The Elephant in the Room is Cancer. Tea is the Relief Conversation Provides.

The First Patient I Diagnosed with Cancer

by Mark LewisGI Oncologist/Whipple SurvivorAugust 16, 2021View more posts from Mark Lewis

The first person I ever diagnosed with cancer was me.

Until that point in my medical training bad news had always been broken to patients before I met them. By the time of our introduction, their shock had subsided, and the initial fractures of their premorbid identities had ossified into therapeutic resolve. This hardening of their will allowed them to accept side effects if they coincided with longer lives, chemo already a fait accompli when I inherited their cases.

Having learned to assist in the aftermath, I thought I was ready to be the initial messenger of malignancy. In preparing to become a cancer doctor I had even rehearsed how to relay hard truths as softly as possible. I envisioned the perfect tableau for that most difficult of conversations: a quiet place, soft lighting, a box of tissues within arm’s reach of a comfortable chair. But I had no precedent for how to set that stage internally; I had always followed the script as a dialogue, not as a soliloquy. 

For a physician it is one thing to separate your head and your heart, the dispassionate sorting of pathologies compartmentalized away from the emotional resonance of applying a life-changing label to another human being; it is entirely another to find that the magnifying glass of your investigation has become a mirror.

In truth I had sensed I was unwell for some time, but postponed a work-up, partly because of the rigorous demands on my time but also because I thought the sleeplessness & poor diet of my eighty-hour work week were explanation enough for my chronic fatigue and abdominal pain. 

The irony of my delayed self-disclosure was thick. Just before I finally realized what was wrong with me, I had spent a year serving as chief resident, a position that involved teaching students and interns the art of differential diagnosis. Each weekday at our morning report conferences we would parse out the salient details of challenging cases and winnow down the possibilities with Sherlock Holmes’ deductive logic: “When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.”

As would-be detectives, I encouraged my house-staff not to anchor on the usual suspects when seeking their culprit. There was a certain intellectual gamesmanship in mastering esoterica, but a practicality too; in the emergency room of our county hospital, I had, for instance, once diagnosed a diffuse rash as leprosy after overcoming my own myopic sense of anachronism.

However, I had also been cautioned by my own mentors not to let a broad medical imagination get the best of me, to extend beyond reason into paranoia. From the vast compendium of human illness it is easy to conjure a phantasm to match whatever ails you. Every nosebleed might presage an exotic hemorrhagic fever; every involuntary twitch could be a harbinger of a Parkinsonian tremor. Hypochondriasis is self-awareness refracted through the prism of knowing too much about how the body can betray.

So no, it is not considered ordinary to name your own anomaly. But then again, I was actually no stranger to the unorthodox arrival of ill tidings. My whole impetus to pursue a career in cancer medicine had been my father’s diagnosis, issued not by a doctor, but from an embassy. 

When we moved to the United States, public health policy dictated that my entire family undergo chest X-rays as a screen for tuberculosis. My mother‘s imaging was clear, as was mine. But a Kafkaesque bureaucrat called to inform my Dad that his right lung was full, not with a contagion, but with a mass. Its opacity cast a long, unwelcome shadow over our new life in the sunny American South. 

My father underwent pneumonectomy to remove the affected lung and began what he called “the slow, puffing process of proving its redundancy.” But his surgeon apologetically explained that he had not be able to excise the tumor altogether, that some of its tentacular margins extended into the anterior mediastinum, a space behind my Dad’s breastbone and beyond his operative reach. This residue required radiation, but the cells that lingered there, like my own immigrant family, had plans to relocate despite the heat. Their metastasis to his spine was agonizing in every sense, wracking his bones with pain, while banishing his hope of cure. He entered the palliative-intent phase of his care, enduring ever-greater indignities of indiscriminate toxicity, until he died of an anaphylactic reaction to his last-line treatment.

Misfortune had haunted him, then, to the end. But his bad luck proved to be no isolated incident. Shortly thereafter, his brother developed a severe headache and lost his peripheral vision to a pituitary tumor that hemorrhaged fatally when his doctors attempted its removal. 

Two points make a line, and my paternal uncle’s death seemed connected somehow to my Dad’s, if only in its untimely cruelty. Much of medical acumen is pattern recognition, though, and I did not yet have the shrewdness to perceive anything other than a calamitous coincidence. 

The last piece of the puzzle was delivered with a gut punch, literally and figuratively. I awoke with a pain that seemed too intense for dyspepsia or for the first-day jitters of a new job as I embarked upon my oncology fellowship. Self-diagnosis being prone to folly, I incorrectly concluded it was appendicitis. But the problem did not dwell in a vestigial organ, nor was it confined to a single quadrant of my abdomen. Some rudimentary labwork showed that the concentration of calcium in my bloodstream was too high, and it was that simple fact – a single result in a basic metabolic panel – which illuminated my family curse. 

Where before I had looked to the night sky and seen only a thousand points of light, I suddenly discerned a constellation. Whatever was wrong with me was both systemic and hereditary, because my father’s labs too had shown high calcium levels, and long before cancer began mottling his skeleton. There are precious few conditions that lead to hypercalcemia in consecutive generations and, having jettisoned the benign causes through process of elimination, I was left with multiple endocrine neoplasia type 1: whatever remains, however improbable, must be the truth. 

This rare tumor syndrome explained that there was more than randomness behind our disorder, that the slings and arrows of outrageous fortune had taken very careful aim indeed. Since its discovery, my entire career has been viewed through the eyes of a patient-physician. I always inhabit the front part of that hyphenate, but in my professional capacity I can think with the bicameral mind of a scientist-turned-empath, instructed by an embodied experience whose lessons no textbook could ever impart. While I would never condescend to say that I completely understand what my patients are facing, I am also no longer bearing passive witness to their suffering. Now, when I tell someone they have cancer, I can feel – on the most visceral level – the weight of those words, and hope that a load carried together is rendered lighter for us both.

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