Thursday, Jun. 02, 2011

What I Learned from My Cancer Scare

At some level, I knew I was standing in the middle of New York City traffic, but my mind was in another dimension entirely. Reminders of your mortality will do that.

The day hadn't started off so strangely and scarily, but it hadn't started off to be much fun either. I was going to my doctor's office for a colonoscopy, my second in nine months. Colonoscopies aren't supposed to happen nine months apart, of course, unless the first one turns up something worrisome — and mine had. Back in August, my doctor discovered a suspicious polyp that needed to be removed. It turned out to be precancerous, and while a large majority of such growths do not eventually become cancer, colon cancer usually starts with just that sort of polyp. So did I have the 40-some years left to me that I had been more or less counting on — or just a year or two? You ask a lot of existential questions like that when you get the kind of news I had gotten. And you do a lot of hoping that when you return for a follow-up exam, all will be well — and the problem will simply go away.

Now I was going in for that follow-up. Surely I would get the all clear, and life would go back to being what it had been. I didn't, and it didn't. My doctor found another polyp, higher up in the colon — a more dangerous location.

I left the doctor's office and stood out on the street wrestling with the news. Pedestrians bustled by — all of them, I felt, untroubled by the kinds of things I was feeling. But of course, I wasn't alone. Indeed, I had something in common with millions of people across the U.S. I was a medical statistic, one of many, many patients who receive the kind of diagnosis I did every day of every year. The very fact that I was joining so large a population meant that this was by definition a routine story. But that's the case only if the story isn't about you.

When it is about you, your mind races. Am I at fault? Could I have done something differently? What do I tell my children and wife? What if I actually get cancer? Have I done everything I set out to do in life? I am a physician who gives advice for a living. I have spent much of my professional life extolling the value of healthy eating and regular exercise, and I practice both. So how in the world did this happen to me?

Part of the answer to that last question is luck of the draw. A healthy lifestyle can dramatically lower your risk of cancer, but it's no guarantee of anything. But there was more at work too — at least in terms of how and when I learned of my condition. I take pride in being a good doctor and a good family man, but the fact is, I had been a pretty bad patient. Living my life on television, dispensing medical advice every day leaves me with a solemn obligation and moral imperative to be honest and to own up to mistakes — and I made some. They may not have been big, but they were more than enough to threaten my health, my future and the well-being of my family. The experience transformed me from Dr. Oz to just plain Mr. Oz, and it taught me a lot, both about myself and about my patients.

50 and Fabulous?
The story started about a year ago, when I celebrated my 50th birthday with a big bash attended by family and friends, many of them doctors. I bragged that I would commemorate my half-century mark by scheduling a colonoscopy, something I routinely counsel my patients and viewers to do — and something that I didn't look forward to with any more enthusiasm than anyone else does. Making light of it by making an announcement of it helped ease the reality that I had crossed midlife's threshold and somewhere out there a colonoscope was waiting for me.

Some guests suggested that the procedure be shown on my program, pointing out that viewers would be well served to see how easy this simple screening could be. I agreed, figuring that if I had to go through the prep and hassle, why not put it to good use? The gravity of the test was the last thing on my mind. Indeed, if I wanted to be truly honest with myself, I might not have scheduled it had I not been such a show-off at my birthday party.

But even though I did manage to make the appointment despite my belief that I had nothing at all to fear, I found a different way to act against my own interest beforehand. I knew full well that I wasn't supposed to eat for at least 36 hours leading up to the test, but I nonetheless sneaked a few mouthfuls of lunch just 18 hours before. How could it hurt, especially for someone as healthy as me? I said nothing to my doctor about this and reported for my test the next day.

During a colonoscopy, many people are completely unconscious. Another option is twilight sleep, which eliminates pain while leaving the patient partly conscious. I chose that, and I also opted to watch on the monitor as Dr. Jon LaPook, my gastroenterologist and friend, conducted the test. It didn't take long before he began grumbling about the inadequacy of my prep. My colon was littered with the lentils I had heedlessly eaten the day before. I had been a mediocre patient, the kind I lecture about — and to — in my practice and public life. As I lay on the gurney, a snapshot of thousands of conversations I had had in my office with patients on whom I was about to operate formed vividly in my mind. My emphasis in those situations is always pointed: I look them in the eye and tell them I need their help, that this is a combined effort and that we will get through this together but that we both have responsibilities. I always feel frustrated when my patients seem to think that precise medical instructions based on years of experience don't apply to them. I was now that person.

