In Plato's Allegory of the Cave, the prisoners, who never had contact with the outside world, were heavily immobilized and could only see images projected against a wall. They were hearing voices and associated shapes, believing this to be the real world. Plato: The Republic – Book VII (427-327 BC)
(Fictional narrative by the doctor)
James Fleck, MD, PhD: Anticancerweb 27 (12), 2022
I kept Arthur's exams with me. There weren't many, as we were just at the beginning of his investigation. I said I would review them carefully and asked his permission to contact other physicians, previously involved in his care.
Arthur agreed. Interestingly, he didn't show much curiosity about his exams. Nor did I find it appropriate to anticipate comments. My impression was that Arthur had lifted a burden from his past. He was starting to regain self-confidence. We had tacitly agreed to continue our conversation at a future appointment. Artur seemed eager to talk to his wife and children, express his feelings, break down communication barriers, and release them to help him cope with his illness.
Even before the first consultation, I had already noticed a change in Artur's attitude. Although he was unable to express himself clearly to Luis, I considered it to be the exact moment of his psychological rescue. Often in life, the most important thing is not what you say, but what you feel. Artur felt in his son's approach a genuine desire to help him. He hadn't been able to express a behavioral change at the exact moment of his contact with Luis. However, he agreed to seek medical help, accepting the family's request. The meeting with Luis had brought him out of immobility.
The first consultation was a natural consequence of the psychological rescue. Arthur was a clever man, but his vision was blurred by the associative idea of illness and death. He lived for some weeks in suffering, dominated by fantasies. The main objective in the first consultation had been achieved, when Arthur undid wrong associations, caused by childhood trauma and guilt. In his previous vision, death was imminent. Now he was a survivor of his own fantasies. Arthur had returned to the real world. A world he had learned to deal with in an adult way. A world that didn't scare him. He was again expressing a desire to fight for his life.
When Arthur and his family left the office that night, I remained alone a little longer, reflecting on the situation.
That consultation had been something unusual, as I did not examine the patient. However, I was feeling fine. The emotional recovery process was so rewarding for Arthur that all the expected worries about his current malignancy were put on hold. Somehow, the active search for survival increased his coping capacity, minimizing risks and insecurities. My initial impression was favorable. But I needed to step out of the guesswork and observe a real change in Arthur’s behavior. I would have that opportunity at the next appointment, asking more specific questions about his current illness and doing a physical exam.
A few days later, Arthur returns for another appointment. He came accompanied by Heloise. She took the initiative and said that the family had talked a lot in the last few days and that Arthur was very receptive to the approach. A major behavioral change has occurred. Arthur was no longer depressed, speaking naturally about his current illness. He felt self-confident and believed that the problem could be solved. Heloise couldn't explain the reason for that transformation, but she was satisfied with the turn the situation had taken.
It reminded me of Plato's Cave.
Fortunately, unlike Plato's allegory of the cave, Arthur enjoyed gratifying contact with the real world throughout his adult life. However, he retained a repressed childhood fantasy. Upon revisiting it, during his current illness, he was immobilized like the prisoners in Plato's cave. He successfully exited the cave, as his real-world references were stronger, allowing him to overcome fantasy.
I asked Arthur to tell me in detail the history of his current illness. At that moment, he was relaxed and fluent, even in the presence of Heloise. I had the impression that they had already discussed the entire clinical expression of his illness. Heloise was feeling relaxed during all the interview.
Arthur reported that about six months ago he began alternating constipation and diarrhea. Abdominal cramps sometimes preceded bowel movements. He felt that his abdomen had distended a little, but he hadn't gained weight. Voluntarily, he had promoted a dietary change, giving preference to vegetables and fruits. Meals became pastier or liquid, but this did not change the picture. The appetite was maintained, but there was always a late feeling of discomfort after eating, manifested by a certain heaviness in the abdomen. He also mentioned a slight difficulty in initiating sleep and that it was sometimes interrupted by a sudden need to defecate. Often the stools were solid and thin.
I tried to explore the existence of symptoms in other parts of the body, but Arthur revealed that he had no other complaints, except muscle weakness, which made him tired. He said he attributed the symptoms to digestive issues at the time. He mentioned that his concern increased when he had bleeding in the stool. He saw a gastroenterologist, who recommended an endoscopy. He informed that he had to fast and prepare with a laxative before the exam. He revealed that he had no idea what happened during the exam as he was put to sleep. He remembered that the doctor would have commented on sending material to a laboratory. He had discussed this situation with Heloise, recently. He already knew he had cancer.
