Going Through the Stages

When I was a medical student, it was recommended we read “On Death and Dying” by Elizabeth Kubler-Ross. This book is considered foundational and established five stages people facing death go through: denial, anger, bargaining, depression, and acceptance.  I don’t recall specifically which one of my professors recommended this book, but I did read it and found it useful in understanding how people respond to the grim news they have a disease that may or will lead to their demise.

Dr. Kubler-Ross’s book was instructional, but years of performing major surgical procedures attempting to prevent patients’ deaths from malignant disease have taught me that not everyone goes through all five stages. I have one notable and memorable patient who started in the first stage, and has remained in the second stage (with occasional visits back to the first stage) for over 25 years now.  And she hasn’t died despite having stage 4 cancer, so it’s working well for her.

The patient I am thinking of was a lady in her mid-50’s when she was referred to me by a gastroenterologist. She had seen the gastroenterologist because she was having bleeding with bowel movements over a three-month period.  The gastroenterologist performed a colonoscopy and visualized and biopsied a tumor in her sigmoid colon.  The biopsy demonstrated a malignant colon cancer, so he sent her to me for surgical care.  He did not provide any warning about her mindset.

At her initial consultation visit with me, I walked into the room and introduced myself to her and her husband. The look on her face and the energy in the room was pure anger.  Her husband sat three or four feet away from her, not making eye contact with her at any time.  My first inquiry was to ask how it was she came to be diagnosed with colon cancer.

I was startled by the vehemence of her response. “I DO NOT HAVE CANCER!” Confused, I looked at the sheet of color pictures taken during her colonoscopy demonstrating a tumor in her sigmoid colon.  I glanced again at the pathology report indicating a colon adenocarcinoma.  I confirmed her name and date of birth was on both of these pieces of information.  I looked up and my gaze met hers, and I asked her to explain.

The patient informed me she had no family history of cancer, she lived a healthy lifestyle, she did not smoke cigarettes, she did not drink alcohol, she was not overweight, she exercised regularly, and she had no other medical problems. Therefore, it was impossible for her to have cancer.  I was mildly abashed.  I had not previously encountered denial of this vigor and intensity.  I mentioned that the reports from her referring physician suggested she did have a malignant tumor in her colon.  She vigorously shook her head from side to side and said, “No!  The doctor is wrong.”

I excused myself from the room and went out to look at the CT images we had obtained. They showed a definite mass in the sigmoid colon, but no evidence of any enlarged or abnormal lymph nodes or metastatic tumors in the liver or lungs.  I returned to the room, feeling stymied about how best to approach this patient.  At this point, for the first time, her husband looked up at his wife and made a simple statement, “You know dear, you may not believe it, but you do have colon cancer. “

The patient shot him a withering look and he sat frozen in position, with the immediate development of a grey pallor to his skin. I instantly thought of the story from Greek mythology of Medusa; a single look at her face and hair made of wriggling snakes would turn any mortal into stone.  The look from the patient was so fierce that I involuntary pushed my wheeled stool two feet back away from her.  I glanced over at the patient’s husband, and after seeing he was quietly respiring and occasionally blinking his eyes, I turned back to his furious wife.  The conversation that ensued was unique in my experience.  She was undeterred in her belief the cancer diagnosis was incorrect.  She went on to explain to me over the next twenty minutes that she would prove to me she did not have colon cancer.  She stated she had been doing “quite a bit of research” and had found some special high fiber natural diets that would cleanse her system of any malignant cells.  I informed her that my recommendation was that she allow me to perform a sigmoid colon resection to remove her biopsy-proven colon cancer.  This pronouncement was met with a sneer and a denigrating remark, “You doctors think you know everything and just want to cut people up.”

Okey dokey. I had made a standard of care recommendation for surgical treatment but this lady denied the presence of any malignant disease.  She was so certain her physician was incorrect in his diagnosis that she promised to return in three months after eating her special diet to allow me to repeat her endoscopy.  I had no choice but to agree.  I can recommend a surgical procedure or a multidisciplinary treatment regimen, but I cannot and will not force anyone to comply.

