The Waiting Game

It is a mistake to look too far ahead. Only one link in the chain of destiny can be handled at a time.
- Winston Churchill

It goes without saying that oncologists often rely on pictures of tumors to determine whether or not a cancer has responded to treatment. These images of tumors are obtained via x-rays, CT scans, PET/CT scans and other studies. One of the caveats in cataloging pictures of the inside of the human body is that some of us have holes, masses or lumps that we were born with or acquired as a result of a non-malignant event. It behooves the doctor, therefore, to document any unusual findings on x-ray prior to starting therapy so that these lesions are not confused with tumors once post-chemotherapy scans are ordered.

This makes sense, doesn't it? Then what, prithee, should oncologists say to patients who have a persistant mass after chemotherapy? Remember, this is a time of anxiety and if we doctors view this visit as an opportunity to interject a lively dose of black humor, or audition for a role on "General Hospital" we just might find a new meaning for the word hysterical. Sometimes it helps to break this situation down into various components before opening mouth and inserting foot, if you know what I mean. The problem of a persistant abnormality on imaging studies after primary treatment for cancer could imply the following:

1. The cancer is still present, although reduced in size.

2. The living cancer cells have been dispatched to the infernal region, but a matrix of inflammatory or fibrous tissue remains behind, a sort of memento mori if you will.

3. The image represents a benign lesion that either was obscured by the tumor's presence or has appeared out of thin air since the last x-ray (cf. radiation pneumonitis).

Why is it important to consider these possibilities when examining re-staging x-rays, you ask? Well, from my experience it is crucial to use the noodle before saying "Toodles" to a patient - in other words, don't assume the worst if something strange still skulks on the scan. Analyze the data carefully before pronouncing the verdict. Resist the temptation to stick a large-bore needle in every cloud that shows up on the dark skies of the CT. Unless the situation is obvious, such as a persistant mass that explains why a patient is deteriorating, let a little time pass before jumping to conclusions about residual lesions on radiographs. We doctors sometimes forget that part of healing is to give the spirit a chance to stand up and breathe again, to let the storm pass before ordering the journey to resume. It is all too easy to press the panic button. It takes fortitude to hold hands with the patient and say "Have faith."