[SMOKING and LUNG CANCER]

[An authentic case filmed at the Royal Edward Chest Hospital, Montreal.]

[The diagnostic tests, assessment, preparation for and removal of a lung from a patient with a long history of cigarette smoking.]

[Narrator:] Patient Wilfred Ayers talks to surgeon B. D. Monroe.

[Dr. Monroe:] So Mr. Ayers, if this proves to be a cancer of the lung,

your outlook or your prognosis 

is almost 100 percent nil for any length of time,

and with operation and complete removal of the tumor

and the tumor-bearing area, you have a reasonably good outlook.

But then once it's completed,

the only thing to do is to go back to your job and live with optimism.

[Mr. Ayers:] And quit smoking.

[Dr. Monroe:] And quit smoking.

[Narrator:] Wilfred Ayers will walk these streets again,

but minus the cigarettes and minus a lung.

In a week he will have a major operation,

which we will see, and which may save his life.

Last year in North America, 50,000 people died 

from cancer of the lung, 

a disease which has become a major killer

only since the smoking of cigarettes has become epidemic.

Many more thousands died of coronary heart disease 

or were disabled by chronic bronchitis, emphysema,

and other illnesses which medical men the world over

say can be related directly to the smoking of cigarettes.

Almost a hundred and fifty years ago Charles Lamb wrote,

"For thy sake tobacco, I would do anything but die."

Medical men say too many people are doing just that.

[CHEST CLINIC/CLINIQUE THORACIQUE]

[Suited man:] In view of his history,

in view of his history of heavy smoking 

for a goodly number of years would you care

to give any opinion as to the relationship 

between his smoking and the fact that he appears now with

proven bronchogenic carcinoma of the squamous cell variety?

[Doctor 1:] I definitely feel that it did have a relation to the smoking,

but I don't think we can prove it.

[Suited man:] I think there is no question 

that prolonged cigarette smoking is responsible, 

I presume, for carcinoma.

Certainly these people get carcinoma

and the logical assumption is the responsibility of the cigarettes.

Now what in the cigarette smoking is responsible for it,

I don't think we can say at all.

Whether or not it's tar or some other product of combustion 

is not at all clear,

but I think the association is clear,

and I think that it is certainly more than adequate to be acted upon 

in, in advising people

whether or not to smoke.

[Second suited man:] And you will be the first one, I'm sure will agree,

that there are other deleterious effects of 

smoking that perhaps haven't got the fatality of a cancer of the lung,

but from an economic point of view

and from the point of view of disabling a person,

they are equally as important.

And I'm talking in particularly about

the chronic bronchitic and the emphysematic people.

[Suited man:] Coronary artery disease seems to have some association.

Certainly there are some cases where this appears to be clear-cut.

There is a time-honored association with Buerger's Disease...

there is no doubt that there are a number 

of areas of medicine where you can get 

this deleterious association between disease and smoking.

[Mr. Ayers:] I've done the stupidest thing,

I've smoked cigarettes before break.. 

before having anything,

three and four cigarettes as soon as I get out of bed 

which I think is uh, no good to anybody.

And my wife said to me several times, 

she said, "Why ever don't you stop smoking with that cough?"

[Dr. Monroe:] You've always had a cough?

[Mr. Ayers:] I always found that I coughed quite heavily

after I had a smoke,

because I always inhale my smoke.

[Dr. Monroe:] Yes. What was the symptom or the reason 

that motivated you to seek the advice of a doctor in the first place?

[Mr. Ayers:] Well, for the past nine months 

when I went to see Dr. Halley I had a streak of blood on my phlegm.

[Dr. Monroe:] In your sputum?

[Mr. Ayers:] My sputum. So I thought well, 

this has gone far enough,

and my wife said why don't you go and see the doctor?

So I said I will. 

I'll make up my mind one of these days.

I didn't know what I was involving myself in.

[Dr. Monroe:] When was that? This is important.

[Mr. Ayers:] I should say about, uhh, nine months ago.

[Dr. Monroe:] And when did you go to the doctor?

