Cancer Victim Testifies From Beyond the Grave

No one wants to hear the words: “You have cancer.” . . . As I understand this case, it’s a wrongful death suit, so therefore, I will not be present at the time (it) is heard.

--Videotape deposition of breast cancer victim Marcine Cohen, Jan. 13, 1983. Died: June 18, 1984.

There is a deceptively home-movie flavor to the picture on the television screen. The camera zooms to a tight close-up of a smiling young woman named Marcine Cohen, who is talking sensitively and, at times, matter-of-factly about her plans for herself, her children and her marriage.

“I would hope I will be my image of what an adequate mother would be,” the young woman says, “which is supportive and protective and there to guide them through difficult decisions . . . and mostly to nurture.”

But it was not to be. The television picture disguises the fact that Marcine Cohen was wearing a wig--necessary because chemotherapy had robbed her of her natural hair. A breast cancer victim who had already undergone two mastectomies, she would be dead in less than 18 months.

She would die shortly after receiving her doctorate in sociology from UC San Diego--at a ceremony to which she was taken in a wheelchair, wearing an oxygen mask, because she told her husband she refused to be accorded her Ph.D. while lying in bed. Her death, on the date of her 17th wedding anniversary, would follow by two days the bat mitzvah of Davora, the firstborn of her two daughters. Surviving to the ceremony had virtually consumed Marcine Cohen for the last few months of her life, her husband recalls.

‘She Was a Fighter’

“The quality of her life had not been good,” her husband said. “It’s hard to tell you what my wife was like, but she was a fighter. She just literally gave up at that point (the bat mitzvah). That’s the way I interpret it.

“I didn’t believe in the will to live, but this sure as hell changed my point of view on that subject.”

And she would go to her grave at age 38 bitter and angry with the U.S. Navy because, she says to the television camera--and her family has contended in a malpractice suit asking $5.5 million because of her allegedly wrongful death--she believes a Navy surgeon, Dr. William MacLeod, failed to follow fundamental medical logic, leading to a seven-month delay in her diagnosis.

By the time the San Diego Naval Hospital finally realized it was cancer, said the civilian specialist who eventually took over the case and treated her until she died, Marcine Cohen’s fate was probably sealed--though it is possible she would have become terminal even if the diagnostic error had not been made. But a mistake it was, says Dr. Mark Green, the UC San Diego civilian oncologist--one that would have been just as avoidable in 1977, when the Navy doctor missed the first opportunity to diagnose the cancer, as it would be today.

Of itself, the case is representative of several pending or settled in the last three years against Southern California Navy hospitals, where military physicians have apparently had significant problems with cancer diagnosis, the general field of women’s health or both. Marcine Cohen’s death is unusual in several respects, however. To begin with, her husband was a Navy doctor, assigned to the same naval hospital.

Dr. Irving Cohen, 39, went to medical school on a Navy scholarship he won after returning from service as an Army infantry lieutenant in some of the hottest spots of the Vietnam War.

Marcine Cohen went to MacLeod when she noticed a lump in her right breast that remained unchanged through three menstrual cycles. A diligent practitioner of self-examination, she was one of many women whose breasts often develop small,

harmless lumps.

This one, though, was different. Her husband, still in his residency, was honing his skills in kidney disease. He recognized he was not technically qualified to evaluate the case nor emotionally fit to deal with something so close to home. He said he got his wife an appointment with MacLeod, then a Navy captain and chief of the hospital’s general surgery department.

Medical records show MacLeod passed a needle into the lump and noticed that no liquid escaped from it. He concluded it must be a benign cyst. And that, other doctors say, was his mistake. He should have known that if a lump is a cyst, physicians who have reviewed the case say, it will produce fluid in the biopsy needle. Failure to find fluid means the next step--a full biopsy--must be taken since there is a significantly increased chance the lump is a cancer. The biopsy remained undone--for seven more months.

Left the Navy

Sometime after Cohen died, MacLeod left the Navy. He now works as a surgeon and general practitioner in Alamosa, Colo. Reached by telephone, he declined to discuss his handling of the Cohen case. “I don’t want to talk about it in any way,” he said.

The television camera was set up to preserve Marcine Cohen’s testimony for use in the trial of her lawsuit--which has not yet been scheduled. The videotape is a lawyer’s tool used increasingly under such circumstances. Cohen, under oath and breaking into tears occasionally, forges ahead on the videotape, under difficult questioning.

“My desire to perpetuate my testimony is because I feel that, if I die . . . the U.S. Navy was responsible and negligent and that my children would be deprived of a mother and all that entails,” she says to the camera. “My desires are for my children and for my husband, and that is predicated on my subsequent death.”

Then, searching momentarily for reassurance, she turns to her lawyer and asks: “Does that make sense?”

Irv Cohen left the Navy two years ago--though, financially, comprehensive health benefits available because of his status would have made it easier to bear the burden of the futile cancer therapies if he had stayed in the service. He left with terribly mixed emotions. He remains loyal to a Navy Medical Corps he remembers when he first got out of medical school in the mid-1970s--an organization, he recalls, dominated by what was then the last group of physicians taken into the service under the medical version of the military draft.

