The Big One
AT NINETY years old, Ms. R had already survived two lung cancers. When she came to the VA radiation oncology clinic to consider treatment for what was probably a third, one part of the workup was missing: a biopsy of the tumor. It would have been risky—the procedure itself could have hospitalized her, or worse. At her first visit, she was wearing jeans, brightly colored plastic bracelets on both wrists, rings on all fingers except her thumbs, white hair cut short. She brought her sixty-year-old son, who was wearing a striped banker shirt, shirtsleeves rolled up to give a view of a scorpion tattoo on the inside of his right forearm. After introducing myself, I sat at the computer next to them and opened up the images from her recent PET scan.
“Some patients like to look at the scans,” I said. Not many veterans from the 1940s were women. “I was trying to figure this out. If you’re ninety, that means you were in—”
“That’s right,” she said. “The big one, baby.”
“Wow,” I said. “Back then, what kind of—”
“Quartermaster,” she said. “Shipping supplies.”
“Huh.” What else to say? “Should we look at your scans?”
Her son gave a nod.
“Here’s a PET scan from last month,” I said. “I’m not sure if you’ve seen this before.”
“We haven’t,” her son said.
I rolled through the images of the scan until it showed a large orange mass in the middle of her chest. “In a former smoker with two previous lung cancers, those orange blobs in your chest represent lung cancer ninety-five percent of the time.”
She sat back. “What about the other five percent?”
“Infection, inflammation, scar, other lung diseases. It could be some other cancer: say, lymphoma. That would actually be better—lymphoma can be easier to treat.” I turned my attention from the computer screen to face her. “I don’t want to give you the wrong impression. This doesn’t look like a scar. Lymphoma would be unlikely. This looks like lung cancer.”
She gazed at the image, her
