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Point of View

Picture of health

By Tawnya Bowles, M.D.

One of the first patients I cared for, after I began my fellowship in surgical oncology, was an elementary school principal with a 30-pound abdominal tumor.

A thin and active woman all her life, Jessica (not her real name) had noticed that she was getting heavier and heavier around her midsection. She tried to lose weight. Her face became gaunt and her arms and legs grew spindly, but the big belly persisted. Strangers began to ask her when her baby was due. The new abdominal girth gave her intractable acid reflux. Her energy level was dwindling.

Ultimately, a CT scan provided the answer: her entire abdominal cavity was filled with a retroperitoneal sarcoma that had pushed her organs aside as it grew. She traveled nearly 700 miles from her home in West Texas to our cancer center in Houston for treatment of this rare tumor.

The Point of View essay provides personal insight or opinion on some issue in medicine or science. Bowles, a 2001 graduate of Dartmouth Medical School, majored in biology at Utah State University. After earning her M.D., she completed a residency in surgery at the University of California, Davis, Medical Center, and she is currently a fellow in surgical oncology at M.D. Anderson Cancer Center in Houston, Tex.

She and I were both new to the hospital when our paths crossed; Jessica was admitted during the first month of my two-year fellowship. It was clear from only a glance at her that the tumor had nearly taken over her physical being. I had never seen a tumor so large, in fact, but in my effort to act professional I did not say so. The surgery to remove it would be complex. My attending surgeon calmly described a long operation that would involve the resection—or removal—of the tumor, as well as parts of her intestine and possibly one of her kidneys. Jessica was anxious but eager to proceed.

Ashen: After the attending surgeon and I met with Jessica, a member of the clinic staff took a digital snapshot of her and posted it on the first page of her electronic medical record. Later that week, in planning for the upcoming operation, I reflected on that photograph. In the picture, she was smiling wistfully. Her face was ashen. She looked sick. All of that might be expected for someone with a huge tumor growing inside her—but I was surprised. My image of her, crafted from the clinic visit, did not fit the snapshot. I had seen her as an energetic, witty workaholic who had joked about rearranging the garage the night before to relax. She was eager to have the operation so that she could resume her life. I remembered the vibrant multicolored jacket she'd worn to the clinic. The colors did not come through in the washed-out snapshot that was taken that day.

In the months since I first met Jessica, I have cared for many cancer patients and have reflected on their electronic pictures. I have learned that these photos are typically taken on the day that the patients make their first visit to our cancer hospital.

And what a day that is. Patients often know their cancer diagnosis by the time they are referred to us, and they usually have endured a whirlwind of events—doctors' appointments, imaging studies, blood tests, biopsies—over a short period of time. Many are still grappling with the implications of their diagnosis. They often have no idea what lies ahead. Most of them have gotten out of bed before dawn and traveled many miles to meet with the cancer specialist. They may have fought for a parking spot after missing the right freeway exit a time or two, wandered through a maze of buildings, and had their blood drawn. Finally, they end up at their clinic appointment and in front of the camera. "Smile!" they are told.

Can one picture encapsulate how it looks and how it feels to be diagnosed with cancer? The reality is that often you cannot tell by looking at people whether or not they have cancer.

Evident: What our patients have been through is usually evident in these snapshots. Many patients look stunned, some look depressed, and others look just plain tired. Interestingly, though, some look genuinely happy, smiling as if they had just been told a good joke. Perhaps the photographer that day was especially effective at helping the patient relax.

Can one passport-sized picture encapsulate how it looks and how it feels to be diagnosed with cancer? Cancer and its various treatments do change people's appearances. As medical students, we are taught to look for unintentional weight loss and unexplained fatigue, which can be subtle clues to cancer. Some cancer patients are yellowed with jaundice. But the reality is that often you cannot tell by looking at people whether or not they have cancer. Patients are struck by this reality and often ask: How long has this tumor been growing inside of me? How could I not have known? Jessica had these same questions. I did not have good answers.

Recovery: But the good news is that many of our patients, including Jessica, survive. As expected, her surgery was long and tedious. The sarcoma had pinched her stomach almost completely closed and wadded her intestines into a tight ball. With careful dissection, the tumor was completely resected and her organs were spared. After several days of difficult recovery, her body gradually healed and she was able to return to West Texas, to her bustling school, and to life without the weight of the tumor.

Jessica's electronic snapshot was recently updated during a follow-up visit to our clinic. Like other cancer patients, she will return regularly for examinations and tests to ensure that the cancer stays at bay. She knows her way around the hospital now, as do I. In the new picture, her hair is curled and flowing freely, her cheeks are pink. And there is nothing at all wistful about her smile.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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