LaPook scolded me for having disobeyed instructions, but he did so playfully; I was in a vulnerable enough position at that moment as it was. The banter ended fast, however, when he looked up from the monitor and announced that he had found a suspicious polyp that needed to be removed. I shifted my gaze to the screen, and there it was: a little teardrop of tissue attached to the colon wall. For a brief period, emotion superseded reason. The growth coming into focus indeed looked precancerous, but that was impossible! I have lived a pious life! I was feeling fear, yes, but also — irrationally — anger. LaPook coolly carved out the polyp and forwarded the specimen to pathology for rapid diagnosis. But it was a Friday — a Friday the 13th, as it happened — and there would be no results until Monday.

The Long Wait
The weekend was what you would imagine the weekend to have been — which is to say, lousy. All these years I have been telling people bad news, sad news, scary news. Now I was experiencing what they so often experienced. The very lonely terrain of awaiting diagnosis is bad enough. But as every parent or professional or employee knows, your responsibilities at home or at work don't stop just because your mind is whirling with worry. The same is true when you're a healer — when your pager continues to go off and the messages continue to come in and your patients expect, and deserve, your full attention. In the free moments I had that weekend, I went through my litany of medical options. Best-case scenario would be a hyperplastic polyp, which behaves like a skin tag and would never have hurt me. Worst case, I had cancer that had spread through the protective lining of the colon, and I would need surgery to remove my colon.

Monday morning at last arrived, and LaPook called and asked if I could come to his office. I immediately knew I could eliminate the best-case scenario. Doctors are taught to share good diagnoses over the phone but to deliver bad news in person, so as to offer better counsel. I sat attentively across from him as he told me that yes, my polyp was premalignant, the kind from which cancer arises to afflict 5% of Americans. The odds are higher if you have a relative with this cancer, if you are obese or if you smoke. I had none of these risk factors, nor do the majority of men and women diagnosed with an adenomatous polyp. This bears repeating, in case any of you believe you are even healthier than I thought I was. Most people with precancerous polyps have no risk factors. If I had not been showing off at my birthday party, I could have easily caught my problem too late and been facing major surgery and perhaps a colostomy, chemotherapy and even death.

I called my wife Lisa from LaPook's office. She was very calm when I told her the news, but by the time I got home that evening, she already had a shopping cart's worth of herbs and polyp-shrinking potions ready for me. We all cope in different ways. The tougher part was telling my children — not so much that I was sick, because I wasn't, at least not yet — but that they were now at high risk for polyps and would need to start getting screened when they are at least 10 years younger than I was. I was advised by friends to do this while driving in the car, which is a brilliant insight since the activity allows everyone to process information without being forced to look at one another.

I have four children, ranging in age from 12 to 25, and we spoke when we were driving to the airport in Maine after the wedding of Daphne, our oldest. The kids asked the right questions and took their emotional cues from me. If I wasn't panicking, they wouldn't either.

I also felt a moral imperative to share this news with my viewers. My unlucky outcome offered a teachable moment to help our audience get screened themselves and potentially save some lives. So we got the word out and heard back about hundreds of early diagnoses that resulted from timely screening. I learned the most not from the people who got screened but from those who didn't — or at least who put it off longer than was good for them.

For many of us, health is binary, sort of like being pregnant: we are as healthy as a bull or are about to be hospitalized. In medical school we are taught much about lifesaving interventions during crises but little about the broad societal screening that profoundly affects the likelihood of needing to face end-of-life decisions prematurely. After all, prevention is pretty boring to learn and does not pay well, especially when compared with specialties like mine (cardiac surgery). This colors the discussions we have with our patients. Every week in my clinical practice, I dutifully admonish people to get screened but often leave the details to them. Between selective hearing, human error and confusion, many mismanage the seemingly simple request, and the tests slip away in the sands of time. Accordingly, we devoted a lot of airtime to the idea that both doctors and patients need to change the way they do things.

Of course, throughout all of this, I still had one serious bit of unfinished business to handle. The lentils in my intestines at my initial colonoscopy had partly obstructed LaPook's view, so he insisted on repeating the colonoscopy to look for potentially missed polyps. He gave me a three-month window, which is about standard in a case like this. Remarkably, I stalled. He called to remind me. I scheduled and then canceled. He sent periodic e-mails. I procrastinated. Once again, I was engaging in behaviors that had left me dumbfounded when my patients exhibited them. How could they be so casual with their health when there was real reason to worry about it?

