When I met Mrs. Pravdowicz, she couldn’t eat. She couldn’t walk, couldn’t stand, couldn’t even turn over in her bed. She could barely even breathe. For four months, Mrs. Pravdowicz’s belly had been swelling as the rest of her wasted away. Short of breath and always tired, she’d been forced to quit her job cleaning houses. A week before, she had quit cleaning herself. Her landlord had found her lying on soiled sheets, looking like a balloon with a head and limbs. He brought her to the hospital where I work--Cook County Hospital, last hope for generations of Chicago immigrants. I knew only the sketchiest details of her life. Mrs. Pravdowicz had arrived from Poland a few years earlier. She was 57 years old and a widow, and she spoke no English.
The internists who had evaluated Mrs. Pravdowicz had eliminated several conditions. It was clear that she wasn’t pregnant. Her CT scans showed that a watery fluid filled her abdomen and half of her left chest. The condition, called ascites, can be caused by cirrhosis, or inflammation of the liver. But Mrs. Pravdowicz’s blood tests had shown no signs of liver malfunction, despite weeks of treating herself with a Polish folk remedy made mainly of vodka. Ascites can also be caused by heart or kidney failure, but Mrs. Pravdowicz’s test results had shown that her heart and kidneys were normal.
From her X-rays and CT scans, the internists saw that Mrs. Pravdowicz’s right ovary had been overtaken by a tumor the size of a grapefruit. They had suspected ovarian cancer, but they couldn’t be sure. Doctors use the word tumor to describe any unusual mass of tissue. As a gynecologic oncologist, a doctor who specializes in cancers of the female genital tract, I would have the job of figuring out whether Mrs. Pravdowicz had cancer. And if it turned out that she did, I would have to determine the source of the cancer and how best to fight it.
My residents and I transferred Mrs. Pravdowicz to our ward and began work. Our first priority was to ease her breathing. As the fluid in her belly had accumulated, her abdomen had become so tense that her diaphragm could barely move. Mrs. Pravdowicz had to move air in and out of her lungs using only her chest muscles, and they were tiring. In fact, the fluid in her belly had seeped into her left lung, causing it to collapse. By inserting a syringe into Mrs. Pravdowicz’s abdominal cavity, we were able to drain the fluid and allow the lung to reexpand. And the next morning we withdrew seven liters of bloody brown fluid from her belly.
But within two days Mrs. Pravdowicz’s belly was swollen again, and she was no better, only more dehydrated. Still, we’d made a little progress. We had sent samples of the fluid for lab tests, and the results confirmed what we clinicians had guessed: Mrs. Pravdowicz had cancer.
Cancer that spreads into the abdominal cavity usually comes from one of only a few sources. To plan an attack, we had to pinpoint the source of the disease. If Mrs. Pravdowicz’s cancer had originated in another organ and spread to the ovaries, it might be so extensive that surgery could not slow its spread. We would have to examine Mrs. Pravdowicz’s internal organs to find out. Before we began I tried to reassure Mrs. Pravdowicz, but I’m afraid she had little faith in doctors she couldn’t understand.
Using a tube that allowed us to look inside Mrs. Pravdowicz’s gastrointestinal tract, we inspected the lining of her stomach, duodenum, and colon. We found no sign of cancer. Mammograms and a physical exam failed to turn up a breast tumor. The CT scans had shown no sign of pancreatic cancer. The odds pointed to the swollen ovary as the source of Mrs. Pravdowicz’s cancer.
Ovarian cancer is among the most insidious and deadly of cancers. Lung cancer kills more people, but the links between smoking and lung cancer are well known. Breast cancer, too, is more common, but it can often be cured. Ovarian cancer is stealthy. By the time it is diagnosed, the cancer is usually so advanced that roughly 85 percent of the patients die within two years. Each year about 15,000 American women die of the disease.
