Comprehensive Treatment Plan

PLOT 3:  Conflict

(Fictional narrative by the doctor)

James Fleck, MD, PhD

Anticancerweb 08 (09),2021

Since the first contact in the emergency room, Robert was the only interlocutor to describe his illness, as so far, no family contact had occurred, confirming his previous statement that he was prematurely alone in life.

In my professional life, I learned to balance affection and neutrality, but Robert's situation was very compelling. I asked social services to explore the situation broadly. We had very dedicated professionals in this area and maybe they would help us find a family member, even a more distant relative. The search would also extend to Robert's workplace. At the same time, I oriented Mark to obtain additional information, conducting a more in-depth clinical history, as Robert's critical condition the day before had precluded a comprehensive approach.

In dealing with the illness, Robert revealed a stoic behavior and, for a moment, I assumed his attitude as an expression of resignation. But I was wrong. In fact, his suffering did not generate any aggressive or depressive reactions. Instead, it was used as a boost for personal growth. At that point, I realized that Robert was a resilient person. He was very objective, had structured reasoning, based on facts. The courage shown in the first 24 hours, when he was alone in the emergency room, was immediately recognized by the entire care team. He used to communicate freely and express a lot of self-confidence. It seemed to me that Robert's resilience was based on a story of suffering. He learned from adversity to seek bonds and develop human values such as affection, empathy, commitment and responsibility.

Robert had what I used to call a winning profile.

However, I was still concerned. 

Although I knew Robert's resilience would help him cope with cancer, he would still need some family support, providing home care, love and encouragement. 

His resilient behavior wouldn't preclude my quest for family ties.

The next day, Mark discussed with me the results of Robert's exams. There was a significant increase in blood levels of beta-HCG and alpha-fetoprotein. These elevated tumor markers pointed to a testicular tumor identified as nonseminomatous. 

Previously collected pleural fluid had no tumor cells. We still didn't have a pathological diagnosis. I explained to Mark that the next step would be the surgical removal of the right testicle and we would call the urology team for a consultation. Robert was stable, responding well to antibiotic therapy and in good clinical condition to face the proposed surgical procedure. Within hours, we were contacted by the urology team. The testicle would be removed by an approach similar to an inguinal hernia surgery. They would make an opening in the inguinal canal and the testicle, pulled by the spermatic cord, would be removed intact, in accordance with the international recommendation for this type of cancer surgery. We went to Robert's room to explain the surgical procedure. Mark took the initiative and said the right testicular tumor would have to be removed. He explained that it would provide a pathological diagnosis as well as being an important step in cancer treatment. Mark also commented on the inguinal approach and the need to remove the entire testicle.

Robert listened in silence. His facial expression revealed some surprise and annoyance at the mutilating surgery. He thought for a moment and asked:

How's the other testicle? Will you also remove it?

Mark said no.

An ultrasonography was performed and the left testicle was normal. Mark explained that there would also be no problems with hormonal function, as the left testicle would maintain adequate levels of testosterone. 

Robert looked at me, seeking my technical impression.

I nodded my head affirmatively.

Robert said resignedly: Well, I'll have to live with just one nut.

Although he didn't question it, I informed Robert that a prosthesis could be placed at the site of the removed testicle. This would provide a better plastic result, maintaining his perception of bodily integrity. He asked to discuss this later, because at that particular moment, his goal was totally focused on curing cancer. He was relieved by the explanation and agreed to surgery. I informed him that surgery would be scheduled in the next two days.  Previously, he would be examined by a urologist as well as an anesthesiologist.

When Mark and I left the room, we were approached by Eliza, head of the hospital's social services. Eliza reported that she had spoken with Robert and went on to report what she had collected from his previous personal history. Robert did not know his father. He was the son of a single mother who would have migrated from the North of the country, still very young, in search of better job opportunities. He was an only child and lived with his mother until he was twenty. His mother had no family ties. Unfortunately, she was diagnosed with AIDS, which caused great suffering for a period of two years before she died.

Robert felt responsible for his mother's care from a very young age. He started working at sixteen as a newspaper delivery boy, helping with household expenses and later paying for his mother's health care. He studied in the night shift, having completed high school. He had been a great son, as often recognized by the mother.

Since the loss of his mother, Robert has lived alone. He continued working as a courier, transporting goods for various companies. More recently, he joined the university, where he studied Management, always on the night shift. He used to feel free and didn't complain about his lifestyle.

I expressed to Eliza my initial impression that Robert's life had been marked by a great deal of suffering, on which he built his resilience. Eliza agreed and informed that, at Robert's request, she would have contacted some people at some of his working places. She had informed them of Robert's recent hospitalization. She reported that everyone asked about a possible motorcycle accident, but she replied that the problem was not a traffic trauma. She mentioned that Robert was highly esteemed. All professional contacts regretted what happened and made themselves available to assist him in whatever might be necessary.

Eliza was a sensitive lady, intelligent and deeply committed to her work. She shared with me the same concern about the lack of family contacts. She also took the first steps in forwarding social security assistance, as Robert, being self-employed, did not have health insurance in any of the related companies.

Robert faced the surgical procedure without complications. He was on the third postoperative day and doing well when we received the pathological exam of the testicle. As expected, it revealed a mixed tumor with components of choriocarcinoma, embryonic carcinoma and teratocarcinoma. This result combined with elevated tumor markers, especially beta-HCG, increased the risk of brain involvement and we immediately requested a magnetic resonance image of the brain. Fortunately, the exam was normal and we started planning chemotherapy treatment. It would be an aggressive and toxic treatment, but with a high cure rate.

To be continued in PLOT 4.

* Attention: The story 8 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 8 from the beginning, just click in the numbered links located at the bottom of the homepage. 

Reference:

Image: A Lotus Flower - Conflict - Comprehensive Treatment Plan: Image created by Gemini [Internet]. Mountain View (CA): Google LLC; 2026 [cited 2026 Jun 27]

Authors Info & Affiliations:

James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil (www.jamesfleck.com)  

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