The Man With the Missing Rib

Lung cancer. Photo from:
Lung cancer. Photo from:


I cannot begin to estimate how many patients with smoking-related lung cancer I came across when I practiced as an Internal Medicine physician in the USA. I had seen enough relatives and neighbours suffer and die from lung cancer in my village, when I was a child. At that time, over a half of British adults smoked.

Unfortunately, while tobacco use is decreasing in many western countries, it is increasing in many developing countries, and I fear that many developing countries will, in the not-too-distant future, suffer the horrors of tobacco-related diseases that have terrorised western societies.

To illustrate how routine it is to see patients with lung cancer as a physician in the USA, and to bring out the horrors of those encounters, I’m going to tell you some of the experiences with that awful disease that I had while I was practicing Medicine in the USA.

Before I begin with my first case, let me remind you that over 85% of lung cancer is due to tobacco, and that lung cancer is just one of many diseases that are caused by tobacco: cardiovascular disease is even more common as a tobacco-related disease.

When, as a medical student, I heard a cardiac surgeon say : “The top five causes of heart attacks are tobacco, tobacco, tobacco, tobacco and tobacco,” he wasn’t far from the Truth. I proffered the sixth main cause as “tobacco,” and he said I was right.

My first horror story, then, concerns a quiet, pleasant 63-year-old  gentleman, Mr J., who came to see me as an outpatient with pain in his left upper back, just below his shoulder. I hadn’t been practising Medicine for very long at the time, and he was a patient of one of my colleagues, who had a full schedule that day; so they “squeezed” him in to see me.

“I’ve had the back pain for about a month,” he said, “and it won’t go away.” When I asked Mr J. if he had injured it, or had a cough, or was short of breath, he said No. It was just a nagging ache without any other symptoms. It didn’t bother him that much, he added, and he wasn’t too concerned about it, except that he’d like it to go away. I looked in his chart- he had no other known medical conditions and had perfect blood pressure. His weight was unchanged from what it was at his last office visit six months previously.

I examined him carefully. His lungs sounded fine and there were no other obvious abnormalities on his physical exam. Movement of his left shoulder, upper back, neck and arm were normal and didn’t elicit any pain. There was no tenderness of his upper back in the area where the pain was located. This didn’t seem to be related to any injury or obvious musculoskeletal problem.

I did detect a powerful odour of tobacco when I was examining him. My nose is very sensitive to the smell of tobacco and I could often identify even a light smoker, though admittedly sometimes a non-smoking patient would smell of tobacco because their spouse or partner was a smoker!

Mr J. was a heavy smoker. “I’ve smoked since I was 14,” he said with a reticent smile, “probably about a pack of cigarettes a day since then.” My gut feeling told was that I needed to do a chest X-ray on this patient right away. There was something unusual about his back pain and now I knew that he was a very heavy chronic smoker. The two added together made me very concerned.

I sent him to a local radiology centre that was close to my office, with an order for a chest X-ray, and advised him to go there straight away and not wait until the next day. The next patient on my day’s list was already waiting to be seen, so I moved on to her.

About 45 minutes later, I received a phone call from the radiologist. “You just sent us a patient, Mr J., for a chest X-ray. Do you know if he had any surgery to remove part of a rib for any reason?” the radiologist asked me, “because I can’t see the posterior portion of his left third rib on the X-ray.”

I checked Mr J’s chart, and found nothing to suggest he’d had any previous chest surgeries, injuries or problems, and definitely I’d seen no scars on his back. I had the radiologist pass the phone to Mr J. so that I could talk to him. He remembered having no problems, or surgeries, or injuries, at all related to his back, chest or ribs.

The radiologist saw nothing else untoward on the chest X-ray. The lungs looked quite normal. Chest X-rays, however, are often poor at picking up some abnormalities, including tumours. So we decided to do a chest CT scan (CAT scan) on Mr J., in order to look in more detail at his chest and lungs.

That same afternoon, a large irregular lung mass was seen on the CT scan.It was likely to be a cancerous mass that had obviously invaded, or-to put it less medically-  “eaten” through Mr J’s chest and invaded and destroyed part of the bone of his left third rib. It was exactly in the area where he had the persistent ache.

It was shocking and, believe me, it was not easy to give this devastating news to Mr J., who thought he was dealing with a simple and curable medical condition.

Mr J. was sent for a biopsy of the lung mass, which confirmed the presence of smoking-related lung cancer, then he was referred to an oncologist. Sadly and tragically, his cancer was incurable and advanced. It had spread (metastasised) to other parts of his body.

He died several months later from terminal metastatic lung cancer. Though his death certificate stated that the cause of his death was “lung cancer,” really it should have said, “Lung cancer due to cigarette smoking.”

Mr J. wasn’t the first victim of the Plague of Tobacco I ever saw, and I knew that he would, by no means, be the last.


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