Cancer Politics: A Cynical View of the Current State of Cancer Treatment in the US
From MANIFESTO FOR A CANCER PATIENT by Colleen Huber, NMD
Are submissive people more prone to cancer diagnosis?
I used to wonder if cancer could possibly prey on the most soft-spoken individuals, because of the preponderance of such personality types among the cancer patients at our clinic. When the doctors at my clinic met on initial consult a couple who demonstrated obviously unequal power, with one dictating what will happen, and the other quietly taking orders, it was almost certainly the case that it would be the passive, submissive one that came in with the cancer, rather than the domineering spouse or family member. It was almost as if the disease itself had chosen which type of person to afflict. We saw this again and again. Our doctors and nurses observed this so often and found the pattern so predictable that when a new couple came in, and one was barking at the other, we’d whisper to each other, let me guess which one of those two has the cancer. It was almost as if either a domineering spouse was a resident carcinogen, or a submissive personality pre-disposed the person to cancer, a more predictable and frequently observed risk factor to our observation than even smoking.
However, I no longer think that. Enough strange things have happened to the submissive cancer patients, that I have a more cynical point of view now. I will illustrate with an unfortunate series of events that transpired in the spring of 2016.
Do hospitals have an interest in positive cancer diagnoses ?
A colon cancer patient, whom I’ll call Sarah, had achieved remission with our treatments in 2014, without history of chemotherapy or radiation, had an active lifestyle following her bout with cancer, including among many other things, bicycling and some snow shoveling at her home in the mountains. Then she came back in to see me in March 2016. She had sudden onset of lower abdominal pain. On physical exam, I palpated a taut lower abdomen without defined masses. There was tenderness generally through the left and right lower quadrants, as well as more acutely at the site of an abdominal wall hernia that had occurred with her colon resection surgery. Inguinal lymph was not noteworthy. There had been a history of constipation in this patient, but stools had been normal recently. Sarah was pre-menopausal, and this pain was unlike any menstrual cramps she had previously. Specific exams for appendicitis, McBurney’s and Rovsing’s points were negative, as well as Murphy’s point, which tests for appendicitis and gallbladder inflammation, or cholecystitis, respectively, all of those being less likely problems.
There was a possibility of recurrence of colon cancer as the cause of Sarah’s pain, but cancer pain is unlikely to have such sudden onset or to worsen so quickly.
An ultrasound may have been adequate to show the cause of the pain, but I knew I could get a lot more information from a MRI. However, health insurance is not so fond of MRIs, and the insurance company dithered, and unfortunately the weekend began without the MRI. On Sunday morning the pain worsened again, and the worried patient and family went to the ER of a large local Phoenix area hospital.
Then, while in her Emergency Room cubicle, no fewer than five doctors walked in and announced to Sarah that her cancer was back, and that she would have to begin chemotherapy and radiation. They had not yet done any imaging or biopsy, yet they announced this diagnosis to the patient. Sarah replied that she wanted to talk to me first, and that she would think about it.
When Sarah called me on Monday morning to tell me what had happened, I said that nothing of that sounded right. By that time, a CT scan had been done in the hospital. Sarah had asked for the disk to look at on her laptop, but was not able to open it. So I hurry over to the hospital with my laptop, as soon as my patient appointments for the day were finished. We open up the CT on my laptop, and all look at it together. What do you know? No cancer visible anywhere! All we saw were two huge fluid-filled ovarian cysts, obliterating each ovary. No wonder the pain was so intense and was worsening so quickly. No wonder no solid mass was apparent to palpation on my physical exam. Ovarian cysts can grow large in a short span of time, quite a bit faster than cancer, and this is likely what happened, since abdominal imaging of several months earlier did not show them at all.
Well, what do you know? Ovarian cysts rather than tumors. Suddenly the doctors who so urgently had to begin chemotherapy and radiation treatments on Sarah were nowhere to be found. Now the hospital admitted that there was no visible cancer, and oophorectomy (surgery to remove ovaries) was now available. And there was no further mention of chemotherapy.