[Mr. Ayers:] It was, uh, a month ago.

[Dr. Monroe:] Just a month ago. 

So you waited eight months.

[Mr. Ayers:] I waited eight months.

[Dr. Monroe:] Why?

[Mr. Ayers:] Well, I thought it was a blood vessel 

I'd broken when I coughed but it wasn't.

[Dr. Monroe:] I put these x-rays up here,

not specifically for you to completely understand them

but to give you a rough idea of what your problem is.

Now if you look at this x-ray here,

you'll see that you have a shadow which is generalized 

in the upper part of the left lung,

and if you compare this to the right lung,

you'll see that there's a difference 

in the degree of penetration on both sides.

What this represents is that you have a complete obstruction 

to the upper lobe of your left lung.

Now let me be very frank with you, Mr. Ayers,

the thing that we're all concerned about this day

is the fact that this could very likely be a tumor 

that's obstructing your airway.

This tumor is undoubtedly likely to be a malignant tumor. 

In other words, it could be a cancer.

And if it proves to be a cancer the only satisfactory treatment 

is to remove it completely.

Uhh, this will mean that you will lose your left lung.

[Mr. Ayers:] And the other lung is good, isn't it?

[Dr. Monroe:] Oh as far as we know it's an excellent lung.

[Mr. Ayers:] Excellent condition,

so that is one reason why I think that the left lung should come out.

Little did I know 'til I came in here 

that I had only a lung and a half or less.

[Dr. Monroe:] All right, Mr. Ayers, 

we'll carry on with the bronchoscopic examination tomorrow,

and after that there will be

no further delay.

If it's indicated we'll take you to surgery.

Now Mr. Ayers, we are going to carry out this bronchoscopy procedure 

that I explained to you yesterday.

And this is the instrument. 

The light is on the end and it's hollow.

We put this through your air tree 

and this is just a simple diagram of your air tree 

with the lung at the side.

Pay no attention to this side.

This is your left lung,

and this is the part that is involved.

In other words, this part of your lung, 

which is your upper lobe, 

is collapsed because there's something 

plugging the airway going into it.

Right here you have a bird's eye view, 

so to speak, 

of the air tree as we look sideways

through a special little instrument that's actually 

a miniature periscope that we can look at a right angle.

And these openings here which feed air into this upper lobe are plugged, 

and the object of this is to put down the bronchoscope--

we turn your head to the side to line it up--

and we have it lying in here,

the main airway going through the entire left lung.

And then we look sideways into this left upper lobe bronchus,

and we observe directly with the human eye 

exactly what the condition and the nature of that air tube is.

And this is the object of the examination.

I don't think it'll bother you very much, 

we'll do it under local anesthesia, 

we'll freeze your throat

and uh I think you'll find it very easy.

[Mr. Ayers:] Okay then, Dr. Monroe.

[Anesthesiologist:] Your tongue will get stiff

and it'll be a little difficult to swallow for you,

so that will be an indication that you start to get frozen.

[Mr. Ayers inhales the solution with deep breaths.]

[Dr. Monroe:] Okay, that's fine.

We are ready to uh, just lie down sir.

All right, thank you. 

Just raise your head sir, raise your head. 

Now put it down.

I don't think you'll find this examination will upset at all,

so just uh, what size is this? Number seven?

[Nurse:] Eight.

[Dr. Monroe:] Eight, that's fine.

Just stick out your tongue, sir.

Now just relax.

Nice and easy. 

Nice and easy.

That's it. 

No problem there at all.

[?] can I have the [?] scope please?

All right.

Now we are right in your main airway now, Mr. Ayers

and we're looking down into your main airway,

and we can see the two divisions.

Now we have these little telescopic instruments 

that I was talking to you about 

and we've got this through the hollow tube 

and we're looking on the interior of your airway,

and we can see it very nicely.

I'll have a right-angle scope now.

And now we're going to put in the telescope 

that's a miniature periscope so we can look sideways.

And with this instrument we're able to see side branches directly.

You're doing very well, Mr. Ayers.

There's no problem here at all and we'll soon be finished.