Early on, the symptoms are ascribed to almost anything else: gallstones, constipation, midlife weight gain, neurosis. The cancerous spread begins when malignant cells burst out of the ovary, slough off, and seed the surfaces of the abdominal cavity. As the cancerous tissue grows, it ruptures tiny lymph-filled capillaries. This fluid distends the abdomen and leaks into the chest cavity, slowly filling the space in which the lungs expand and contract. Eventually the cancerous growth can squeeze the bowel shut.
Before doctors had the tools of chemotherapy and radiation, they tried to carve cancer out with a knife. Unfortunately, it is nearly impossible to remove all the cancerous cells. A surgeon can cut out a cancerous ovary, but by the time the patient has recovered, often the cancer has, too. In frustration, surgeons have tried cutting out more and more tissue, excising the gut, the spleen, lymph nodes, the belly lining, and bits of liver, only to find them caked with cancerous cells. The lesson they learned from such measures is that the more radical the surgery, the longer it took for the cancerous cells to grow back, and the longer the women lived. That innovation--removing as much cancerous tissue as possible during the first operation--is now the traditional treatment for ovarian cancer.
But that treatment wasn’t devised for someone in Mrs. Pravdowicz’s condition. As an undocumented alien, she had worked off the books, saving up cash to return to Poland in her old age. When she developed symptoms that would have driven other women to a doctor, Mrs. Pravdowicz stayed at home, uninsured and terrified of deportation. When she was brought to the hospital, her cancer was so advanced that she was on the verge of death.
Still, surgery could be done. Surgery is always possible; it’s the recovery that is tough. I could excise Mrs. Pravdowicz’s ovaries and as much malignant tissue as possible. But I couldn’t predict the outcome. She would either recover well enough to receive chemotherapy or suffer overwhelming complications and die.
I knew of an alternative. Three months before, I’d been party to a new approach: chemotherapy before surgery. Another Polish woman had come in for treatment. She too had had ascites and ovarian cancer. Although she had been operated on in Poland, the surgeons had been cautious. They had done only a biopsy of the ovaries and a quick examination of her organs. Then she had received six months of chemotherapy. After her treatment ended and she moved to the United States, she came to my hospital seeking surgical treatment for her cancer. I performed the operation that should have been done when she was first diagnosed. When I examined her ovaries, I was surprised to find that the cancer had shrunk into masses of scar. I was able to remove it all.
That patient did so well because of advances in chemotherapy. The current strategy for fighting ovarian cancer was developed 20 years ago, when neither chemotherapy nor radiation alone worked very well. Drugs back then weren’t very effective, and radiation that could kill the tumor could kill the patient as well. Today new drugs like tamoxifen and cisplatin have revolutionized chemotherapy. When they are given after surgery, these drugs can eradicate all signs of the patient’s cancer. Unfortunately, all too often the cancer grows back within a few years--this time more resistant to the drugs. But immortality is a gift of the gods, not of doctors. Most patients now have a window of time in which to grieve, grow back their hair, and savor the life that’s left to them.
When a group of senior oncologists gathered to discuss Mrs. Pravdowicz’s case, I told them how my other patient had done well with chemotherapy before surgery. They dismissed her outcome as anecdotal, unverified, unreliable. The discussion was brief. The consensus was for surgery, then chemotherapy. Elegant studies had proved the effectiveness of that strategy 20 years ago. It was standard. It was traditional.
In medicine, tradition is the sum of the successes, errors, and failures of generations of doctors. It is proven. It is uncontroversial. And it is safe. But today’s traditions developed from yesterday’s science, and yesterday’s science is obsolete. Science feeds on change. It asks new questions and demands new answers. So science challenges old traditions, overthrows them, and sets up new traditions. Yesterday’s wild innovations are the medicine we practice today.
For clinicians, the difficulty comes in deciding when to challenge established practice. Wait too long for rigorous proof, and patients die needlessly. But change practices in the wrong direction and the result is the same. Innovation may be noble, but it isn’t always safe.
