I’m a radiation oncologist, a type of doctor who uses radiation to treat cancer. Radiation is a very useful treatment – in many cases, it’s part of a treatment package aimed at curing a cancer. But even when a cancer cannot be cured, radiation can be useful to improve symptoms related to the cancer, like pain or shortness of breath.
So it was quite routine when I was asked to meet Susan, a lady in her 60s who had been recently diagnosed with stage IV lung cancer. A few months earlier, she had developed a chronic cough. Her family doctor ordered an x-ray which showed a suspicious spot in her lung, which led to a CT scan that showed the spot to be a tumor. A biopsy confirmed that the tumor was lung cancer.
Before treatment for lung cancer, it’s crucial for doctors to know where the cancer has spread. This allows us to determine the stage of the cancer. In lung cancer, stage I means there’s a small tumor in the lung that hasn’t spread anywhere else, a situation that’s usually curable. At the other extreme, stage IV usually means that the cancer has spread to other parts of the body and is unfortunately incurable. It initially looked like her cancer was stage III, which is a cancer that can be treated with the goal of cure.
To see whether Susan’s cancer had spread further, she underwent a PET scan. A PET scan involves injection of a radioactive sugar into the bloodstream, and areas of cancer light up when they take up the sugar. Other non-cancerous things, like infections, can also light up. On Susan’s PET scan, the tumor in her lung took up the sugar, but so did one of her adrenal glands. Our adrenal glands sit atop of our kidneys, and lung cancers tend to spread there, so Susan was classified as having a stage IV lung cancer.
Susan knew to ask her doctors about her stage. Because of the spot on the adrenal, she was labeled as stage IV. She was started on some chemotherapy, with the goal of slowing down, but not curing, the cancer.
She came to see me for some radiation to help her cough. We looked over her records again. The doctor who reported her PET scan wrote that the sugar uptake in the adrenal was “highly suspicious” for a spot of cancer. Since Susan’s whole treatment approach hinged on whether that spot was cancer or not, I explained to her that it was worthwhile double-checking the adrenal. “Chances are very high that it is indeed cancer, as the PET scan suggested,” I told her, “so let’s not get our hopes up.” I sent her for an MRI.
The following week, we had the MRI report back. The spot on the adrenal was not cancer. Susan actually had stage III cancer. We quickly modified her treatment to one intended to cure the cancer.
We had almost missed the opportunity to treat Susan’s cancer properly.
Susan had done some background reading and knew to ask about her stage, which she did. But we, as doctors and health care providers, are not teaching our patients to ask all the right questions. We’re not telling them to ask important follow-up questions: Why have you assigned me that stage? Are you 100% certain in the findings of the tests, or is there anything equivocal on the scans that we need to confirm?
Despite the fact that cancer patients are better informed than ever, most aren’t aware that they can take extra steps to ensure they are getting the very best care. Patients can double-check several aspects of their treatment, including their stage, and their doctors’ recommendations, and can make sure that they have a top-notch treatment team.
In the book , I provide patients with several tools to help them make sure they’re getting good care, including checklists of questions, and online videos to help explain some of the issues around cancer care. If you or a loved one have been diagnosed with cancer, here are 3 key steps that you can take, along with some questions that you can ask your doctors:
Step 1: Confirm the right diagnosis
Can you provide me with copies of the reports from my imaging tests and from my biopsy, and explain them to me?
Step 2: Confirm the stage
Why have you assigned me this specific stage? Are there findings on my scans that need to be investigated further?
Step 3: Confirm the treatment options
How would my cancer be treated at other medical centers? What do treatment guidelines recommend for my specific stage?
Dr. David Palma, MD, PhD is a Radiation Oncologist the London Health Sciences Centreand a Clinician-Scientist at the Ontario Institute for Cancer Research. He holds degrees from Harvard University, the VU University in Amsterdam, Western University, and Queen’s University in Canada. Dr. Palma runs the patient website