All right, Mr. Ayers, we're all finished. Just sit up, sir.

I'll take this off your head.

Just swing your feet over the side.

Now did we bother you very much?

[Mr. Ayers:] No, Dr. Monroe I.. no bothering, no bothering,

no trouble, I could feel very little of it.

[Dr. Monroe:] Well, we've determined that your right lung 

looks very clear and your left, 

the main part of your left airway is fine, 

and that our suspicions that the left upper lobe airway was blocked 

has been confirmed.

And uh, so this is plugged, and it's plugged by a tumor growth.

So our next job now is uh to fix you up

and to get rid of this and uh 

we'll proceed with that next week.

[Mr. Ayers:] Sure.

[Dr. Monroe:] Okay, Mr. Ayers.

[Mr. Ayers:] Thank you, Dr. Monroe.

[Narrator:] Not all smokers have the reasons to stop that Wilfred Ayers has.

But not all who develop cancer have the warnings he had either.

Cancer is a silent killer and more often than not 

does not proclaim its onset.

And doctors now urge that those who smoke have x-rays twice a year. 

Too many smokers come with their problems too late,

when surgery or radiation or other treatments cannot cure them.

[Man in hospital coughs violently.]

Breathing tests help determine 

how he will function on only one lung.

[Nurse:] Deep breath and blow.

[Mr. Ayers:] And if I ring the bell 

you're going to give me a cigar, right?

[Nurse:] Or force you to stop smoking. 

Blow. Keep blowing, keep blowing, keep blowing as much as you can.

[Physician:] I'm really interested in his oxygen uptake. 

This is really what I'm...vis a vis one lung against the other. 

Easy.

[Narrator:] The capacity of each separate lung 

can be plotted on a spirometer.

[Physician:] That's all you need calculated, sure.

We just want one against the other anyway. 

[?] increase after.

[Technician:] I think we'd better give him some more Demerol, don't you?

[Physician:] This is the moment of truth.

That's a bang-on, you know. 

That thing's in there real tight.

I mean it's a good differential spirometry.

[Head Doctor speaking to seated group of medical staff:] Physical examination was essentially unremarkable

apart from the fact that there was gross abnormality

in the respir.. respiratory sounds in his left upper chest,

suggesting a collapse of his left upper lobe.

The rest of the physical examination was negative 

and the test x-ray was grossly abnormal.

He's had extensive investigations,

many of which are of little interest because they're essentially 

normal including electrocardiograph and his pulmonary function studies.

[Suited man:] Has he lost any weight? 

Does he have any constitutional symptoms?

[Head Doctor:] He's had no weight loss at all, sir.

[Doctor 1:] When I first saw the patient,

he was an extremely healthy-looking man. 

I think almost clinically you could tell that

he wouldn't present a risk to surgery,

and I think it's his only chance for, uh, 

possible cure of his disease.

[Head Doctor:] He has no evidence of cardiovascular disease?

[Doctor 1:] None whatsoever.

[Audience member:] May we see the x-rays?

[Radiologist presenting x-rays:] Now, the [?] findings are such 

that they indicate an obstruction in the left upper lobe bronchus.

[Doctor 1:] Would you call the remainder of his lung normal?

[Radiologist:] The remainder of his left lung is normal. 

His right lung shows no evidence of any disease.

[Doctor with dark hair, standing up:] We took a biopsy from this tumor mass

and Dr. Bellin can tell us about that.

[Dr. Bellin:] Yes, the biopsy showed it's squamous cell carcinoma, 

there's no doubt about it.

[Voice from audience:] And no uh symptomatology elsewhere 

that would suggest extra duress?

[Dr. Bellin:] No, none at all, sir.

[Suited man:] These pulmonary function studies will be more helpful 

in making sure that he has enough reserve to 

withstand this sort of surgery. 

Is that how you got the...

[Dark-haired doctor:] Well, sir, he had lung capacity done,

maximum breathing capacity, timed vital capacity, 

and pulmonary diffusing capacity,

and with carbon monoxide uptake.