Three months later, as agreed, the patient and her docile husband appeared in my clinic. My nurse instructed her how to administer two enemas to cleanse her lower colon.  She completed this task, and I then inserted a flexible sigmoidoscope into her rectum and directed it upstream into her colon.  There, 25 cm up into her colon was a slightly larger, but still non-obstructing colonic tumor.  I took photographs through the scope and biopsied the tumor.  I informed the patient that I still saw the tumor, and even had her and her husband look through the scope.  After withdrawing the scope, I temporarily departed and the patient got dressed.  I returned to the room to find the patient and her husband, the latter speechless throughout the entire interaction, seated in two chairs.  Rather than being contrite, she smugly said, “Let’s just see what those biopsies show, shall we?”  I politely agreed and made an arrangement to call her the following week when the biopsy results returned.

The biopsy confirmed colonic adenocarcinoma. I dutifully called the patient and informed her that she had a sigmoid colon cancer, now proven by two sets of biopsies.  The phone line was silent for almost ten seconds, and then she cut loose with a string of curses.  She explained to me (unnecessarily) that she was very angry and she just did not understand how this was possible.  I allowed her to vent for several minutes and once she had calmed down, I asked if she would permit me to schedule an operation to remove her colon cancer.  With an exasperated tone, she agreed to allow me to proceed.

The next week I performed a routine sigmoid colectomy that went well. The patient recovered from the operation uneventfully and was discharged on her fifth post-operative day.  When she saw me the following week in clinic for her first post-operative visit, I explained the pathology showed a cancer that had invaded into only the superficial muscle layers of the colon and, fortunately, there was no spread of the cancer into any of the nineteen lymph nodes we had removed during the operation.  She had what we designate as stage II disease, and at the time there were no clinical studies indicating any clear benefit for giving chemotherapy in this situation.  She asked for a copy of her pathology report, which I provided.  She read the description line by line, asking frequent questions about specific terminology and meaning.  At the end of a ten minute interrogation about the pathology report, she looked at me suspiciously and asked, “So you’re sure this is cancer?”

Yes, I was sure. I informed the patient and her obsequious husband that I recommended a follow up visit in six months with a cancer blood test and a year following surgery we should perform a repeat colonoscopy.  She begrudgingly agreed.

At her six-month visit, her blood tests was normal. At her one-year visit, the colon cancer blood test, called a serum CEA, was elevated to almost ten times normal.  Her colonoscopy revealed no colon tumors or polyps.  I explained to the patient and her husband the abnormal serum tumor marker was worrisome, and after a twenty-minute negotiation, she agreed to a CT scan of the chest, abdomen, and pelvis.

The CT scan was obtained, and a single liver metastasis near the surface of the right lobe of her liver was identified. I walked into the examination room armed with the CT images and showed them to the patient and her husband.  Once again an aura of fury permeated the room.  The patient repeatedly stated it was not possible for her to have recurrence of her cancer.  She reiterated she was doing everything right and could not understand how cancer could have reappeared.  At one point she looked at me and declared, “You took all of the cancer out of my colon.  It is impossible for it to now be in my liver.”

I calmly explained how a malignant colon tumor can spread to lymph nodes or can invade into microscopic blood vessels in the wall of the colon and release cells that then implant in another organ. I indicated the liver is a common place for colon cancer to spread and eventually grow into a tumor we can detect.  I also informed her it was possible to remove this solitary tumor nodule, and then consider a course of chemotherapy in an attempt to eradicate any other microscopic cancer cells possibly present in her body.  Finally, I mentioned surgical removal of the liver tumor followed by chemotherapy was not guaranteed to prevent the cancer from recurring in the future.

She sat in her chair fuming. You think he would have learned, but her husband stepped in it again.  “Dear, you need to let Dr. Curley take care of this for you.”

Medusa returned. A medical student and a surgical resident had accompanied me into the examination room for my conversation with the patient and her husband.  When the patient whirled with a face of rage directed at her husband, a quiet gasp escaped from the medical student standing behind me.  I interceded before the patient could say anything and spent the next twenty minutes explaining in detail how the operation could potentially help her control and beat this cancer. I based my opinion on published data and reiterated we could potentially provide an effective treatment by removing this tumor.  After continuing to fire occasional sidelong warning glances at her husband, she finally agreed to an operation.   When we walked out of the room, the medical student and resident looked at me and the student said, “Wow! That look could have melted metal.”

Yeah, it was that searing.