Finally, after a full nine months, I came around. Once again, I found myself at home, reading the instructions for mixing the huge chemical cocktail that would wash out my intestines. This time around, I was taking this business seriously. As directed, I drank a big glass every 10 minutes without fail. I also took laxative pills and magnesium citrate and fasted for two days. I did not want a third look in my colon in one year. You could have eaten tapas off my colon lining. LaPook was thrilled. He had a great time looking around until he got to the most distant part of the colon, the most difficult section of the intestines to see and operate on.

Then, through the same anesthetic fog as before, I heard the same concerned voice I'd heard from him during the previous test. He had found another polyp, in a more hard-to-visualize location than the first one. He needed to excise the lesion deftly. Under the influence of the narcotics, I mumbled, "Good luck." Once the polyp was in the bucket, we repeated the same pathology exercise as the first time around and awaited the diagnosis. What kind of a reward was this for showing up dutifully for my test?

The best thing about a colonoscopy is that the test itself can be curative if the polyp is successfully removed before cancer pushes into the colon tissue. But if the tumor has spread into the wall of the intestine, my 10-year survival odds are about 72%. If any lymph node is involved, I am in the 50-50 club, and if the tumor has spread to another organ, I have less than a 5% chance of being alive in 10 years.

This second polyp, which worried me more than the first, turned out to be hyperplastic and not precancerous. This was good news, of course, but the fact that I had had a polyp at all did mean I would have to be vigilant for the rest of my life. I will probably be at little risk of dying from colon cancer — but only as long as I faithfully show up for periodic testing and continue to use a capable gastroenterologist who can meticulously do the procedure.

Getting Smart
Those colon-cancer numbers are likely to keep me on the straight and narrow from now on. But it was an awfully close call. Why did I almost blow it?

It was while I was sitting in my office's waiting room before the second test, watching a half-dozen patients pacing back and forth thinking many of the same anxious thoughts I was thinking, that I finally had the epiphany. The reason so many otherwise rational people don't screen themselves for disease is not that they don't understand the risks — they do. And it's not even that they believe they're somehow immune from disease or death. We all grasp that in a primal way from the time we're very small. But even as we age, death still seems somehow remote — something that will happen at some vaguely later time and that we'll deal with it in some hard-to-fathom way. It's that distance that helps us cope with the idea of our mortality.

What we can grasp much more clearly — and what we dread much more immediately — is the world-jolting way a bad medical diagnosis will affect us today. Our lives get complicated fast, and we are very uncomfortable being uncomfortable. We detest the passage into the unknown — that feeling of being out of control, victimized. Numbers like 75% or 6% or 50-50 are abstract and conceptual. The sickly, swoony feeling you get when your doctor says, "Come see me in my office," is something we can all imagine today. And so we avoid the test to avoid that experience — and that was precisely the choice I had made.

In hindsight, I recognize that the universe had to drill through three distinct layers of arrogance (or denial) as it changed my perspective on cancer and cancer screening. First, I was cavalier going into my initial screening. I was healthy, and I knew the statistics, and I figured the risks didn't apply to me. Second, I felt that decades of research and experience that led to the prep-and-testing guidelines as we know them also didn't apply to me. And last, I felt that the follow-up was somehow a formality and the risk still didn't apply to me. The transformation from Dr. Oz to a modest, wiser Mr. Oz did not become complete until I was staring directly at a pathology report.

So am I satisfied with the results of my birthday-boy bravado? Well, I have learned to embrace the uncertainty and terror that we all experience as we confront threats to our health. I will perhaps fear bad news a little less and will thus show up for screenings more willingly in the future. I am surely pleased that what I learned will help me manage a disease risk that might otherwise have killed me. So, if a newly modest me can still be immodest enough to offer advice: Learn from my mistakes.

The goal, I now know better than I did before, is not to be the perfect patient but simply to be as good a patient as you can be. Many of you have not had any kind of cancer screening in a decade or more. Please know that it's often not too late for a clean medical slate and that even if something is detected, it's better to find it sooner rather than later. The fact that you have never had a screening or have failed to keep up with the appropriate schedule has no bearing on the karma of cancer, but it has an enormous bearing on the outcome.

Most important, my colonoscopy wasn't entirely about me. It was about my wife and our children. It's about our someday grandchildren. It's about my childhood friends whose lives remain closely intertwined with mine. It's about my colleagues and patients at the hospital who teach me as I learn from them. I need to be there for all these people I know and care about. I need to show up in my own life. And you need to show up in yours. Sometimes that requires courage — the courage to undergo a colonoscopy or Pap smear or mammogram or chest X-ray. It's not easy, but it could save your life. And if it helps even a little, remember that I will be rooting for you.