So Sarah then had the surgery to remove the cysts, as well as the ovaries that were completely blown out by the cysts. Follow-up imaging through early 2017 again confirmed no visible tumor burden.
However, the hospital’s mischief was not finished: After the surgery, the hospital pathologist alleged that there were cancer cells in the tissue that was removed from Sarah. So Sarah, now starting to become as cynical as I already am, requests the slides from pathology, so that she and I can study them together.
Once I have the slides in the office, Sarah and I look at a few of them, taking turns examining each field of view at the microscope, but it is very time-consuming to study all fields of some two dozen slides. So after Sarah left, I looked at the rest of them alone. I did not find any cells appearing to be cancer cells on any part of any of the slides.
Interestingly, the hospital made several phone calls to our office demanding the slides be returned to them, even though my understanding – although I am not an attorney – is that legally they are Sarah’s property. Therefore, if Sarah ever wishes to prosecute the hospital for misrepresenting the slides, Exhibit A has been stored in a safe place by a third party. How unfortunate that one must take so many precautions because of the dishonesty in hospitals. As of this writing, the hospital has still not accepted our answer, and is still demanding all of the slides. This is even though the slides legally belong to the patient, and her insurance paid the hospital for them.
Cancer treatments- a hospital’s money maker
But of course, such level of corruption should not be surprising, and given my experience with them, is to be expected. Hospitals are required to help anybody stumbling into their emergency departments. This service is an enormous revenue loss, and as the hospitals bleed money out their emergency room doors, there is another sector of the hospital that is the big rainmaker: Oncology. One chemotherapy treatment can be charged to a patient’s insurer for up to $50,000 or even $100,000. A cancer patient is worth $180,000 or more to a hospital or cancer clinic. The National Institutes of Health estimate the cost for the first 2 years of breast cancer treatment is $159,442 and $182,655 for Stages III and IV respectively.i This is where the hospitals get their largest source of revenue, and this, as you might expect, is why you hear such relentless and aggressive advertising for chemotherapy treatments on the radio.
So is it the timid patient who is more inclined to get cancer? One might think that cancer then offers some protection from a psychic wound, or is like a pearl built by an oyster around an irritating grain of sand. If the cancer patient were so submissive and suppressed that he or she had not expressed himself or herself adequately or cathartically in the past, then maybe that psychic pain needed to be expressed, even if the only alternative, the only feasible means of expression, was to grow a tumor. If one is unable to rebel against one’s oppressor, self-inflicted wounds may be the only cathartic release available to the desperate sufferer.
In fact, because passivity seemed to be such a co-morbidity with cancer, I had imagined that it was something that I should also treat, along with the cancer. The way that I did that was, as a typically assertive person myself, to sit back, speak quietly and seldom, assure the cancer patient that he or she was in the driver’s seat, and basically try to ease them into a dominant role in the conversation, hoping that it would help to liberate them and allow them to try on a role other than the passive / obedient one for size.
That is, the passivity of cancer patients was just that predictable. Perhaps one out of eight would be assertive, and the rest passive. When almost every cancer patient seems to be less assertive than their family members, the observer begins to think that this cannot be coincidence, that there is something timid or passive about cancer patients in general, as if it were a predictable personality trait, or that passivity itself predisposed a person to have cancer. Or perhaps their pain and pathology made them too glum to talk much.
But as I said earlier, I no longer think that.
Because chemotherapy brings in enough money to turn the heads of the corruptible, I now think that a more likely scenario is this: Patients who give the appearance of being obedient are easier marks for enterprising oncologists. After all, when a doctor has a business to run, it is a lot easier for the doctor to hear, “Yes, Doctor, I’ll do as you say,” rather than to hear, “You want me to take what kind of poison, doc? Are you out of your mind?” Chemotherapy may be a bit harder to sell to the more assertive members of the population. And those of us who know better than to have any of it would be more of a headache for an oncologist to deal with than an obedient patient, a submissive patient who is inclined to say, “Yes, doctor.” So perhaps chemotherapy finds its target market in the more submissive souls among us.
