It is written in Ecclesiastes, “To every thing there is a season . . . A time to be born, and a time to die.” So it is with the cells of our body; so it is not for cancer cells.

Cancer patients are beset by doubts. And doubts are formulated into questions. And questions need answers. We cannot recall a patient or relative or friend who didn’t seek the assurance which comes from authoritative answers to their troubled questions.

What is Cancer? Cancer is a disease caused by the growth and spread in our bodies of cells that do not know how to die.

When I first laid eyes on A., I could tell she was in trouble. “Trouble” for me, a as doctor with oncology surgical practice bur not medical oncologist, means that a patient is sick from cancer and in urgent need of treatment. But like so many patients whom I meet for the first time, A. was not even sure she had cancer. So “trouble” also means that I faced a daunting task: I had to explain to A. (and her family) what cancer is, why it may have arisen, what it was doing to her body, which treatments were recommended, how those treatments worked, and how she could cope when her world was crashing in on her-all this in about an hour.

Furthermore, I needed to convey this information with great empathy and sensitivity, never forgetting that although my brain may sleep, eat, and breathe cancer, the cancer “lingo” is completely foreign to a person newly diagnosed with the disease.

As I present my assessment of a cancer situation to a new patient and family, my senses enter a state of heightened awareness: I continually monitor the body language of my listeners to discern if I am making myself understood, if my words are too strong or not strong enough, or if I should stop the flow of words to allow the necessary flow of emotions. I have taken to using a marker board, like a mini-lecture, to write out the technical words and details. As with so many other doctor is particularly oncologists, there is no need to ask me, “What would you do if I were your brother, wife, or mother?” Please understand that this is always a given. As A. walked into my office for a consultation, her husband and daughter were close behind. She was clearly exhausted, gasped slightly with each breath, and, after spotting the chair nearest to me, slumped into it. She exuded a soft, sincere demeanor, though she was obviously weighed down by worry.

A. gathered herself as I introduced myself, and then she asked me in a sweet, perplexed voice, “Doctor, what’s wrong with me? I am so tired I can’t even climb a flight of stairs. My stomach is bloated and I hardly eat anymore. Am I dying?” Before I met with A., I had reviewed her medical records. She had recently seen her internist, complaining of several months of unremitting fatigue, loss of appetite, and shortness of breath with exertion.

Her doctor had ordered CT scans of her chest, abdomen, and pelvis. These showed a large tumor on one of her ovaries, many other tumors throughout her abdomen, and smaller tumors throughout her lungs. He ordered a biopsy of one of the abdominal tumors, and it revealed a diagnosis of ovarian cancer. The tumors throughout A. abdomen and chest indicated that she had the most advanced stage of that cancer. A blood marker of ovarian cancer, named CA-125, was many times above the normal range, consistent with this diagnosis. When A. walked through the office doorway, I knew immediately that all her symptoms were caused by cancer. The sheer burden of having tumors involving so much of her body was exhausting her. The disease was competing with the rest of her body for vital nutrients, and the cancer was siphoning most of these away. The tumors in her lungs were interfering with the ability of her lungs to transfer oxygen to her bloodstream for delivery throughout her body; this accounted for her shortness of breath. The many tumors in her abdomen were causing her belly to swell and taking away her appetite. I began to talk to her. “I can see that you are suffering. Your breathing appears labored to me, and I can tell that you must be struggling just to get through the day.” With this, she nodded and began to weep. But this was a cry of relief; someone had finally explained why her condition was deteriorating so fast. “I will explain exactly what is wrong with you and tell you what we need to do to get you feeling better,” I said. “But I want to start off by saying that you will very likely be feeling better soon.” With that, she relaxed and started to breathe more easily. I explained what her CT scans showed and what the pathology report indicated. I told her she had ovarian cancer and that it had spread from her ovary to her abdomen and into her lungs, which classified it as stage IV. I explained how the extent of the cancer was causing all her symptoms and that if we could shrink it, she would begin to feel better. “Do I need chemo?” she asked. “I’m afraid of that, I don’t know if my body can stand it.” “Yes,” I replied, “we do need to use chemotherapy. But since most of your symptoms are due to the growth of the cancer, once we stop that growth with chemotherapy, you will actually feel better. There certainly will be see de effects from treatment, but we will monitor you closely for them and try to prevent as many as possible.” A. did not voice further opposition to the chemotherapy. She understood that she would be fighting for her life. “The standard recommended treatment,” I continued, “is two chemotherapy drugs, called Taxol and carboplatin, which are administered intravenously every three weeks. We are also participating in a study to determine whether adding a new medication to this standard treatment improves the outcome.” We discussed the short-term and long-term side effects of chemotherapy and went over the pros and cons of participating in the clinical trial. I told her that after our meeting, she would visit one of our oncology nurses, who would further explain what to expect and how to prepare for treatment. “Why can’t it just all be cut out?” A. asked. “For most cases of