I asked Arthur to prepare for the physical exam. The nurse guided how to proceed with his clothes and put on the apron. I asked Heloise to wait in another room.
On physical examination, Artur did not present changes in cardiac or respiratory auscultation. His blood pressure was normal. A brief neurological examination revealed no change in strength, sensibility, reflexes, or balance. His nutritional status was maintained, but he showed signs of anemia. There was no jaundice. His abdomen was slightly distended and painful, making deep palpation difficult. The tumor described in the endoscopic examination was not identified either in the abdominal palpation or in the rectal examination. The prostate was slightly enlarged, but there were no palpable nodules.
I communicated my impression of the clinical examination to him. Arthur asked how this tumor could be so hidden that it could not be detected in the current physical examination. I asked him to get dressed and I would come back in a few minutes to clear up his doubts. I asked if he would like Heloise to come back to the examination room and he said yes.
While Arthur was getting dressed, I was looking at the results of his laboratory tests. There was a form of anemia on the blood test, typical of that caused by iron deficiency, compatible with a chronic history of blood loss in the stool. This was a frequent finding in patients with gastrointestinal tumors. His endoscopic exam was a colonoscopy, the best exam to visualize the entire rectum and the entire large intestine. On the colonoscopy there was an image of constriction and erosion of the mucosa at the level of the sigmoid colon, a lower part of the large intestine, named for its shape resembling the letter S. Pathological examination of a biopsy of the tumor, taken during the colonoscopy, revealed the diagnosis of mucinous adenocarcinoma.
When I got back to the examination room, Arthur and Heloise were talking and I realized that the matter was still related to the non-identification of the tumor in the clinical examination. I explained to both of them that this was not unusual. Arthur's tumor was shaped like a napkin ring. It was not bulky enough to be palpable on examination of the abdomen. Its characteristic was more infiltrative in the intestinal wall, promoting narrowing of the lumen of the organ. If it hadn't been diagnosed, it would have ended up obstructing the intestine.
I explained that the diagnosis was made at an appropriate time and that his gastroenterologist had performed a very accurate examination. Using the fiber optic device, he had passed the narrowing point, managing to examine the rest of the large intestine, which was normal. This was very important data, as sometimes a patient has more than one tumor in the intestine, which was definitely not the case with Arthur.
Arthur interrupted and asked: How long have I lived with this tumor?
Anemia indicated that the disease had existed for some time, although it showed few symptoms. I said that the colon tumor is normally a slow growing tumor and that it could have been going on for years. However, I advised him to stay calm, as it was a very frequent tumor, known and predictable in its biological behavior.
Even so, Arthur insisted: Could I have discovered this tumor earlier?
I said yes.
I explained to Arthur and Heloise that this was one of the screening recommendations in oncology. All people, after the age of fifty, should have a colonoscopy, as this would allow for an earlier diagnosis. In certain circumstances, colonoscopy is even therapeutic. When the tumor is very small and restricted to the mucosa, it can be removed during the examination itself, avoiding the need for a major surgery. However, I recommended that he should not blame himself for this distraction. It happened to a lot of people and the failure is the lack of public disclosure of preventive recommendations. The important thing, at the moment, is that his situation was being addressed and that we were going to solve it.
Arthur asked, proactively: What do we need to do?
I said I would order some tests to better assess the behavior of the tumor and its extent. These tests would include a tumor marker called carcinoembryonic antigen, better known by the acronym CEA, which would be very useful for monitoring the disease. CT scans of the chest and abdomen would also be performed to increase the assurance that the disease was restricted to the intestine. Additionally, tests would be done to assess his overall clinical condition. With these results, we could define the most appropriate treatment orientation.
During this consultation, Arthur assumed that he had regained control over his life, as he faced the issues with clarity and determination. The questions were direct, objective and clearly expressed his desire to have precise answers. The presence of Heloise did not represent an inhibitory factor. Arthur had sought free communication with the family and with the doctor and felt strengthened by these alliances.
When saying goodbye, he thanked for the open dialogue and stated that he would carry out the exams as soon as possible. He said he was not afraid of the results. He wanted to clarify the pending doubts. His biggest enemy, at that moment, was the unknown.
Heloise left the room and Arthur, as he left, confided to me in a low voice: “After all, doctor, for someone who already considered himself dead, everything that comes ahead can be easily overcome.”
He was out of Plato's Cave!
* Attention: The story 10 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 10 from the beginning, just click in the numbered links located at the bottom of the homepage.
James Fleck, MD, PhD is a full professor of clinical oncology at Federal University of Rio Grande do Sul, Brazil
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