The opinion of the uh pulmonary function consultant uh was, 

in summary, the findings reported above 

are reasonably good for a male in this age group.

[Doctor 1:] And the flow rates are perhaps a little bit down. 

Not as much as I would expect

with his long history of smoking.

His diffusing capacity was normal.

I wouldn't consider these a contraindication 

to a pneumonectomy.

[Suited man:] Dr. Pollack?

[Dr. Pollack:] I agree with Dr. Monroe

and with the general course of the discussion

and I think in this case, 

operation is the best way to proceed.

[Nurse:] As a result of the anesthetic,

you pile up secretions in your chest

and it's difficult for you to cough, 

and the breathing exercises can make this simpler for you.

So let's just check them again.

[Mr. Ayers:] All right.

[Nurse:] You don't have to fear coughing after the operation, Mr. Ayers,

because I'll be supporting your incisions.

So I'd just like to practice again with the breathing in and out.

Short breath in, long breath out.

And cough.. [Mr. Ayers coughs] in and again.

[Narrator:] There is little hope among medical men 

that those who now smoke will stop,

despite new medical knowledge that much lung damage can be reversed by stopping.

They only hope that examples like Mr. Ayers 

will cause non-smokers not to begin.

[Nurse:] Good morning, Mr. Ayers.

How do you feel about the surgery now?

[Mr. Ayers:] Oh I uhh, the way I look at it is,

it's a must, through what Dr. Monroe and other doctors have told me.

And uhh I put myself into their hands completely.

I mean he told me once, that he said he, 

a little while back there that he didn't give 

too much chance for my life, you see,

if I didn't have something done. 

I've heard that there is lots of uh individuals

going around with one lung.

As a matter of fact there is a lady I know very well through uh, 

daily contact sometimes in a store you see, 

and she only has one lung.

And I think that you can't tell any difference

whether she's got one or a half a dozen.

[Nurse:] We'd like to recommend that you try to rest as much as you can, 

and to relax as much as you can.

[Mr. Ayers:] When I start to come to from the anesthetic, you call it?

[Nurse:] Yes.

[Mr. Ayers:] Umm, am I likely to get into a tantrum, 

will I get mad?

[Nurse:] No, no, no you will wake...

[Mr. Ayers:] I had that experience once. 

They uh plugged the ether right about here.

and I was asleep at seven o'clock, came round about midnight the same.. 

I was wounded you know from [?] 

and it took about twelve of 'em to...

and I was cursing everybody around me you know.

[Mr. Ayers chuckles.]

It wasn't funny...

[Nurse:] Yes, well, Mr. Ayers, there is nothing to that.

[Mr. Ayers:] I just had my little doubts 

because I wouldn't want to uh cause any commotion like that you know.

[Nurse:] No, no there's no fear of that, no.

[Mr. Ayers:] In my.. I'm not going to uhh say that 

it's actually done uhhh by smoking, you know what I mean, 

I've left it to the doctors to say,

but when I was told not to smoke, I had not coughed.

And I should have taken my dearly beloved wife's advice years ago 

and cut down on the smoking you know.

But sometimes you get into a little bit of a uhh,

sometimes you, I mean you get into a jam

and the first thing you do is pick up a cigarette

and you keep smoking and smoking and smoking you know.

[Nurse:] Um hmmm.

[Mr. Ayers:] When you're told you that have only got...

that the prospects in life is not very far ahead of you, you know, 

then you sit up and take notice, because life is sweet.

[Anesthesiologist:] Blood pressure is 130.

Mr. Ayers, we are injecting the pentothal 

in the intravenous now,

and you will just fall off to sleep 

very quietly, very pleasantly.

You may notice a little peculiar taste or smell,

something like onions or garlic.

[Dr. Monroe:] We are now ventilating only the right lung. 

The left lung is excluded from the airway.

[Anesthesiologist:] Blood pressure is 120.

Now, we let the respirator, the automatic respirator, 

take over control of ventilation.

Now we're ready to position the patient for the surgery.

[Dr. Monroe:] Help position his legs properly, please. 

[Anesthesiologist:] Heart rate has speeded up now.

