Letter to the Editor

On Oct. 27, my wife died from lung cancer at age 68. In 1950, while a freshman in college, she started smoking and she continued for about 42 years, gradually working up to over two packs a day. She stopped smoking about eight years ago after hypnosis sessions with a clinical psychologist at the University Medical Center. I am writing this letter to describe to you what happens when you learn that you have lung cancer. I do this so you will be more informed as to the facts that you should take into account if you are presently a smoker or at some point take up that activity. The bottom line is that, if you get “non-small-cell” lung cancer — 75-80 percent of all new cases — the overwhelming likelihood is that you will be dead within one or two years. For confirmation of that statement, see the quotations at the end of this letter from the Oct 26, 2000 editorial in The New England Journal of Medicine. According to that Journal, most patients die within 12 months after being so diagnosed. The rest of this letter is to tell you what that last year or two may be like for you. In December 1998, my wife had a chest x-ray because she had a lingering cold and the doctor was concerned as to whether she had pneumonia. During the last year that she smoked, she had pneumonia 4 times. The x-ray showed no pneumonia, but it did show a lung tumor of more than inches in diameter –without pain or other symptoms. The first step in January 1999 was to identify the type of lung tumor in order to determine the treatment. That is usually done by obtaining a biopsy by inserting a tube into the nose and down into the lung, and out the proper branch until the tumor is reached. A small slice of the tumor is extracted to be analyzed. In her case, that process did not succeed in reaching the tumor. Therefore, a needle biopsy was required, which means inserting a needle through your chest wall, past the ribs and into the lung, and then into the tumor in order to withdraw the sample. That process obtained the sample, but unfortunately the process also caused a partial collapse of her lung. She came out of that operation being administered oxygen, and from that moment on until she died she was always on an oxygen supply. She was sent home from the hospital that night, but returned by ambulance a few hours later because the lung collapse problem had deteriorated. At that point, in the Emergency Room, a tube about as big as a finger was inserted through the back of her chest into the cavity between the lung and the rib cage in order to help the lung refasten itself to the wall of the cavity and thereby seal the hole in the lung. She remained in the hospital for a week, came home and had to return again that night by ambulance because of further complications. She remained another week. Treatment of the cancer tumor then finally began, and the procedure of choice was radiation. Starting in February 1999, she went every weekday for over seven weeks to the Highland Hospital (a part of Strong Memorial Hospital) for radiation ? 37 treatments. Technicians don’t just radiate the tumor; they radiate an area substantially larger than the tumor, because it may have spread. Although the radiation tends to destroy the tumor gradually, it also destroys all other lung tissue that is in the radiation beam — turning the whole area into scar tissue. The radiation process itself is not uncomfortable, but it gradually wears you out, so that at the end of the seven weeks, the patient is close to total exhaustion. During all this time she had to have oxygen continuously. At home, that meant having an oxygen concentrator machine in the house to which she was tethered 24 hours a day by a 50-foot plastic tube, thereby limiting her movement to that distance. When we went out of the house or anywhere beyond 50 feet, a portable oxygen tank had to be taken along. As a result of her many years of smoking, my wife developed emphysema, which is a lung condition that basically interferes with the lung’s ability to absorb oxygen and transfer it to the blood stream. It produces shortness of breath and therefore lack of endurance. It can’t be cured, is usually progressive and ultimately fatal. Her emphysema was a contributing factor in her need to have oxygen continuously after the lung collapse. After the radiation ended in April 1999, there were monthly visits to the radiation doctor, with a CT Scan each time to check on the condition of the tumor. In early October 1999, the CT Scan revealed that the cancer had spread to her liver, and that there were two tumors there. The medical opinion was firm that this was a spreading of the lung cancer and not the spontaneous creation of some other kind of cancer. The liver is close to the lungs, and it is common for lung cancer to spread to it. The CT Scan also showed that the lung cancer had spread to one of her ribs, which is another common development. At that point, radiation can’t be used anymore because a much wider area of treatment is necessary; therefore, chemical treatment is required. That regimen started immediately and continued for a little more than six months. The first medicine was Taxol, which is commonly used for lung cancer. That caused her to lose all her hair and she got a wig and some other head coverings. The medicines are administered in the Chemical Infusion Room at the hospital. This was a once a week, or every other week or so, process, depending on the medication. It usually took a couple hours for the medicine to be infused through a tube into a vein, as you sit in the room with a dozen other people being similarly