Hindsight is 20/40

July 9, 1980 is a day that though I didn't understand then, I understand now was a defining moment in my life. I do not remember much of the later 70's, bits and pieces come to me here and there, but for the most part I see faded faces, muffled voices. I cannot see who is talking, nor can I understand what it is they are saying. I do remember standing in line outside of the matamoras theater, waiting with my two sisters to get tickets to go see The Empire Strikes Back, George Lucas sequel then, prequel now to the original star wars released five years earlier, which to this day I might add, can recite most of the lines start to finish for most of the characters. Yet I am still unclear of how I got into that line, who drove, what we talked about on the way. I know we left from my Aunt Esther's house. I remember seeing my mother approach, and I remember her almost whimsical face, attempting strength and composure, I don't remember sadness though, I remember relief was her overall tone. I remember her holding onto me tight like a mother would hold onto her child preventing a fall from a height that would cause certain death. She whispered softly into my ear, "it's over, he's gone" referrring to the death of my father. I rememeber the wailing of my sisiters, and the feel of wet skin wrought with tears as her cheek pressed against mine. Fast forward thirty years later- Mr. G, a fairly healthy seventy year old man and patient of mine for my first five years of practice sat quietly next to me in my office, we had just completed his annual physical. His hands nervously folded and unfolded the New York Times crossword puzzle of which he was an avid and vocal fan. I'm sure it also helped to pass the time while he waited in my waiting room. His only complaint this year was that of a month or so of diffculty swallowing liquids and soft food, and that occasionally if his head was turned in just such a way, that he would have pain when swallowing. No weight loss. He never smoked or drank a day in his life. I jokingly asked him what he did for fun. "chased women" He wryly replied giving his second wife sitting across from him a half wink. He was a widower ten years prior, his wife tragically killed in an automobile accident. This was his second wife.
     I often wonder if my father's medical record could be found anywhere. There hasn't been much advancement in the treatment of esophageal cancer, but there are signs. Thanks to an Australian physician approximayely fifteen years ago, we leard that GERD or gastroesophagel reflux disease is a condition that is not caused as was previously believed to be the case by excessive acid secretion from the proton pumps of the stomacg, but rather by a bacteria that caused inflammation and weakening of the stomach wall. An acididophilic, thermophilic beast that thrived in the harshest conditions of the acid filled hot environment of the stomach. Tums was no match for this guy. We learned it would take antibiotics. It is discovered fairly easily through the use of routine endoscopy, a procedure that has been done for decades. A biopsy is taken from the stomach and grown in a petri dish. If the symptoms persist, and are not treated appropriately, the cells that line the farthest end of the esophagus (the tube leading from mouth to stomach) will begin to change into pre-cancerous cells which we call Barretts Esophagus. By this time one would have daily quite severe symptoms of heartburn, one often mistakes the severe pain of heartburn for that of a heart attack. Belching, passing gas, chest pain and pressure, these symptoms would most certainly be waking one up at night at least several times per week. If the disease is not found at this point it will progress to fulminant esophageal cancer, an adenocarcinoma. This diagnosis yielded a prognosis of less than 3 months thirty years ago; today...3-6 months.
     I was concerned about Mr. G- I referred to my local gastroenterologist who as expected performed a routine upper endoscopy- as expected he biopsied a suspicious looking inflamed bulging area in the lower two thirds of his esophagus, 1 week later I received the pathology report. Esophageal Adenocarcinoma was confirmed. I had my receptionist call him for an office visit immediately. Again, he sat nervously next to me in my exam room. I flipped through a few pages and came to his report. There would be no dancing. Mr. G was not a dancer. He was a no nonsense man who liked the truth no matter how jagged it was. I looked him square in the eye and said Mr. G we have a problem. You have cancer. It is in your throat. Silence. He nor his wife appeared not that surprised. There was no weeping. There was no self-pity, there was no "why me?" He stoicly gazed back at me and said what now? What do I do? How long do I have? I told him that only the good lord above was privy to that information, but did hint that this was a particularly aggressive cancer. I gave him the choice of fight or flight. He chose to roll up his sleaves.
     A whole body scan revealed no evidence of metastasis. Several axillary (arm pit) and mediastinal (chest wall) lymph nodes were negative for disease as well we had a good shot at surgical resection for a cure. That is exactly what we did. Further pathology showed the 2.5 inch tumor had grown into the 2nd layer of his esophageal wall and that he cells of the tumor were "poorly differntiated" which means that there was no discernable organization to the different parts of the cell. No nucleus, no ribosomes, etc. T2N0. A poorer prognosis, nonetheless, Mr. G had almost 1/2 of his esophagus removed, the surgeon reported good margins. 3 rounds of taxotere, 5fu and cisplatin, and although bald, nauseous and with burning feet, 4 years later Mr. G is alive with no evidence of recurrence of his cancer. He met his grandchildren, two sons and daughter in florida later that month to celebrate his yearly birthday. He was no longer 72. He was 5. Five years survival past diagnosis. Neither his oncologist nor surgeon could explain.
     Because Medicine is practiced by humans it is subject to the imperfections of those humans that practice it as a craft. There are good practitioners and bad ones. Some will miss the subtle symptoms, some will reognize them and make the diagnosis. I often wonder what kind of doctor cared for my father. Did he miss subtle symptoms, or did my father seek care too late.  It was a differnt time then.  It matters not to his sapponified body that lays six feet under the grass of a cemetary in Port Jervis, NY.