ovarian cancer,” I replied, “surgery actually is the first step of treatment. But in your situation, because the cancer has spread outside of the abdomen and is causing so many symptoms, we need to attack it with a treatment that will shrink the cancer wherever it is growing in your body; the disease is too extensive at this point for surgery to be effective. So we need to start with chemotherapy and reserve surgery for a later date.” I inquired about her family history and whether other family members had been affected by cancer, in particular breast and ovarian cancer.  When she answered yes, we discussed the need for genetic testing, which she wanted to do at another time. We talked briefly about her family life, habits, and spirituality as I tried to get a sense of the person. After I answered the questions A. and her family had, I told them about the counseling services for patients and families at our center: group counseling, in which those who have traveled or are traveling a similar road can share experiences; and individual counseling, in which patients can privately express to an experienced therapist their feelings,fears, and needs as a cancer patient and survivor.

We ended our first meeting exhausted. But we also ended it as partners, hopeful that A. condition would improve. I knew that we had covered a tremendous amount of new and complicated information and that A. would probably remember only a part of it. I reassured her that we would have ample time, in future meetings together, to go over what we had discussed.

My meeting with A. and her family highlights the essential information that any patient must find out when he or she is diagnosed with cancer. The following list summarizes this information.

• The type of cancer

• The stage (extent) of the cancer

• Whether cure is to be expected

• Possible environmental or genetic influences that may have predisposed you to develop cancer

• Important aspects of the cancer, called “prognostic factors” (tell later), that may help determine your prognosis

• Whether you have other medical problems that may affect your choice of treatment

• Recommended treatments, their schedules, and their duration

• Side effects from treatment (likely and less likely), both short term and long term

• What can be done to prevent or minimize those side effects, should they occur

• Other treatment options, such as (1) a different but equally effective chemotherapy drug whose side effects may better meet your needs (for example, less hair loss or a reduced chance of numbness in the hands and feet, called peripheral neuropathy), and (2) a different sequence of chemotherapy, radiation, or surgery than is being proposed and the merits of the different approaches

• If a clinical trial (research study) testing new ways to treat the cancer is available and the pros and cons of participating in the study

• What the strategy might be if the first therapy does not control the cancer

• Whether a second opinion is advisable (initially or at a future time)

• How the treatment costs will be covered

• A review of the medications, vitamins, and supplements you may already be taking

• Where to find counseling and support groups to help you and your loved ones cope with the many emotional and life challenges posed by cancer

These essential topics we will approach later. First we wish to focus on the disease itself and answer the deceptively simple question, “What is cancer?” A. story provides one answer: All of the above is cancer. Cancer is all the physical and emotional upheaval that a person’s body and mind must endure in response to an “invasion from within” of bizarre collections of cells that form troubling growths called tumors. From a medical point of view, cancer can be defined another way:Cancer is a disease caused by the growth and spread in our bodies of cells that do not know how to die.

4. The Three Essential Properties of Cancer

All cancers begin with the conversion of one cell from a normal state into a cancerous state. During this process, which in most cases takes many years, the changing cell acquires three main properties that distinguish it as a cancer cell. These three essential properties are the defining characteristics of the disease. Normal cells have none of these properties.

The three properties are:

 1. An unlimited capacity for growth

 2. An inability to die

 3. An ability to spread (from the site of origin)

To know these properties is to appreciate the very nature of cancer.

They define how well a cancer grows and survives in the body, and they largely determine how curable any particular cancer is. It is extremely important to realize, however, that the power and extent of each property is different for each cancer.

Some cancers grow slowly, others quickly; some have a great capacity to spread throughout the body, others a more limited ability to do so. Just as every person is unique, so is every cancer. This is why I caution patients that the information they receive about other people with cancer will probably not relate to their case.