The diagnosis of recurrent cancer was crimping the patient’s style, so I waited three weeks to perform her liver resection while she took care of other business and matters at home. I was able to perform a segmental liver resection removing only ten percent of her liver.  Once again, she recovered uneventfully.  The intra-operative ultrasound failed to reveal any additional liver tumors and my survey of the entire abdominal cavity showed no evidence of spread of disease at any other site.  I presented the patient’s case at a multidisciplinary tumor board the following week and a plan for six months of adjuvant chemotherapy was recommended.  It required over two hours of conversation and question-answering from me and one of my medical oncology colleagues, but the patient grudgingly agreed to receive the treatments.  But only after I reconfirmed numerous times the tumor in her liver was actually metastatic malignant colon cancer.

I never witnessed this patient enter the bargaining, depression, or acceptance stages following her diagnosis of her stage 4 cancer. She was rooted in denial and anger. Who knows if this had any impact on her outcome, but I saw her back recently for a 25-year cancer-free follow up visit.  The patient and her husband are older and moving much more slowly compared to when I first met them.  Before I walked into the exam room, the patient’s husband quietly pulled me aside and informed me his wife had recently been diagnosed with Alzheimer’s disease.  He remarked they would not be returning to see me for follow up visits, and he expressed his heartfelt appreciation for my care over the years.  When I walked into the examination room and greeted my patient, I was met with the usual steely stare and expression of grim determination I was expecting.  When I informed her she had no evidence of recurrent or new cancer, she merely nodded and said, “Of course I don’t have cancer.”  I have never seen this patient smile.  But I’ve been seeing her for over 25 years.  I’m a happy man who likes a good joke and a laugh, but it’s not for everyone.  As cancer clinicians, we see patients go through all five stages of emotions after a diagnosis of cancer.  It is incumbent on us to recognize the stage, respond to the patients’ and their family’s questions and concerns, and help them move on with their life or prepare for a looming death.

Because we don’t know exactly how much life we have left, we might as well live the hell out of it.

I’m Still Around, Doc!

We live in a remarkable time of advances in science and medicine. The human genome has been sequenced and mapped.  Materials and drugs on a nanoscale are being designed and developed to treat cancer, infectious diseases, and other human medical … Continue reading

The Coach

I have played sports throughout my life. Baseball, football, basketball, tennis, soccer, badminton, table tennis, running, cycling and even a short, and impressively painful, stint as a rugby winger.  I would much rather play sports than watch sports.  My wife … Continue reading

That Thing was Growing Inside Me?

Sensory abilities and acuity vary drastically from person to person. Some people have partial or complete loss of one or more of their five primary senses.  They must adapt to the world around them using their remaining neurosensory capabilities.  The … Continue reading

Homeless and Unhealthy

We’ve all witnessed it at major intersections: a homeless man or woman with a cardboard sign trying to coax a few dollars from motorists stopped at red lights.  When the light turns green and we hit the accelerator, we leave behind an individual who not only has no place to live, but may have no health care of any kind.

It’s well known that mental health and addiction issues are rampant among the homeless and drive many of them to the streets in the first place.  But many are physically unhealthy as well.  The diseases they often suffer from include:

*Substance abuse and addiction



*Wound & skin infections


*High blood pressure and heart disease

According to the National Health Care for the Homeless Council (NHCHC), the homeless are also at higher risk of communicable diseases from living on the streets or spending time in crowded shelters.  Even if seen by a shelter medical professional, there’s not much opportunity for treatment follow-up for high blood pressure, diabetes, and other ailments.  The NHCHC says the homeless are three to four times more likely to die prematurely than people who live in traditional housing.

Homeless children face a dire health care situation as well.  A recent study by North Carolina State University found that 25 percent of homeless boys and girls have mental health issues.  That adds up to an estimated 625,000 homeless children who need, but often don’t receive, mental health treatment.

In addition to inadequate health care, the study notes that homeless children are more likely to be exposed to domestic and neighborhood violence, which leads to developmental delays and social and emotional problems.

So, how do we do a better job of providing health care services to homeless adults and children?  I suggest you start small. What does that mean? Consider these statistics from 2014:

In January 2014, there were 578,424 people experiencing homelessness on any given night in the United States.

  • Of that number, 216,197 are people in families, and

362,163 are individuals.

