Cancer and the Fog of War
I owe you a report on the upshot of my oncology visit. What we learned was, briefly:
The point of the visit was to determine whether we needed to change my cancer treatments in light of my worsening symptoms. I’ve been on immunotherapy. Every three weeks, I get an infusion of a monoclonal antibody that helps my immune system attack the tumour. This usually doesn’t work for recurrent throat cancer, but I’ve done well. My symptoms, however, suggest that the immunotherapy may be failing. If so, we’ll switch to classical chemotherapy. Chemotherapy works by poisoning the tumour, and the rest of me. It’s a grimmer course of treatment.
Step one, however, was to confirm that the tumour was, as they say in CancerSpeak, ‘progressing.’ To that end, I had a CT scan before the visit. The tumour would be measured from the new scan and compared to the previous scan.
Specialist radiologists read CT scans for neck cancers. The time for the appointment came, but there was no radiological report. I doubt the radiologist was negligent. The pandemic has stressed Ontario’s health care system. Hospitals are full, and many doctors and nurses are out with COVID. Health care systems are networks of interdependent clinical processes: many clinicians must work together and deliver things on time to make care happen. In a traffic jam, delays at one intersection can propagate quickly across a city grid, likewise, in a hospital. This starts a vicious cycle: unmet demands for care lead to delays in delivering critical services like radiology. Delays in essential services reduce the efficiency of the clinicians who need the images, which delays caring for patients like me. If I get sicker, that contributes to the unmet demand for care. Things spiral downward.
The CT report appeared two days later. It said that the tumour was there, but it hadn’t grown. Good news, but how do we reconcile this with my increasing throat pain and difficulty swallowing? Here are two possibilities:
CT images can be noisy, making the tumour size hard to judge, and sometimes radiologists make errors in interpreting them. (Or so the oncologists tell me.) Perhaps the tumour is growing, but we can’t see it.
My throat has a lot of damaged tissue from many weeks of radiation. My throat hurts, and I have trouble swallowing because the tissue is inflamed from some cause other than cancer.
Those are my speculations; it will be weeks before I can get another meeting with my oncologist.
Television doctors deliver precise and authoritative diagnoses. Actual clinical medicine is like what Clausewitz said about war:
War is the realm of uncertainty; three-quarters of the factors on which action in war is based are wrapped in a fog of greater or lesser uncertainty.
I live in this fog. Sometimes uncertainty works to my benefit: I’ve outlived the prognosis I got when my cancer recurred.
The tumour, however, is still there. As James Mattis said,
In my line of work, the enemy gets a vote.