With the help of an interpreter, I talked the situation over with Mrs. Pravdowicz. Trying to convey medical nuances through an interpreter was frustrating, but I figured that if Reagan and Gorbachev could negotiate the future of the world without sharing a language, Mrs. Pravdowicz and I could succeed when the subject was her life. As we talked, I stopped after every sentence to let the translator catch up. I explained the alternatives: surgery before chemotherapy, or chemotherapy followed by surgery. I explained what we knew of the risks of each procedure. I said there was little chance for cure either way, but I hoped she might get well enough to go home. I told her that nobody knew for sure whether chemotherapy had been improved enough in the past 20 years to make the current strategy obsolete.
Mrs. Pravdowicz listened without listening. She looked not at me, not at the translator, but at the curtainless window or a stain on the wall. She bobbed her head, not agreeing, not disagreeing. Her face spoke for her. It was a portrait of bitter resignation: she would allow me to do whatever I wished but believed nothing I said. She had given up hope and was waiting to die. She spoke one sentence in Polish, then folded her hands and looked up at me.
She says, the interpreter informed me, that her life lies in your hands and the hands of God.
I scoured the Internet for more information. I found several reports describing how patients with advanced ovarian cancer did not benefit from radical surgery. But only one study specifically addressed my problem. Researchers at Yale had found that for patients with very advanced disease, chemotherapy can achieve the same results as radical surgery. I showed it to the chief of the chemotherapy team.
I’m skeptical, she told me. But if you want to try it, we’ll go ahead.
As any clinical scientist will tell you, one case proves nothing. But in the first week after Mrs. Pravdowicz’s chemotherapy, we were able to take out the tube that had been draining half a liter of malignant fluid from her chest each day. As the cancerous tissue withered and died, her breathing eased, the swelling in her feet subsided, and her appetite and her spirits returned. Two days after her second treatment, Mrs. Pravdowicz was released from the hospital.
When I saw Mrs. Pravdowicz af-ter her third course of chemotherapy, she was a changed woman. A wig of fierce platinum blond curls replaced the dull gray hair she’d lost to the drugs. Mrs. Pravdowicz had shed her passivity like a second skin. She complained constantly--about the food, the lack of privacy in her cubicle, the nurses who hadn’t the time to plump her pillows, the extra day it took to undergo chemotherapy because someone in the pharmacy went home early. Her anger was a measure of how far she had come.
I didn’t sleep much the night before we went to surgery. The hubris of my actions troubled me. Who was I to challenge tradition? What right had I to offer a woman an untested option when her life depended on the outcome? But every cancer doctor’s career is cobbled together from dilemmas like these, and I had chosen. We went ahead with the surgery.
We made an incision that ran from the breastbone to the pubis, carefully hooking around the navel. I could see that the cancer was still there, knobbed and ugly like an alien ectoplasm. It had overtaken both ovaries. Malignant knots spotted the lining of the peritoneal cavity behind the bladder and above the rectum. The omentum, a fatty net of blood vessels that hangs from the stomach and colon, was solid with tumor, as if an exuberant cancer, rebuked by the chemotherapy, had tried to shelter itself within a giant scar.
The operation took four hours. When we finished, no visible trace of cancer remained. Mrs. Pravdowicz’s belly--once so heroically distended-- looked like that of any woman her age. The only difference now was a long, thin red line hatched with staples running down her torso.
Last week I presented Mrs. Pravdowicz’s case history to a large group of oncologists at my hospital. We all know that her battle isn’t over; we know that tiny fragments of cancer remain. We will fight them with chemotherapy. We all know the odds are against a cure. But at that meeting, the residents were excited. The others, the old physicians in the room, wanted to wait and see. They wanted to be convinced. I would have liked the same luxury, but Mrs. Pravdowicz didn’t give me time. Right or wrong, I chose the new treatment.
Mrs. Pravdowicz has recovered from her surgery, and the last time I saw her she was putting on weight. During that visit, she told me that as soon as she completes her remaining chemotherapy treatments, she’s converting her dollars into zlotys and flying back to Warsaw. She and I both expect that she will die there of her cancer. I will never know if I was right in challenging tradition. But that is what makes doctors different from scientists at the bench. We act with insufficient data and learn only in hindsight. That is why some say medicine is an art as well as a science.
