Speaking of Cancer

S.Q. Lapius always enjoyed presiding at joint medical-surgical staff meetings.  It gave him a chance to wear his blazer, and to display his red cashmere vest with the gold buttons.  (“It helps to rivet attention on the chair” he told me).  Fortunately he had to doff his alpine hat with the feather in the cloak room, but nevertheless he resembled the king pea-cock at a bird sanctuary.

Today, however, Lapius wore a conservative blue plaid, the squares accentuating the several acres of abdomen that they were forced to cover.  As a matter of fact he was annoyed, possibly angry.

He called the meeting to order with a tap of the gavel and made a few acerbic remarks.

“Today we have to review five cases, three of breast cancer, one of uterine cancer, one of cervical cancer.  In each instance there have been extensive metastases.  All the patients are dead or dying.  But I’ve taken the trouble to review the charts and note that in each case of breast tumor a biopsy was performed, another was performed in the case of cervical cancer, and the woman with the uterine cancer had a diagnostic curettage performed. –“

Before Lapius could enunciate another word he was interrupted from the floor.  It was Dr. Ty Cotton, his favorite surgical sparring partner.

“May I address the chair?” Cotton asked in a commanding voice.

“You may make a few comments, Dr. Cotton.  I’m not sure we are prepared for an address.”

“I think we can anticipate what you were going to say, Dr. Lapius, having heard you express your sentiments on the subject so often before.  In fact it is becoming somewhat boring.  The fact is -.”

Now it was Lapius’s turn to interrupt.  “At the risk of boring you further and for the benefit of newcomers to this conference, I would like to state my position before you continue with your well-prepared extemporaneous remarks….I have been trying to make a point about biopsies. –“

Cotton was up on his feet.  “Yes.  Dr. Lapius is trying to make the point that we shouldn’t do biopsies in all cases.  Just go ahead and do the radical surgery.  Preposterous.”

Lapius regained the floor, and with it some momentum.  “Had Dr. Cotton not missed so many meetings, and refrained from sleeping through those he did attend, he would have understood me to say that biopsy is obviously necessary to determine whether or not there is a cancer, but that to cut through a malignant lesion does nothing but spread it.” 

“Now hold on there,” Cotton was on his feet again.  “These are breast lesions.  Sometimes there is a big mass.  If we don’t cut through the mass we have to excise it.  This will disfigure the breast.  Women don’t like that.” 

“Better disfigure than take the chance of spreading the lesion.” 

“There’s no proof that the lesion will be spread by cutting through it.” 

“Perhaps not,” said Lapius, “But when you cut through cancer you open blood vessels and the cancer cells may drain through these channels to be disseminated to the rest of the body.  It puts the tumor beyond immediate control.  If you do have to cut through the lesion, then you should be prepared to do radical surgery immediately, not wait three days for the pathology report, as you did in one of these cases.” 

“Well,” Cotton stammered.  “I thought that it was a benign lesion.  It fooled me.” 

“Yes, of course.  These things happen sometimes.  But I think that definitive surgery should follow immediately any biopsy, and the excision biopsy in which the entire suspicious lesion is removed is preferable to incisions which chance a cut through the tumor.  The same thing occurred in the gynecology cases.  A week was lost between the initial surgical diagnostic procedures and the ultimate surgery.  This, in my view is too long.” 

“But,” Cotton reiterated, “You can’t find any proof that surgical biopsy spreads cancer.”

“It does in experimental animals.  I don’t believe there have been any definitive studies in man.  It would be a very difficult study to undertake.  But in medicine sometimes we should go along with what is reasonable, instead of always waiting for proof.” 

Wanda Scrape, the only female gynecologist at the institute waved for attention.  There was silence as everyone turned towards her.  She was almost too pretty to be a doctor. 

“Dr. Lapius what is the gynecologist to do?  After all you can’t expect frozen section diagnosis of endometrial fragments that are removed during curettage.  There isn’t enough tissue to take the chance.” 

“With the modern techniques you could probably get away with it, Dr. Scrape.  Certainly if you enter the uterus with a sharp curette and penetrate an invasive cancer with it, the cancer cells will have more of a chance of spreading than if they were left alone.  Agreed the diagnostic curettage must be done.  There is even instrumentation now that will permit a proper paraffin section for pathologic diagnosis to be turned out in an hour.  All hospitals should have such equipment.” 

Afterward, Cotton came over to Lapius, and said “Why don’t you stop belaboring the point Simon.  You are in the minority you know.” 

“Of course.  But if I convince enough people, then I will be in the majority and you will be the minority.”