It’s always the early morning calls that change everything. At 6 a.m., my phone rang — a hospice aide on the line, her voice gentle but final: my patient had passed. She was a woman whose colon cancer had grown quietly for years, hidden beneath decades of immunosuppressant treatment for her colitis. The very medicines meant to help her had made her cancer more aggressive. Only recently had the disease revealed itself, and now she was home after a hospital stay — a reaction to chemotherapy delivered through a port in her chest.
I rushed to her bedside. Her son, overwhelmed by grief, had turned away the hospice nurse who came to pronounce her death and tend to her final needs. The room was heavy with sorrow and unfinished goodbyes. I closed her eyes, gently shut her mouth, and cleaned away the traces of her last breaths — small, human acts of care and respect. Presence isn’t always about words; sometimes it’s about bearing witness and tending to what remains.
In that moment, I was transported back to my father’s final days. Pancreatic cancer — the hardest diagnosis, the one that moves fastest and gives the least warning — had claimed him not long before. The story began quietly: he’d mentioned vague discomfort in his abdomen, something he told his doctor but that never seemed urgent enough to pursue. One evening at home, surrounded by my partner and my mother, came the unmistakable sign — he passed a bowel movement that was part black tar, part red blood. We rushed him to the ER. The news was swift and brutal: stage 4 pancreatic cancer. The medical team discussed risky surgeries, but at 78 and so frail, we chose instead to honor his quality of life. There’s no right answer when it comes to these decisions — chemo or no chemo, surgery or no surgery. Each path is subjective, shaped by circumstance and love. Atul Gawande’s Being Mortal helped us understand that distinction: sometimes, the kindest thing is to choose comfort over intervention, to let quality of life come first.
When he was discharged, my father came home to hospice care — first at my house, then at his, where he could find peace in familiar surroundings. He lived for six more months, the cancer slowly taking everything but his dignity. I was present for his last breath, just as I had been for my patient. I cleaned him up, honored him, and paid my respects — understanding, in that quiet, that life and death complete a circle. Presence at the threshold is one of the most sacred acts we can offer.
This is not simply an article about cancer. This is about what it means to be present at the threshold — whether as an advocate, a son, or simply a fellow human being. I’ve learned that the body speaks long before anyone listens, and the cost of not listening is paid in exactly these rooms, at exactly these hours.
These are not questions medicine asks enough. They are not questions the system is designed to sit with. A seven-minute appointment cannot hold them. A port in the chest does not answer them. They require presence — the kind that Ma exists to provide, in the space between the institution and the life being lived inside the body it is treating.
Cancer is not a sudden event. It is a process — often years or decades in the making before it announces itself. The cells that become malignant have been accumulating damage, evading immune surveillance, acquiring the hallmarks of cancer one mutation at a time. By the time a diagnosis is made, the story is already long.
What makes cancer so devastating is not only its biology but its silence. Many of the cancers that kill the most people — pancreatic, ovarian, lung, colon — develop without symptoms that register as urgent until the disease has advanced significantly. The body speaks, but in a language we have not been taught to read. Fatigue that doesn’t resolve. A change in bowel habits that persists. Weight loss without explanation. Discomfort that comes and goes but never fully leaves. These are not dramatic. They are easy to dismiss. And the system, pressed for time, often does.
My patient’s story is not unusual. It is, in fact, one of the most important and least-discussed intersections in oncology: the relationship between immunosuppression and cancer risk.
Immunosuppressant medications — prescribed for autoimmune conditions like colitis, rheumatoid arthritis, lupus, and organ transplant management — work by quieting the immune system. That is their purpose. But the immune system is also the body’s primary surveillance mechanism against malignant cells. When it is suppressed, cancer cells that would otherwise be identified and destroyed can proliferate undetected. Long-term immunosuppression is a documented risk factor for multiple cancers, particularly colorectal, lymphoma, and skin cancers. It is a risk that is often inadequately communicated to patients, and inadequately monitored over time.
I had tried to raise this with her. She became upset — her assumption was that the medication was what was saving her, and any question about it felt like a threat to that safety. I was also navigating the perception of being an uncredentialed advocate up against the authority of the physician who had prescribed it. But the agency was hers. She was the patient. My concern was not to stop the medication. It was simply this: you have been suppressing your immune system for decades. Talk with your doctor about what that means for cancer surveillance. That conversation never happened. The colonoscopies that might have caught the polyps before they became malignant never happened. The cancer grew in the silence between what was said and what needed to be said — and in the space no one felt permitted to fill.
The question that should be asked at every appointment for anyone on long-term immunosuppressants: Are we screening for the cancers this medication increases my risk for? Do not wait for the system to ask. The system, as my patient learned, does not always remember to.