I once had an oncologist call me saying, “This woman must begin chemotherapy right now! She has to start tomorrow.” The patient had Stage 1 breast cancer, DCIS, just diagnosed less than a week before. Whose urgency was at work? The patient’s? Not so likely as that of the doctor.
I am not alleging any more of a conspiracy theory than would be warranted regarding any other marketing strategy. Ads tailored to your demographic come up on your web browser for similar reasons. Candy is sold in brightly colored packages at kids’ eye levels for similar reasons. Halloween costumes are marketed more in October than March for similar reasons, and the reason, as everybody knows is this: Marketing is most effective when its targeted, and if you want to get away with making a lot of money by legally poisoning a person, you’ll have an easier time of it with an obedient person rather than a short-tempered, or outspoken, or outside-the-box or in-your-face type person.
And, in my opinion, that is likely why we keep seeing the submissive one of a couple having the cancer diagnosis.
Playing right into their hands
There is one other cancer type, as predictable and easily identified when you meet them as the submissive type. And that is the Pessimist. The Pessimist shows up at our office telling us that they have a terminal cancer, which has us thinking Uh-oh, we’re going to have a challenge here. Then often we find out from imaging or pathology that there is a small or easily resected or already resected tumor burden. But more characteristically, we see the scenario described below.
Blood labs are notoriously unreliable with regard to cancer. Imaging can be contradictory or ambiguous. Physical exam has severe limitations, but we do these anyway, on initial consult and then periodically, for further data and information. Thus, over time, we acquire accumulating data points and evidence of which course the disease takes, as the patient’s file thickens.
You will recognize the Pessimist by this behavior: The news comes in, arriving in this order: good, ambiguous, good, good, bad, excellent, good, good, and ambiguous. And the Pessimist says, “Aha, bad!” sometimes almost sounding relieved or satisfied. Working with this kind of patient as their health improves can be awkward, because their improving prognosis almost seems disorienting to them, as if they had made some comfort or acceptance or even end-of-life plans with their disease, and now things have to be thought through all over again.
So then if the Passive Type does not necessarily have an active case of cancer, and the Pessimist does not necessarily have an active case of cancer, how much cancer is really out there in the population? Didn’t you ever think it odd – and we all know people who have said this – “Thank goodness they did that CT of my abdomen after the car accident, because that’s when they found the cancer! And the doctor said if it hadn’t been found right then it might’ve killed me in a few months!” Didn’t you ever think it odd that we hear that kind of story so often? At least I hear it from every few new patients. Doesn’t it seem a bit statistically improbable that imaging just happened to catch the cancer just in the nick of time to save the patient with chemotherapy?
Might this just have something to do with a story told to me a long time ago by an Emergency Room nurse:
She said when the hospital beds are all full and the waiting room chairs are overflowing, you could be openly bleeding on the floor, and you’ll be told, “You’ll be fine; you can take care of that at home.” Yet when the hospital is empty, “the census is down,” as they say, and if you have the misfortune to walk into the ER with a sniffle, it turns out it’s the worst thing they’ve ever seen, and you need a complete workup and to possibly be admitted. If cancer / chemotherapy / radiation are the most lucrative aspect to hospital finances, then are you more likely to be “found” to have cancer when their census is down than on a busy day?
This of course begs the question: If certain patients are singled out to receive the cancer diagnosis because they are more receptive to it, then did those people really have cancer at all?
Who audits the auditors?