  • About 15 percent of the homeless population – 84,291 – are considered “chronically homeless” individuals, and
  • About 9 percent of homeless people- 49,933 – are veterans (many of whom have given much for us, how can we now help them?).

The numbers have only increased since January 2014, with now more than 650,000 people homeless in America on any given night. That’s a lot of people, and a seemingly big, daunting problem. Starting small doesn’t mean giving some change or a few bucks to somebody on a street corner, it means getting involved at shelters and addiction treatment programs in your town or city. For medical professionals, it means volunteering time and using your contacts to evaluate and treat people with acute or chronic conditions. For everyone, it means finding out what programs or services are available in your community, and then volunteering with your time, your talents, or your resources to promote and aid those programs.

Here in Houston we have many great organizations to assist people struggling with homelessness, mental illness, and addiction. I volunteer at several of them, but The Women’s Home is my favorite group because they are fully committed to changing the lives of the women they take in and treat. This means treating addicted and mentally ill women in a safe, supportive inpatient facility for months or years instead of a few weeks. It means providing the clients (as they call them!) with treatment, counseling, and real life job skills. The Cottage Shop at The Women’s Home is a resale boutique that helps fund the programs and which gives the women a chance to develop productive skills. Most impressively, The Women’s Home includes an affordable housing facility, the Jane Cizik Garden Place, that provides permanent housing to women, including their children, that allows them to maintain sobriety, receive ongoing treatment and counseling, and to develop long-term, successful employment. I was amazed when I learned we had this program in Houston. Does your community have similar programs?  Whether they do or not, the programs that are available need your help and support (financial and otherwise). Start by helping one organization or one person; whatever you do will be a small step in providing help to someone in need. Seeing the lives that are changed one person at a time will change your life!


A Houston Treasure: The Cottage Shop

In 1971 The Women’s Home established a resale store in the Montrose neighborhood that now shines as one of Houston’s brightest lights.  The Cottage Shop is one of our community’s premier resale stores.  It also serves as a training center for residents of The Women’s Home as they conquer the crises in their lives that led them to the agency.

My wife, Natalie, and I were so impressed with The Cottage Shop that we commissioned paintings to be placed on the exterior front and rear of the store.  We wanted the artwork to be a symbol of The Cottage Shop’s vibrant programs and to help raise the visibility of the building.

We asked artist Homer Allen to create the paintings and he came through with works of art that perfectly illustrate the Shop’s impressive record of success.  The paintings feature monarch butterflies rising from orange chrysanthemums.  Homer used the butterfly to symbolize the evolving nature of The Women’s Home over the past half century.  The butterfly’s flight from the flower also symbolizes residents graduating from the Home’s programs.

Homer’s brilliant paintings are done with waterproof enamel on recycled billboards.  The works can be displayed indoors or outdoors and will remain a permanent part of The Cottage Shop’s exterior.

Natalie and I couldn’t be more pleased with the paintings.  The Cottage Shop generates 20% of The Women’s Home revenues.  We believe the paintings will draw more people into the Shop and perhaps help increase revenues to fund the Home’s programs for women in crisis.

As volunteers at The Women’s Home, Natalie and I invite you an exciting fundraiser with a best-selling author.  The Afternoon Tea with Barbara Taylor Bradford will be held April 8th.  You can learn more about the event and services offered by The Women’s Home at the agency’s website: http://www.thewomenshome.org/

The welcoming front door of the Cottage Shop,  811 Westheimer, Houston, TX 77006. Open Monday through Saturday, 10:00 am – 4:00 pm. Donations accepted Monday through Saturday, 10:00 am – 4:00 pm.

The welcoming front door of the Cottage Shop, 811 Westheimer, Houston, TX 77006.
Open Monday through Saturday, 10:00 am – 4:00 pm.
Donations accepted Monday through Saturday, 10:00 am – 4:00 pm.

Artist Homer Allen and Dr. Steven Curley pose with one of the photos donated by Dr. Curley to hang on the Cottage Shop exterior.

Artist Homer Allen and Dr. Steven Curley pose with one of the photos donated by Dr. Curley to hang on the Cottage Shop exterior.