[Dr. Monroe:] All right, now uh, we're about to make the incision.

Dr. Brendel, is everything all right?

This particular patient, we'll undoubtedly take out a rib 

to facilitate the surgery.

[Dr. Brendel, anesthesiologist:] Blood pressure reading is 90.

[Assisting surgeon:] Can I hold this for you?

[Dr. Monroe:] Now up to the second rib. 

That's two, that's three, that's four, that's five. 

This rib is very high up.

[Surgeons work together to remove a rib in order to get to the left lung.]

[Surgeons murmuring.]

[Dr. Monroe:] This is something...we'll get it out.

[Surgeons talk amongst themselves as they deal with complications.]

[Dr. Monroe:] Can you hold that [?] over...

[More talking and murmuring.]

Right there.

It's going to come.

It's going to come but it's not uh,

it's not the most favorable situation.

[Words difficult to discern because of surgical masks over faces.]

The [?] doesn't seem to be...

[Dr. Monroe:] The [?] is clear.

[Assisting surgeon:] It's not involved.

[Dr. Monroe:] And there's nothing in the mediastinal area up above.

[Assisting surgeon:] It seems to be mainly the pulmonary artery 

and maybe the superior [?] vein.

Well, we'll just have to work away

until we get the thing cleared out.

All right, we're just about through. 

Just about ready to sever the lung.

Now what I have in my hand here is just the air tube

and the other air tube along going to the other

lung branch is right there.

We're going to put a clamp across it right here, 

This is a soft clamp.

It's gentle to the tissues

and we'll clamp the air tube like so.

Now just give me a knife please. 

I think we should set that a little further down.

We'll sever the connections here.

And as we do Dr. [?] keeps cutting it out.

And there we are. 

This is what we've been after this morning is to remove this lung 

containing the tumor mass which I have in my fingers here. 

Dr. Bieland will take this and demonstrate 

how all the big vessels,

and everything that's come off the heart,

they're all tied off here.

This is an important side of course, 

this side is next to the heart.

[Assisting surgeon:] Now let's [?] the lung completely,

so that we can have a good view 

of this neoplasm or tumor.

We start from the upper lobe,

and we'll go down to the base of the lung.

Here is the tumor in the upper lobe,

occupying almost half of it. 

It's not a very large tumor,

just I would say medium-size.

It is a hard white mass as you can see here.

The rest of the tissue is soft and spongy

and this tumor is very hard

It is fairly well demarcated 

and the definite prognosis can be established only 

after microscopic examination.

[Nurse:] How do you feel now?

[Mr. Ayers:] Oh, not too bad.

[Nurse:] Not too bad. The operation's all over.

[Mr. Ayers:] Thank you.

[Nurse:] Try to keep your eyes open.

Now will you take a deep breath for us? 

[Mr. Ayers makes raspy breathing sounds.]

Deep, and out, and in, out... 

That's it.

You're trying to give us a smile now?

[Mr. Ayers:] Sure.

[Narrator:] Wilfred Ayers has opened his eyes again on a world 

that wears a cigarette in its face.

Where he will have to live with temptations 

that confront a smoker wherever he looks and listens.

Where persuasion filters out of the mind of the beholder

the consciousness of the harms that medicine

now definitely attributes to cigarettes.

A world whose governments are split between the revenues they gain from cigarettes 

and the responsibility they feel for the health of their peoples.

A world that seems to have no ready answer to the question

of how far laws should go in curbing the 

rights of people to make their own choices 

and take their own consequences.

A world where the young are taking ever earlier 

to a habit that public health associations 

have estimated will claim the lives of millions

who are now schoolchildren 

before they reach the age of 70.

[Thanks are due to the patient who shared his experience for the benefit of others

and to the staff of the Royal Edward Chest Hospital, Montreal.]

[Written and directed by ROBERT ANDERSON  Camera JACK LONG  Sound RICHARD FRANCE  Editing DONALD EVRAIRE]

[SMOKING and LUNG CANCER the END produced by ROBERT ANDERSON ASSOCIATES LTD. CANADA]