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July 21, 2008

A Rant on Tony Snow's Death

I’ve debated for some time now whether or not to write on this subject, but with his demise I find it compelling. I’ve never been anguished over the illness and death of a man I don’t even know. It is his familial history which bothers me, and for those who just might happen into this essay I’d like to clarify the situation. Having spent my life practicing gastroenterology, I did learn more than a few things about it.

This is a rant on the medical profession and the management of his illness, which represents hubris on stilts! While I never had the privilege of meeting—never mind examining—him, his disease clearly was familial colonic polyposis. This is not the common problem many face with a family history of polyps, requiring periodic colonoscopy for removal of same, ideally beginning at age 40. Instead, it is a hereditary situation wherein thousands of polyps literally smother the colon, from which some die of colon cancer before age 30, making serial colonoscopies a practical impossibility and making death from colon cancer a virtual certainty. These polyps are so numerous that some may be overlooked, and the cancers often begin in microscopic polyps which cannot be identified at all.

Clearly Tony was caused to believe that routine colonoscopies, with attendant polypectomies, would be sufficient. They are not! His case proves this. Removal of the entire colon is the only answer in such situations, preferably before age 30, and ideally when the diagnosis is confirmed. This requires the construction of a stoma, or abdominal exit for the bowel waste, which in turn requires the constant use of a bag to collect the effluent: an ileostomy. I have seen many situations wherein this was necessary, for familial polyposis, ulcerative colitis, and more rarely Crohn’s Disease.

The problem with all is that the ileostomy creates a nuisance which all attempt to avoid except where absolutely necessary, as ileostomies are much more trouble to manage than colostomies.

Recall that Tony’s mother died of colon cancer when she was young . . . as was he. Herein lays the problem. With all but absolute certainty I will state that Tony was reassured that “that was then, and this is now,” and that ritual colonoscopies are all that is necessary, today, to prevent death from colon cancer. Either that, or colectomy was recommended, but not insisted upon, which allowed him to believe that he had a choice. I believe the former to be the case, which is why I have described it as hubris on stilts.

The arrogance of modern physicians is frightening to me, but it reflects the generational attitudes of the 60’s; those who trivialized the wisdom of age and judgment, and chose to believe that there was little reason to trust anyone over 30 (until, that is, they reached 30 themselves). Confident that Tony needn’t live with an ileostomy, they assured that he would die of colon cancer. He could have lived a normal life to a normal age, even died of old age! He certainly would have lived to see his children grow up.

More than occasionally I had to counsel, sometimes even frighten patients into accepting, that there was no alternative to a given course of therapy, based upon my training, experience and reading of contemporary literature. They might find another physician who disagreed, but it would not alter my opinion, forcefully held by years of experience—not all of it good. As many sages have observed in the past, some things are simply true, whether or not you like it. This is/was such a situation.

For those who have, specifically, familial polyposis, removal of the colon is the only way to absolutely prevent colon cancer. Period! An ileostomy is nowhere as bad as an early death, especially when accompanied by the agony of repeated surgeries, chemotherapy and all the rest.

Posted by respeto at July 21, 2008 2:38 PM