I don’t think it is difficult to imagine that a common question and refrain from patients with a newly diagnosed cancer is to inquire, “Why me?” The usual patient will tell me how he/she did not smoke, ate properly, etc., so why did they now have a cancer? Often (not always) I suppress the urge to reply, “Why not you?”
Of course, the fact that this question seems so natural and logical underscores the success of the scientific enterprise over the past 50 years and goes hand in hand with the increasing disappointment of patients and families when we are unable to cure people with cancer. Many years ago, it was not assumed that there was a “cause” in the sense that we use the term nowadays, but that diseases like cancer or heart disease are outcomes of luck or the stars or a deity. And on some level, that remains true.
But multiple successes in the identification of etiologic factors—certain genes, tobacco and lung cancer, asbestos and mesothelioma—have led to an expectation that causes or reasons account for all cancers. And added to the classical etiologic factors, like tobacco and diet and genetics, are the much more speculative factors, such as the chemicals in plastic soda bottles, genetically modified fruits and vegetables, exposure to anything with the word “radiation” in it. And as an epidemiologist, I believe that is so. But causal factors do operate on a probabilistic basis. As a television addict who learns most of his knowledge about life from TV, it is like the homicide detective who recognizes that each murder must have a murderer, but only on television do the detectives always find the perpetrators. And many deaths occur in ambiguity as to whether they were even murders in the first place.
The truth is that it is easier to bear adversity when you think there is a reason for it, even if you are responsible for it. Smokers who get lung cancer are obviously not happy, but they often do have a certain ability to shrug their shoulders and concede that they had it coming. In contrast, a random unexplained kick in the gut is much more difficult to bear. We can fall back on our religious beliefs—look at any number of doctrinal sources on the Holocaust—or perhaps we can hypothesize that we did not give enough charity or light candles Friday night.
The concept of God as a Prime Mover or First Cause that is then perpetuated through multiple subsequent pathways to cause all subsequent events in the world, as adduced by Aristotle and then filtered by later philosophers and thinkers like Maimonides, seems strikingly straightforward and consonant with modern scientific theory and practices. The problem for the bewildered questioning cancer patient is that the final pathway may still not have a large arrow on it. While everything may have a cause or causes, they are not all writ large, or easy to identify.
This was brought home to me some weeks ago when I attended this year’s Joseph N. Muschel Memorial Lecture at Columbia, something I have missed for several years due to the pandemic, laziness and various other reasons. Joseph was an intern in medicine over 30 years ago when I was a junior faculty member. He was an excellent physician, empathetic and very devoted to medicine when, at age 26 or 27, he was diagnosed with an incurable lung cancer. Thanks to an excellent oncologist, he lived for four years during which time he gradually decreased his clinical work load, and because of that worked for me for a year doing research (easier than the every third night schedules at that time). The Muschel family was generous and gracious to donate a lectureship and resident award in his honor that has continued for three decades.
Even then, as a young cancer epidemiologist and oncologist, I was as appalled as the patients are by the mystery of the youthful, innocent nonsmoking lung cancer patient. Intellectually I recognize that 10% of lung cancers occur in nonsmokers—nonetheless, it seems unfair to be singled out that way. Of course, this seems more striking in the case of lung cancer where we have identified such a powerful culprit. There are certainly multiple other cancers where we have much less knowledge about etiologic factors, and so there is less reason to say “why me” as opposed to the next person.
I confess that it is surprising to me that it seems that patients get some comfort from being able to answer the “why me” question. I might have thought guilt would be a negative. But maybe uncertainty is an even greater negative.
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
