Stifle that wacky plot and it all makes sense

“Breaking Bad,” Episode: “ . . . And the Bag’s in the River,” Feb. 10, AMC, 10 p.m.

The premise: High school chemistry teacher and nonsmoker Walter White (Bryan Cranston) has been diagnosed with inoperable lung cancer and told he won’t live more than two years, even with chemotherapy. He decides to make extra money to help his family by partnering with a former student, Jesse (Aaron Paul), in cooking and selling crystal methamphetamine. In the process, they become embroiled in a dispute with two cousins (drug dealers) and use chemical inhalation to murder one of them. To dispose of the “evidence,” Jesse pours hydrofluoric acid on the body in a bathtub. The human remains seep through the floor, and the episode begins with Walter and Jesse cleaning up the bloody mess, the exertion causing Walter to have a coughing fit. Later, when Walter tries to murder the other cousin, he has another coughing fit and passes out, drooling bloodless phlegm onto the floor. When he wakes up, he continues to experience intermittent fits of coughing as he stalks his intended victim.

The medical questions: Is a poor outcome with inoperable lung cancer so predictable? Would someone with advanced lung cancer be prone to fainting? Or to coughing up clear phlegm?

The reality: Almost all inoperable lung cancer is fatal at two years if untreated. But recent studies on lung cancer (most commonly adenocarcinoma) show a five-year survival rate of 15% to 40% with a combination of the latest chemotherapy and radiation therapy, says Dr. James L. Mulshine, associate provost for research at Rush University Medical Center in Chicago. In some cases, shrinking the tumor can then make surgery an option.

“Never smokers” such as Walter tend to respond better to chemotherapy, adds Dr. Abraham Chachoua, associate professor of medicine and thoracic oncology at New York University School of Medicine. “Newer treatments such as Tarceva can work better in never smokers and sometimes induce remissions that last years.”

Fainting is not unusual in lung cancer patients. “A forceful cough may stimulate the vagus nerve producing a drop in heart rate which can lead to fainting,” says Dr. Francis V. Adams, pulmonologist and author of “The Breathing Disorders Sourcebook.”

Adams points out that a lung cancer sufferer would be especially susceptible to noxious stimuli and prone to frequent coughing “since the tumor often grows within the highly sensitive bronchial tubes, irritating the nerve endings which trigger cough.” Most lung cancers are peripheral, he says, whereas gross bleeding is more common when the tumors are central and can erode into a large blood vessel -- so Walter’s clear phlegm is believable.

Even in the case of smokers, Mulshine says, the use of filtered cigarettes has pushed lung cancers into the small air spaces on the outside of the lung because the cigarette’s toxins are cooled and diluted by the filter, delaying their effects to the periphery of the lung, making a bloody cough less likely in all lung cancers than it used to be.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He is also the author of “False Alarm: The Truth About the Epidemic of Fear.” In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at marc@doctorsiegel.com.