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| Milton during his follow-up oncology appointment, 6 months after his initial cancer diagnosis. |
In 2008, after a long bout of excruciating gastrointestinal
troubles, my cat Milton—then 8—was diagnosed with intestinal cancer.
Specifically, carcinoma of the jejunum and colon.
The pathology report described “multiple intestinal masses
that are mucinous in appearance.” The cells retrieved through a fine needle
aspirate of the masses revealed a “severe degree of nuclear variation and
variation in cell size.” All possible treatment options were either too
invasive for him to endure (sick as he was at the time) or unlikely to impact
the particular kind of cancer he had. They didn’t even try to book us a
follow-up appointment—the letter simply concludes, “I do expect him to decline
over the next 2-8 weeks.”
At the time, these words were terrifying, final, the source
of hours of tears and lots of Googling for alternative interventions and
treatments. In the years since, they have meant afternoons spent at various
veterinarian offices investigating mysterious symptoms that may have indicated
that the cancer had spread (always turning out to be absolutely nothing),
countless ultra-sounds and further small biopsies of his intestines to see how
the tumors were doing (fine, by all of our best estimates), so many elaborate
diets and supplements that Milton oftentimes ate better than I did, and a lot
of fear and anxiety and worry for all of us that any mis-step in his care might
bring dire consequences.
But, this week, at an appointment with the very same
oncology unit that gave Milton a 2-8 week death sentence 5 ½ years ago, I
learned what those words really meant:
There’s actually very little accuracy associated with these
tests, surgical biopsy being the gold
standard for this type of diagnosis, so although the conclusion at the time
was that he likely did have cancer, the fact that it hasn’t killed him yet
indicates that he actually never had
cancer at all.
What?
Wait, what?
This was my response. Very eloquent.
So, what is wrong with him, then? I asked, still knowing
that my dear cat experiences, well, for the sake of protecting his privacy,
I’ll say “frequent gastrointestinal distress.”
Hmm. Not sure, the doctor says. IBS? Combined with old age?
So, 5 ½ years of doctors, medicines, alternative treatments,
expensive tests, and constant worry all because he has, basically, been an
aging cat with an upset stomach?
This experience has been interesting for a wide range of
reasons (and infuriating as well), and I’ve had a wide range of reactions to
it. But, for right now, I’ll put on my rhetorician hat, and analyze the
situation through that lens. Because, looking at this case through its
discourse is incredibly revealing.
Looking back through the original pathology reports, you can
actually see the spaces where the discourse makes itself available to both
offer a devastating diagnosis and explain away a mistake at the same time. As
terrifying as the words on the report were, they were still couched in
contingencies that I was too saddened to see when I originally read them: “the
radiologist suggests carcinoma,” “a
carcinoma is suspected but cannot be
proven with this cytology,” “surgical biopsy would be required to make a definitive diagnosis.” None of
those contingencies ever mattered at the time, and I never revisited them. Once
the word “carcinoma” entered my world, my focus was on identifying, addressing,
and defeating that, not on
questioning its presence.
Yet, the contingent words were the words the oncologist
relied upon this week as she delivered the news.
When I said, “But, I thought you took cells out of tumors. I
thought those cells were cancerous, and that meant he had cancer.” She said,
“Well, all we can see are irregular cell patterns, and irregularity can exist along a spectrum of pathology, from
healthy, to sickened, to fully diseased cells. So, we may have seen cells that
were cancerous and were later resolved by the immune system or cells that just
looked abnormal because of inflammation.”
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| Milton, sitting on papers (of course). Also, if you look carefully, you can see his belly is pink after being shaved for an ultrasound. |
And, naturally, “this is why surgery is the gold standard for diagnosis,” because
without a chunk of diseased tissue, there’s no way to know for certain that
what’s really in his body is really cancer and what kind of cancer it is. So,
the combination of the ultrasound showing a mass and the extracted cells are
the least-invasive best guess. That’s all they really have—a best guess that
you can hope isn’t as bad as it seems.
The problem is, of course, that a lot of decisions are made
based on that best guess. Most gravely, I could have chosen to have him put to
sleep. This wouldn’t have been an inhumane option, given a cat that was pretty
sick and going to die at the time. It wasn’t an option that I considered, but
it is something that some people absolutely would.
On the other side of things, I could have chosen one of the
more invasive options they provided, and that subsequent doctors have
recommended since, like chemotherapy and radiation. This is the only point at
which the oncologist did express some acknowledgement of the consequences of
this error: “Well, in retrospect, it’s really good that you didn’t move forward
with any more aggressive treatments, like radiation or chemotherapy treatment
for a cancer that wasn’t there.”
“Humph, you think?” was my knee-jerk retort.
Overall, the experience reified everything I’ve read and
suspected and analyzed about communication and medicine over the past few
years. That, in that examination room, objective truths are hard to find (try
as we might to find and rely upon them), conversations are rarely the same for
doctor and patient, and the documents produced and the words those pages simply
are different for the person who
types the words versus the person about whom they are typed.
A similar sentiment is reflected in one of my favorite
quotations from Kathryn Montgomery:
“The lump is there. It is a sign, caught in medias res,
a clue to a natural history that is unfolding. Science describes and explains
it and determines what can be done about it. But the importance of that lump,
the acts its discovery entails, and what those acts will mean are social and
cultural matters.” How Doctors Think, page 15
There may be cancer—except
when there’s not—but cancer isn’t the same thing for the doctor as it is for
the patient. Cancer, for this veterinarian, was a series of pieces of paper,
test results, and a subsequent medical history that seemed to disprove original
observations made by another veterinarian years ago. Cancer, for Milton, had
meant that he had lived an entirely different life for the past 5 years than he
would have without that diagnosis.
To put it in Montgomery’s terms, the veterinarian offered a
scientific ending to the story of the lump, in the form of a conclusion: the
lump was never there, and that was a good thing. But, it’s not as simple as
that. The lump was never just the
lump for Milton and for me. It was a series of treatments that were doing very
little or nothing to treat the (still to be determined) disease he actually
had; side effects of those treatments that were endured in vain; and a lot of
time, energy, and fear funneled into a disease that wasn’t there. The narrative
of that experience works very differently with such a scientific twist—gotcha!
He didn’t have cancer at all!—at the end.
I share all of this with a rhetorician’s lens and a certain
level of seriousness because, well, I can. As much as we love our pets, feline
cancer isn’t as important as human cancer—pathology can get a cat’s cancer
wrong; oncology can afford the educated guess that turns out to be a mistake.
Owners can set the boundaries and refuse treatment without being called—at
least openly—negligent. All of it happens without consequence; the consequences
for the owner or the vet if one makes the wrong interpretation or the wrong
choice aren’t as dire as they are if this were to happen to a human. So, in
many ways, the rhetoric of the science here is a bit more raw, closer to the
surface, open about its reliance on its own discursiveness. Well, we never knew,
for sure, that he had cancer, and we never really
said so either.
Regardless, as I say, this is good news. The best news I
have ever received in an oncologist’s office, that’s for sure. But that’s only
part of the point. Every part of the end of this part of the story is fraught,
shaped by discursive contingencies, marred by rhetorical mis-steps, and shaped
by the fact that the facts were never as certain as I thought they were. A
lesson I still don’t know what to do with but that I should probably figure out
before I arrive at the next vet appointment.
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