One of the photos by Homer Allen donated by Dr. Steven Curley

One of the photos by Homer Allen donated by Dr. Steven Curley

Exercise Your Way to a Lower Colon Cancer Risk

It’s no secret that exercise reduces your risk of heart and respiratory diseases.  But did you know that running, walking, playing tennis, swimming or whatever exercise you prefer can help prevent colon cancer?

Numerous studies indicate that regular exercise can reduce your risk of colon cancer by as much as 40 per cent.  One study at the Dana-Farber Cancer Institute in Boston included the collection of data from more than 150,000 men and women over a period of three decades.  Researchers found that cancer of the colon or rectum was far less common among people who exercised for 30 minutes several times a week, compared to those who led a sedentary lifestyle.

Another study, this one at the University of Vermont, also concluded that exercise lowers the risk of colon cancer.  Researchers studied 17,000 middle age men and found that those who exercise regularly and kept their weight down were 38 per cent less likely to be diagnosed with the disease.

It’s unclear why exercise lowers the risk of colon cancer, but these two studies and many others indicate the connection is unmistakable.  Research also shows that cancer patients who exercise regularly are less likely to die from several types of the disease.

As we come to the end of March, designated as Colon Cancer Awareness Month, it’s vital to remember that nothing can eliminate the risk of coming down with the disease.  So, even if you live a physically active lifestyle, you shouldn’t run away from colonoscopies and other forms of colon cancer screenings.  They can lead to prevention and early detection of the disease and make it much more likely that your healthy lifestyle will continue for many years to come.

Beating Colon Cancer

Colon Cancer will kill an estimated 50,000 Americans in 2015.  That sad prediction comes from the American Cancer Society.  It is especially tragic because early screening for the disease would have saved the lives of many of those who will lose their battle against Colon Cancer this year.

March is National Colon Cancer Awareness Month.  We need to focus on this disease because it is one of those cancers that can often be prevented.  A colonoscopy can find precancerous polyps in the colon or rectum.  The polyps are then removed before they develop into cancer.  If the screening leads to the discovery of colon cancer in its early stage, treatment often leads to a cure.  According to the Centers for Disease Control (CDC), 90 per cent of patients whose colon cancers are found and treated early are still alive five years later.

Who should get screened for Colon Cancer?  In general, men and women should get a colonoscopy at the age of 50.  Patients with certain medical issues or family history of the disease need to be screened earlier.  The CDC currently recommends colonoscopies or other screenings at regular intervals until the age of 75.  Your doctor may advise screening beyond 75, depending on your medical history.

Thanks to increased screening, the American Cancer Society says the number of Colon Cancer deaths in the United States has been declining for two decades.  Even so, an estimated 130,000 new cases of the disease will be diagnosed this year.  Screening will lead to the discovery of some of those cases in time for the patient’s life to be saved.  Tragically, many other patients who had never been screened will have no such reprieve.  It doesn’t have to be that way.  Have you had your colonoscopy yet?

Making a Difference

As a cancer surgeon and research scientist, my life’s work is geared toward fighting the disease in the operating room and the laboratory.  My life in medicine has been a true blessing for me and my family.  It has introduced me to people and organizations making a remarkable difference in and out of the medical community.

For more than half a century, The Women’s Home has stood out as one of those amazing institutions, serving women in crisis in the Houston community.   The Home provides a wide range of services, including residential care, vocational training and spiritual development.  The Home’s staff also offers nurse practitioner care and treatment for chemical dependency and mental health issues.

The success of The Women’s Home has been recognized by The Substance Abuse and Mental Health Services Administration (SAMHSA).  That organization has invited the Home to take part in a national workgroup that identifies the most effective methods of providing sober treatment and housing for homeless women.  The Home is one of 15 agencies in the United States to receive this recognition from SAMHSA and the only one in Texas.

The Women’s Home also operates one of Houston’s premier resale stores, The Cottage Shop.  Established in 1971, The Cottage Shop serves as a training center for residents and offers a wide selection of gently used clothing, accessories, furniture and household goods.

It’s been an honor for me and my wife, Natalie, to serve as volunteers with The Women’s Home.  We invite you to attend three upcoming events:  The Women’s Home Annual Crawfish Boil on March 28th, the Men & Women’s Invitational Golf Tournament April 6th, and the Afternoon Tea with best-selling author Barbara Taylor Bradford April 8th.  You can learn much more about these events and programs available at The Women’s Home by clicking on this link.