I told you about a patient who called me because he was hoarse and ended up being told he had kidney cancer. I purposely didn't finish the story then because what happened next is more relevant here. This man, you will recall, had a small cancer on his vocal cords. It hadn't spread anywhere, and it was easily removed.
But as part of his evaluation we got a chest X-ray, which raised the question of an abnormality in the chest, which led to a CAT scan of the chest, which showed that there wasn't any issue in the chest but raised questions about the kidney, which led to a CAT scan of the abdomen, which detected what was almost certainly a kidney cancer. It was a testing cascade that led to a totally unexpected finding.
The question was what to do next. I discussed the issue with a radiologist and a cancer surgeon. Both were convinced that this was cancer. Because the mass had pockets of fluid in between areas of tissue, neither thought a needle biopsy would be helpful; a negative biopsy would simply mean the needle had missed the tissue. So their advice was simple: take the kidney out.
Neither the patient nor I felt very good about that. Sure, he had another kidney, and we had every reason to believe he could manage well with just one. But taking out a kidney is a serious operation: the incision is big, so he would be very sore for weeks afterward, and some people do die from the operation (for an average patient in his mid-60s, the expectation is about 12 deaths per 1,000 operations).
And most important, my patient felt well. He wasn't taking any medicines, he had stopped smoking three years earlier, he was walking over three miles a day, he regularly traveled to New york city to visit friends. Indeed, removing the vocal cord tumor had fixed the only thing that was bothering him: hoarseness. Why upset the apple cart?
The cancer surgeon was taken aback that I would even entertain such thinking. He thought I should be forcefully persuading the patient to aggressively fight this cancer. He looked at the same patient, saw the same person, and came to a totally different conclusion. His assessment was straightforward: "Look, here is an otherwise healthy guy who has kidney cancer. Yes, it's major surgery, but because he's healthy he'll sail through it. We've got the chance to save this man's life."
I hate being on the reverse side of this argument. Why would any doctor want to forgo the chance to save someone's life? But my patient and I shared a sense of unease about where we were and how we had gotten there. Maybe it was a fast-growing cancer.
Maybe it had just started growing. Maybe it hadn't yet begun to spread and surgery would solve the problem that is, maybe we had stumbled on it at just the right time. But that you will find incredibly good timing. In fact, the chances were much more likely it absolutely was there quite a long time that it was a slow-growing cancer. The patient wanted to know why we couldn't simply check on it again in another three months.
The cancer surgeon persisted, and now he had statistics. He told me that when we remove a kidney cancer before it metastasizes, 90% of patients are alive in five years. But if we wait until after it metastasizes, only 10% of patients are alive in five years. He went on to indicate that because of early detection, the average five-year survival for patients with kidney cancer had increased from 34% in 1950 to 62% currently. Pretty convincing stuff.
I thought I ought to check his statistics. He was right. Patients with early-stage kidney cancers are much prone to survive five years than those whose cancers have spread beyond the kidney. Because of CAT scans, we are finding more kidney cancers at an earlier stage than we did in the past. Most important, the proportion of Americans with kidney cancer who are surviving five years is increasing. The evidence seemed conclusive: testing for cancer is helping people live longer. But I noticed something else: the number of Americans dying from kidney cancer is not decreasing.
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