My question is: Who is auditing the pathologists? The hospital described above that Sarah went to was very eager to have their slides back, slides that their pathologist alleged to demonstrate cancer, but which on careful examination showed no cancer at all to us. They called about once every two weeks for a few months to demand the slides back, that were not their property, from a patient who had not been there since months earlier. We thoroughly examined this patient’s slides, because of what had happened with her and the hospital, and we found no cancer. So therefore, is it possible that the massive amount of money that has been flowing through the chemotherapy industry has found its way also to the pathologists? After all, if a pathologist says: clean as a whistle, no cancer here, that is potentially up to a few hundred thousand dollars lost to the institution. And if that same pathologist looks at those same slides of patient tissue and pronounces the presence of cancer, there is all that much more income to be had. Are we so trusting to say that no pressure is ever exerted, no bribe has ever been placed before the pathologist? Is such a suspicion only the subject of fiction? The Fugitive was a film with Harrison Ford, which contained the idea of switching normal and abnormal pathology reports, expressed in a fictional context.ii
Pathologist Laura Spruill, MD, PhD, of University of South Carolina has acknowledged overdiagnosis of cancer in histopathology labs, and points out very similar appearances of cancerous and non-cancerous tissue, which is commonly deemed cancerous by default.iii
Certainly, there are people who have cancer, many of them. We find individuals who came in with hard palpable lumps in the breast, bleeding tumors in the colon, massive lumps bulging out the liver, prostate cancer metastasized to the lumbar vertebrae or huge, hard lymph nodes, to name a few types. The pathologist’s role here not only confirms what is overwhelmingly likely to be malignancy, but the pathologist lets us have more and more helpful information, especially regarding likely origin of the biopsied tumor.
Another series of incidents that has made me more cynical over time is the eagerness I’ve seen in oncologists to exploit the pessimism of their patients. Many patients have come to me saying, “It’s a good thing I had all that imaging! My tumor wasn’t seen on ultrasound or MRI or . . .” Finally, it was this other procedure that found it.”
Well, my response to that is that photographs do not lie. If neither the ultrasound nor MRI found your tumor, I would be more inclined to question the existence of that tumor than if it had shown up on such imaging. Certainly, it is theoretically possible for a tumor to escape imaging, but with the sophistication of contemporary imaging technology, this is less likely all the time. If you keep going back for imaging, repeatedly, and of numerous body parts, I think your risk of having something “discovered” increases all the time. If you consider that our ancestors did not have anywhere near the amount of imaging that our current generations indulge in, it seems very likely that they had lumps and bumps all over that nobody had imaged, and that they lived with and likely died with when succumbing to another cause of death. Autopsies often turn up such incidental and benign hematomas, fibroids, adenomas, cysts and such.
Whereas the pessimistic patient assumes that the most pessimistic imaging must be the true one, invalidating other reports, I take all of that imaging as important data points in trying to find out what is really going on with that patient’s cancer, especially as it is repeated over time. This is because time, long periods of time, tell the most truth. I may be uncertain today of the tumor burden of the patient in front of me. But five years from now we will be able to look back fairly certain of what this year’s situation really is.
And, having been trained in cynicism by repeated strange occurrences in the conventional medical world, I assume nothing. Rather, I look for a preponderance of evidence in order to determine what is happening with a cancer patient. Some of that evidence is what we observe of the money trail and where it may lead. Cancer is such massive business, shouldering the work of keeping hospitals – the nexi of one of the largest growth industries in the US – in the black. It would be naïve to assume that all decisions made with regard to cancer were simply independent of that money, and only related to the best interests of the patient.
Let them not make merchandise of you. Follow the evidence and leave the emotions at the door.
Therefore, esteemed readers, just to keep things as honest as possible, let us, you and I, take responsibility for keeping a vigilant eye on such a financially robust industry, just to make sure that our acquaintances, our loved ones, our patients, who are suffering a cancer diagnosis, from possibly a real cancer or perhaps an alleged cancer, are not deceived or otherwise victimized by those with pecuniary priorities.
i Blumen H, Fitch K. et al. Comparison of treatment costs for breast cancer, by tumor stage and type of service. American Health Drug Benefits. 2016 Feb; 9(1):23-32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/
ii StudentDoctor.net. Pathology movie coming to theaters. https://forums.studentdoctor.net/threads/pathology-movie-coming-to-theatres.1158889/ Aug 2015.
iii Spruill L. Pathologic assessment of breast core biopsies: limitations and pitfalls. 6th World Congress on Breast Cancer and Therapy. October 16 – 18, 2017. San Francisco, USA. https://breastcancer.conferenceseries.com/america/scientific-program#tab1