The Hardest Conversation - Part 2 (The "C" Bomb)

Dr. Blog has a discussion about this New York Times article. He advises us Primary Care types:

...to wait until they are 150% sure of the diagnosis before breaking out the ‘C’ word. One can find onself neck-deep in fear, tears, wadded-up tissues and hard questions in a very short period of time after saying it. The ‘C’ word tends to turn off rational thought and turn on the “white noise of emotion” machine at 110 decibels. You can’t take back the ‘C’ word very easily.

I understand that this is a pediatric oncologist talking, so the situations he is addressing are very different from what I encounter in practice. Nevertheless, I understand the principle behind this statement and, in general, I agree with it. On the other hand, I have "broken" this rule on occasion, fully aware of what I was doing, because of a carefully thought out rationale that effectively accomplished what I wanted to do: provide the best possible care -- psychological and emotional, in this case -- for the patient.

A patient in her late 50's came into my office complaining of upper back pain, and two small lumps "on" her right breast. I had last seen her three years earlier for a checkup, at which time I suggested she have a routine mammogram. She hadn't.

The entire right breast was replaced with a locally advanced, stony hard, obvious carcinoma. The two "lumps" the patient was referring to were areas where the tumor had broken through the skin. She had large nodal masses in both axillae, as well as the right supraclavicular area. My strong suspicion (which turned out to be correct) was that her back pain was from bony metastases.

Now technically speaking, because I didn't have a tissue diagnosis, I couldn't be "150% certain" that it was cancer. Except that it was. It was like coming across a guy from a motorcycle accident with his leg bent mid-femur and telling myself that I couldn't tell for sure his leg was broken if I didn't have an x-ray.

I stepped out of the room while she dressed and collected my thoughts. I went back in, pulled my stool up next to her chair and took both her hands in mine. I held them tightly for the remainder of the visit, and began by saying, "This is cancer." She didn't freak out, because obviously she had had a pretty strong suspicion from the start. I went on to tell her that we needed to find out just what kind it was, what cell types and receptor status we were working with, because that would determine treatment. We also needed to find out exactly how much it had spread.

I told her that it was very possible that this is what she would die of eventually, but that I had no idea how far in the future that might be; she might live 10 or even 20 years more with treatment. (I did not say she might live as little as six months, partly because I really didn't have enough information to come up with a meaningful prognosis at that point, but also because even though I was telling her she had cancer I was specifically trying to give her hope.) I also told her -- several times -- that whatever happened, I would be there for her and for her family, whatever happened. I wasn't going anywhere; I wasn't going to be afraid to talk about dying, if that's what was going to happen. She was not going to be abandoned.

Here was my thinking: There was no doubt clinically that this was a malignancy. By coming out and saying so directly, I was removing the uncertainty of "maybe it isn't cancer" and letting her get through the 110 decibel "white noise of emotion" machine now; here; with me, instead of a surgeon she'd meet once before the biopsy and once afterwards, perhaps as much as a week later, "once the pathology report is back" (in order to be 150% sure it was cancer.)

I believe that my approach put her in a much better position to hear what was being said when it counted: when those vital reports came back. Having had the several week lag time it was going to take to complete the diagnostic work up to adjust to the idea that she had cancer, when talk began of chemo and surgery and radiation options, she wouldn't also be dealing with the shock of the "C" bomb.

It worked. At least, she told me that it worked. I got her hooked up with surgery for the biopsy and oncology for the metastatic work up (which showed tumor in her upper thoracic spine; right where her pain was.) Her wonderful oncologist (the same one who so thoughtfully sent me this) told her that chemo first was the best option, with further treatment dependent on her response.

It's been well over a year. (Perhaps even two; I'd have to check her office chart.) She's responded amazingly to her chemo. All her tumor masses have shrunk drastically, and she hasn't even had any surgery yet (except the initial tiny punch biopsies the surgeon did in the office.) She feels great. Her back doesn't even hurt anymore. She looks wonderful (she has a great wig.) Her son had twins; she just helped them celebrate their first birthday, and she is looking forward to the birth of her daughter's second child. This lady has metastatic cancer, and although "cure" is not an option, she is certainly not "dying" at this time.

There is such a thing as compassionate honesty. It can even include the "C" word.