treated for various types of cancer. A mixture of chemicals is used. Each month, there was another CT Scan to check on the progress. Sometimes the tumors would get bigger and other times they would get smaller. The larger one reached 10 centimeters in diameter, a little bigger than a baseball. The medicines were changed if the tumors increased in size. All told, there were at least three different medicines tried. After Taxol was discontinued, her hair grew back over the next six months. By April of this year, she was totally exhausted and weak and run down and her doctor recommended stopping the treatments for a while, in order to recover her strength. The medicines are very toxic, and they don’t just attack the tumors; rather, they are poisons that also attack other aspects of the body, the obvious example being hair loss. It is typically the case that patients stop the chemotherapy treatments, at least for a while, after a certain point. Monthly CT Scans and visits to the chemotherapy doctor continued. Last August, the CT Scan showed that there was now a third liver tumor. The question then was whether chemotherapy should be resumed. However, her general physical condition was then poor enough that the medical opinion was that she would not be able to tolerate any more such treatment; further chemical treatment would probably result in her becoming hospitalized. So the decision was made to forego any further treatment of the disease and instead turn to “comfort care” — treatment only to keep the patient as comfortable as possible. By this time, she was regularly using low-level amounts of a strong pain medication. In her case, the pain level could be controlled reasonably well. While she was in continuous pain, apparently lung cancer is not as painful as some other types of cancer. We elected that she stay at home as long as possible. By mid-September, we had signed up for Visiting Nurses Hospice services. The job of the hospice people is to help the patients be as comfortable as possible, deal with pain control and bring in whatever other services and equipment might be needed. They are there neither to hasten nor to prolong the natural course of the disease. In the beginning, that meant only weekly visits by a nurse. Soon, however, those visits became two or three times a week and workers installed a hospital bed and a urinary tract catheter, while home health aides came in every day for two hours.
The tumors continued to grow, and also spread to my wife’s breast. They were quite visible. At the end, her final hour was not peaceful; rather it was a terrible struggle to breathe. A few days ago, a long time doctor friend of ours sent me a recent editorial from The New England Journal of Medicine, which is the most prestigious medical journal in the country. It was in the issue of Oct. 26, 2000, and it dealt with the treatment of the type of lung cancer my wife had ? “non-small-cell lung cancer.” The article showed that the treatment given my wife was the current accepted treatment protocol, and therefore we had done all that could have been done and that “she did very well by what is available in the way of treatment.” So that you will understand the terrible risks “Lung cancer is a major health problem, and each year the overall rate of death from this tobacco-inflicted disease increases. In a few countries, including the United States, the death rate has decreased slightly, reflecting changing attitudes toward cigarette smoking. “… In patients with non-small-cell lung cancer, the possibility of cure depends mainly on their suitability for surgical resection. Unfortunately, at the time of diagnosis, only about 30 percent of patients with this cancer are candidates for curative surgical resection. Another 30 percent have locally advanced, inoperable disease [e.g. my wife], and the remaining 40 percent have confirmed metastatic [i.e. it has spread] disease. Most patients die within 12 months after receiving the diagnosis, because the disease is already advanced at the time of detection. . . “Almost 30 percent of patients with newly diagnosed non-small-cell lung cancer have locally advanced, inoperable disease. The standard care is usually radiotherapy, and the expected median survival is one year, although a few patients survive for five years. . . “Patients with advanced metastatic [i.e. cancer which has spread] non-small-cell lung cancer constitute the largest group of candidates for chemotherapy. Despite its widespread use, the benefits of chemotherapy in these patients are unclear. The prognosis in this group is grim: the median survival without cytotoxic [i.e. chemotherapy] treatment is less than six months, and even with treatment, cures are almost unheard of. Before chemotherapy is initiated in such patients, its effect on the quality of life must be considered. . . . . . . . . . . . . “Lung cancer is the most preventable of all common cancers. The elimination of cigarette smoking remains the best hope for reducing mortality from this disease. . . . ” (Emphasis and material in brackets added] (The New England Journal of Medicine, vol.343, No. 17, p.1261, Oct. 26, 2000) * * * * * * * * * So now you know what you might face if you continue, or choose to take up, smoking. I unswervingly support your right to make free choices; I just want to be sure that you are well informed of what risks you are assuming, and what your life may be like, and how short it may be, under the present state of medicine, if you should become one of the unlucky ones. –Don B. Allen
Allen is a Senior Lecturer at the William E. Simon Graduate School of Business.