That Navy Medical Corps was an exciting institution filled with doctors pulled from the nation’s best academic medical centers--many of whom have gone on since the Vietnam era to establish themselves at the pinnacles of civilian medical practice and research.

But then there is what Cohen perceives as the Navy Medical Corps that existed when he left--an increasingly hard-pressed, financially strapped organization, unable to attract highly qualified physicians--especially those in potentially crucial specialties like surgery. Even the Department of Defense concedes that recruitment of some specialists into the military has become almost impossible.

Woefully Unprepared

In an interview in Washington and in congressional testimony, Dr. William Mayer, assistant secretary of defense for health affairs, has confirmed that especially in exotic subspecialties such as brain surgery, military medicine in general is woefully unprepared for what might be required of it in wartime.

Cohen contends that, in the years since Vietnam, the Navy--and the rest of the armed forces--have experienced a discernible drop in the quality of medical care they offer. That decline, Cohen contends, has pushed the San Diego Naval Hospital, where he practiced as a kidney specialist for nine years, to status almost as a second-class hospital.

It is not an isolated observation. Three other physicians with similar backgrounds were interviewed by The Times during a four-month inquiry into malpractice and the quality of care at Navy hospitals here, at Camp Pendleton and in Long Beach. Each one volunteered observations almost identical to Cohen’s:

That, though many physicians forced into the service detested their situations at the time, their conscription program was close to a system of universal national service since few physicians escaped the draft. It was unlike the draft at large, from which many young men escaped entirely. This universal physician service fostered a medical care system of high quality that has, in the decade since Vietnam ended, passed into a period of eclipse. For doctors, the Vietnam era meant there was a far greater chance they would be called into the military than not. For many physicians, the doctor draft became something that was simply planned into a career.

As a Vietnam combat veteran, Irv Cohen wasn’t quite in the same position, but by accepting a Navy scholarship for his medical education, he agreed to return to uniform.

“Most of the guys didn’t like having their lives interrupted,” he said, sitting in an office at the private nephrology group where he has practiced since he left the Navy in 1983. “Most of them (doctors who dominated Navy medicine when he first reported to San Diego Naval Hospital) were good doctors from good institutions who were bent on teaching (when they got out).

“I think I benefited. Medicine at the naval hospital was high-quality medicine then. I remember going from the Navy hospital to UC San Diego (for a two-year kidney disease fellowship), and thinking I would be like the poor cousin. But I had vastly more experience than their fellows. I went there very timidly but I was wrong.”

From the videotape deposition of Marcine Cohen:

Question: And what was the result of the biopsy?

Answer: (The witness sighs). It was, ah, malignant.

Q: How did you learn it was malignant?

A: While I was upstairs getting dressed, unbeknownst to me, my husband went downstairs to look at the tissue. My husband came back into the room while I was getting dressed. And my husband said, “Marcine, you have cancer.”

I did not know the stage of the cancer, but I knew I had been there seven months earlier and whatever it was was bigger than it was seven months before.

Q: Did you bring that to Dr. MacLeod’s attention?

A: I sure did. . . . It was shortly thereafter but it’s a blur of time because, after you’re told you have cancer, you cry for a little while. . . . When he came into the room and I was crying and my husband was crying and we were all upset and I said, “This might cost me my life, your mistake.” And he said, “I know.”

Irv Cohen today draws a careful line between his concerns about Navy medicine and the alleged diagnostic error that may have played a role in his wife’s death. UC San Diego’s Green, who eventually handled her treatment, also cautions against presuming responsibility on the Navy’s part. In this, Green treads very carefully, aware he may eventually be called to the witness stand.

“If you argue,” Green said, “that a disease could have been picked up earlier because the patient presented herself (then, the question is): Would (seven) months have made a difference?

“If you have a lump, and everyone agrees it is a lump, it is our impression that the individual who suffers that delay is probably at a lower chance of having (a favorable outcome). You can’t rule out cancer with negative findings. If you put a needle in it (and none of the expected fluid comes out) you have not proven it’s a cyst and you have not disproved any number of things.

“The burden falls upon the physician to show what it is.”

Understandably, Marcine Cohen could not be that coldly clinical. In the years between her diagnosis in 1977 and her death, she and her husband struggled with a complex of anger, fear, pain and fatigue. As Irv Cohen remembers it, Marcine was “propelled” by her rage. Filing the lawsuit against the Navy was a troubling step, but one Marcine Cohen insisted on.

Finally, she could resist the disease and its progression no longer. Irv Cohen picked up Marcine at the hospital, put her in a wheel chair with oxygen and took her to Davora’s bat mitzvah that morning in June, 1984. And then he took her home.

“She did not want to die in University Hospital, she wanted to die in her own bed,” he recalls. After the ceremony for Davora, “I brought her home that Saturday night. She died that Monday morning.”