

A while ago while still site chief, I got embroiled in a dispute between a department member and a surgeon.  (Wow like that never happens).

This was over a patient presenting for a mastectomy during the summer.  The patient was obese, had COPD and sleep apnea and now had a URTI.  My colleague listened to the lady's chest which apparently sounded gross, asked another colleague for an opinion as to what to do and then cancelled the case.  

"What?", said the surgeon, "you can't cancel the case, she has cancer".  She cancelled the case anyway.  Letters ensued.  

Now the real issue was that it was summer and the surgeon was about to embark on 4 weeks of vacation so it wasn't like he could do her next week but there are solutions, like for example asking one of his colleagues to do her next week.  I wasn't there and never got to listen to her chest which may have actually been the best it had ever been for years on that particular day.  Maybe I or another of my colleagues might have just bitten the bullet and gone ahead.  

One thing I do know it this.  When you do a case against your better judgement and things don't go like you prayed they would, nobody thanks you.  Or as my former professor told me, "the object of anaesthesia is not to see what you can get away with."

Later that year while still chief I was involved in mediating a problem between the administration and my department for which nobody has thanked me  (and which probably got me fired).

In Canada we have waiting lists for surgery which can be anywhere from days to months.  This causes a lot of angst.  Surgeons generally prioritize cancer cases although not always.  So it came that there was a report in the local press about lung cancer patients dying while waiting for surgery.  Thoracic surgery is of course a little more complicated than other cancer surgery, especially as they insist on doing everything through a scope now, so OR times are long, they usually require ICU or some type of high intensity unit post-operatively etc, all of which limits the number of cases that can get done.  Typically I have found that when waiting lists are long, it is more than a question of available resources, it is also a question of failure to prioritize and quite often lack of organization often by the surgeon's office.  The other issue is that despite advances in surgery and oncology the outcome for lung cancer no matter how quickly and expertly it is excised is pretty grim anyway.  That is why I am glad I don't do thoracics anymore.  You would bust you ass for 2-3 hours trying to oxygenate the patient, not to mention the occasional massive bleeding and then read the obituary a few months later.

Our health authority's response to this bad publicity was to announce extra money to do extra cancer cases.  Any type of cancer case, not just lung cancers.  This was not a problem for the other hospitals in the city which have unused ORs.  They did off course have to find anaesthesiologists which was a bit of a problem that nobody thought of but these were recruited.   Our hospital which runs at 100% capacity was a problem. 

Our hospital's solution was one that is becoming more frequent.  Extend the OR day by two hours to accommodate the additional cancer cases.  This sounds like an easy solution except for a few problems.  Firstly many cancer cases don't easily fit into a 2 hour slot and so predictably rooms that were supposed to finish at 1700 were now running until 1900.  The other issue is that our hospital is staffed to run 2 rooms in the evening.  We use these rooms to do "emergencies" and we frequently run 2 rooms all evening.  Except if you have a late running room, you can't start emergencies until that room finishes and as some emergencies are actually emergencies this meant we were now finishing our emergencies well into the early morning.  All of this I predicted when they first proposed it and like Cassandra was ignored. 

The worst issue for my was that our department has become a sheltered workshop for burnt out baby boomers and entitled generation Yers.  We like finishing at 1530 so we can exercise, run errands and eat dinner with our families.  When I announced the plan to run one room until 1700 2-3 times a week, the pitchforks came out.  I pointed out that if we were seen as obstructing timely care for cancer patients we were going to look like huge assholes but this didn't sway them.  I went back to admin and got "promises" of staffing and ground rules for booking extra cases all of which they reneged on.  (One surgeon booked a hydrocoele as an extra cancer case, "none of my bladder tumours could come in on short notice", was his excuse). 

This is still as far as I know, going on.  As I mentioned I eventually got fired as department head so I don't have to deal with it and I don't really mind working late occasionally.  It is a little tiring but the extra money brings me one step closer to retirement. 

Now before people start calling me a hard-hearted asshole for wanting to deny patients with cancer timely treatment let me state this.  I realize that many people die horrible deaths from cancer.   I realize that cancer cuts short many lives, depriving people of fathers, mothers, siblings, children and friends.  I also know that the odds are pretty good that I will ultimately die of cancer.  Hopefully it will be in a morphine induced haze at home, not puking my guts out in the oncology Ward or bleeding from every orifice on the hematology Ward.  

I also have to accept the progress made in diagnosing and treating cancer in my lifetime.  When I was in medical school, childhood leukaemias, testicular cancer and most lymphomas were death sentences whereas they are now mostly curable.

The bottom line is however what was true 30 years ago when I was in medical school and is still true today.

• Most cancers are slow growing (except for those which are fast growing and if you get one of those, you are fzcked).  This means that within limits how soon your cancer is diagnosed or treated makes little or no difference to your survival.
• Early and aggressive treatment is no guarantee of no metastatic disease.  It only takes one little cell to escape.  That's why we see people who had cancers treated 20 or more years presenting with metastatic disease.
• Many cancers like prostate cancer and some breast cancers are extremely slow growing and the patient will die of what we used to call old age before they die of cancer.  In fact treating them possibly hastens death rather than prolonging life.
• We are all eventually going to die of something.

So I am not saying we shouldn't screen for cancer or treat it expeditiously; I just resent the way self-interested physicians and surgeons use the cancer card to advance their own agenda.  A lot of physicians and surgeons out there are exploiting cancer patients for their own gain in a way that is just as bad as the Laetrile and coffee enema people.  There are lots of other conditions out there that affect longevity or quality of life that don't seem to get the attention or their share of the finite resources.  We don't even treat all cancers equally.  Breast and prostate cancer to mention two seem to have a lot of political clout.  Every November all our urologists grow moustaches for Movember.  Most of them look stupid (er), the few that don't shave them off December 1 anyway. If for example you have pancreatic cancer which is one of the more common cancers nowadays, nobody is wearing ribbons, or not shaving for you.

You could make the argument that having diagnosed a patient with cancer, just for their piece of mind you should treat it as soon as possible and there may be some merit in that.  If or when I get diagnosed with cancer the patient in me would probably like it whacked out ASAP.  This is despite that the physician in me knows that within a range of months, it doesn't make much difference and I should probably go on that bucket list vacation first.  As a matter of fact I know there is a good possibility as I type this that some cell in my colon, pancreas or bone marrow is starting to behave in a distinctly anti-social fashion.  This should keep me up at night but I have enough keeping me up at night like work, the price of oil, the stock market and of course Donald Trump.