Dr. Hassaballa in the Chicago Tribune


In the Name of God, the Most Compassionate, the Most Merciful

Thanks be to God (and then the editors at the Tribune), my article was published today in the Persepctive section of the Chicago Tribune. It is reproducted below.


WHEN CANCER RETURNS

Disease’s destructive path often perplexing, fickle

By Hesham A. Hassaballa. Hesham A. Hassaballa is a Chicago pulmonologist and writer
Published April 1, 2007

“How can this be, doctor?” my patient asks me. The anguish is palpable across the room. “They told me that all the cancer was removed. They told me I was cured. How could it have come back?”

It is a gap that no cancer survivor ever wants to bridge: the gap between cancer that seemingly has been cured and the dreaded cancer that has returned and spread. This is what has happened to White House spokesman Tony Snow, whose colon cancer has spread to his liver, and Elizabeth Edwards, wife of presidential candidate John Edwards, whose breast cancer has spread to her bones and possibly elsewhere.

Although Stage IV cancer can be treated with varying degrees of success, it can never be cured. Unfortunately, many people already have Stage IV cancer when it is first diagnosed, and it is difficult to break such news to patients and their anxious and worried families.

Yet many others do not come to their doctors with Stage IV disease. Many, in fact, see their cancers diagnosed at a very early stage, when the tumor is small and localized and has not spread to any other organ. These are typically called Stage I cancers. These cancers are potentially curable. They are the cancers that many, many Americans have had. These people have been treated and now are living healthy, active lives that are cancer-free. And then, for some, the cancer comes back.

The problem lies in the biology of cancer itself. At its very essence, cancer is a disease of immortality, characterized by unrestrained cell growth. Due to a variety of factors — genetics, environmental exposures and chemical toxicity, to name a few — cancer cells acquire the ability to grow and divide ad infinitum. The exquisite and delicate processes that govern normal cell growth and death are disrupted, and a tumor arises.

Some cancers are slow-growing and are not likely to cause much harm to the patient. Others, however, can be particularly vicious, spreading all over the body seemingly at will. Sometimes I feel as though the cancer has a mind of its own; it almost seems as if the cancer is self-aware, willfully going to the places in the body where it knows it will cause the most damage.

How do cancer cells ultimately kill? Wherever they go, they destroy healthy tissue in their path, and if that includes a vital organ, such as the brain, the patient can die.

Yet if a cancer is found early enough and taken out, how does it ever come back? Again, the problem lies with cancer biology. A malignant tumor starts out as one abnormal cell. Yes, the tumor seemingly can be completely removed. But all it takes is one cell to escape the surgeon’s scalpel, or the pulverizing blow of the X-ray radiation, or the caustic burn of chemotherapy drugs. Wherever that cell ends up in the body, it can form another malignant tumor.

That unyielding fact is why I am hesitant to tell patients they have been cured. True, some cancers are completely curable, such as testicular cancer and some childhood leukemias. Still, it is usually recommended that patients with Stage I cancer undergo continued disease surveillance — such as periodic CT scans — to make sure the cancer does not come back. All it takes is for one cell to escape, and the whole process will start again.

It is a devastating blow to any cancer survivor to learn that not only has her cancer come back, but that it now has become incurable. Again, it is hard to break such news to a patient. Yet another part of my job is to help counsel and console my patients during this difficult time. It is the part I truly enjoy, and it was one of the principal reasons I became a doctor.

Even though I know I can’t make their recurrent cancer go away, I still can help them feel better by holding their hand and saying: “It’s OK. I’m here for you.” It helps ease the pain I feel knowing that my patient’s cancer, despite having been treated correctly, has returned.

Copyright © 2007, Chicago Tribune

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