Not all cancers are equal in their willingness to announce themselves. Understanding which ones are most likely to develop undetected — and what screening exists for them — is one of the most important things a patient can know.
Develops slowly from polyps over years. Highly preventable and treatable when caught early. Colonoscopy is the gold standard — it finds and removes polyps before they become malignant. Most people are not screened early enough, or often enough, particularly those on immunosuppressants.
Early signals: change in bowel habits, blood in stool, unexplained weight loss, persistent abdominal discomfort.The most silent and most lethal of the common cancers. Located deep in the abdomen, it rarely causes symptoms until it has spread. There is currently no reliable population-level screening tool. Vague abdominal discomfort, back pain, and new-onset diabetes in an older adult are among the few early signals.
Early signals: vague upper abdominal or back pain, jaundice, new-onset diabetes, unexplained weight loss, dark urine.Often called the silent killer. Symptoms are vague and easily attributed to other causes — bloating, pelvic discomfort, changes in urinary or bowel habits. By the time most cases are diagnosed, the disease has spread beyond the ovary. No reliable early screening test exists outside of high-risk genetic surveillance.
Early signals: persistent bloating, pelvic or abdominal pain, difficulty eating, urinary urgency or frequency.The leading cause of cancer death. Develops silently in many cases until advanced. Low-dose CT screening is now recommended annually for high-risk individuals — current or former heavy smokers between 50 and 80. Most people who qualify are never offered it.
Early signals: persistent cough, coughing blood, chest pain, hoarseness, unexplained weight loss, recurrent respiratory infections.Significantly elevated risk in patients on long-term immunosuppressants. Can present as painless lymph node swelling, persistent fatigue, unexplained fever, or night sweats — symptoms that are easy to attribute to the underlying condition being treated rather than a new malignancy.
Early signals: painless swollen lymph nodes, persistent fatigue, fever without infection, drenching night sweats, unexplained weight loss.Slow-growing in most cases, but aggressive in some. PSA screening is controversial but valuable in the right context. Black men develop prostate cancer at higher rates and at younger ages, and tend to present with more aggressive disease — making earlier and more frequent screening a clinical and equity imperative.
Early signals: often none. Later: urinary changes, difficulty urinating, blood in urine or semen, pelvic discomfort.Gawande’s great contribution in Being Mortal is not a clinical framework. It is a moral one. He argues that medicine has become so focused on defeating death that it has lost the ability to ask what a life well-lived looks like in its final chapters. The result is patients who receive aggressive interventions they never wanted, in hospitals they never chose, without anyone having asked them the questions that would have led to a different answer.
What do you want the time you have left to look like? What are you willing to trade in order to have more of it? What would make the remaining days feel like yours?
These questions are not defeatist. They are the most important clinical questions a person can be asked — and they should be asked long before a terminal diagnosis makes them urgent. They should be part of every annual visit, every serious health conversation, every moment when a patient and a provider have the rare gift of time and attention together.
My father answered them, in his way, when he chose hospice over surgery. He had lived a full life. He wanted to die at home, in familiar surroundings, with his family present. He got that. Not every patient does. And the difference, in my experience, is almost always whether someone was present to ask the question — and to stay for the answer.
Cancer is not always preventable. But its trajectory — when it is found, how advanced it is, what options remain — is profoundly shaped by attention. By presence. By the quality of the relationship between a patient and the people responsible for their care.
Screening saves lives. Colonoscopy prevents colorectal cancer by removing polyps before they become malignant. Low-dose CT catches lung cancer at a stage when surgery can still cure it. PSA testing, used appropriately, catches prostate cancer early. Pap smears and HPV testing have made cervical cancer one of the most preventable cancers we have. These are not controversial tools. They are underused ones.
Family history changes the calculus. If a parent or sibling had cancer — particularly before age 50, or of a type associated with genetic syndromes like BRCA, Lynch, or Li-Fraumeni — standard screening protocols may not be sufficient. Genetic counseling exists for exactly this reason. Most patients are never referred to it.
Inflammation is the common thread. The same chronic inflammation that drives cardiovascular disease, metabolic syndrome, and gut dysfunction also creates the conditions in which malignant cells thrive. The anti-inflammatory lifestyle described throughout this library — movement, sleep, whole food, stress management, a healthy microbiome — is not only protective for the heart and the metabolic system. It is protective for the immune system’s ability to surveil and destroy the cells that become cancer.
And immunosuppressant use requires oncological vigilance that is rarely built into the prescribing relationship. If you are on long-term immunosuppressants for any condition, ask specifically and annually: what cancers am I at elevated risk for, and what screening should we be doing? Do not wait for the system to ask. The system, as my patient learned, does not always remember to.