Mr. L. greeted me with a strong handshake. He seemed like a very fit fellow, particularly for a 90-year-old. His nephew and nephew's wife accompanied him to the consultation.
As he spoke, unknowingly, Mr. L. was telling me the diagnosis. He reported several months of unrelenting hoarseness. Not good news. The examination revealed what I suspected: a tumor of both vocal cords, most likely cancer.
I could detect no enlarged lymph nodes or other signs that it had spread beyond the voice box; that much was good news.
I told the patient and family there was a tumor involving both vocal cords, that it was the cause of the hoarseness and that it may be malignant. A biopsy and examination by a highly specialized pathologist would give us a certain answer. That biopsy report was unsurprising: malignancy of both vocal cords that was happily not aggressive. Scans showed no tumor beyond the voice box.
Standard treatment options were radiation or removal of the voice box. Both treatments had a high cure rate. However, each would incapacitate him. Radiation causes dry mouth and throat with difficulty swallowing, while voice-box removal would have left him without speech -- a fearful prospect. Although "esophageal speech," a technique that uses belching to force sound out of the mouth, can be taught and mastered, the technique is taxing and demanding at any age, let alone age 90.
Because of the importance of the treatment decision, and to reassure the patient, I recommended consultation at the medical school where I taught. There, the Tumor Board -- a panel of senior specialists -- gave a consensus opinion that the two treatment alternatives were standard and reasonable. Immediately after the consultation, I met with the patient, his nephew and the nephew's wife and relayed the board's consensus.
There was a period of silence. Then Mr. L.'s nephew, an engineer, posed a question: "Since both treatments are rather radical and likely to create some disability, and since my uncle at 90 has a limited number of years, what if you just nibbled away at it every so often? And just see what happens."
I pondered that unanticipated question, then replied, "You know, not a bad idea. Not standard textbook treatment but . . ."
