Breaking the Bad News

I don't have to diagnose patients with cancer very often, thankfully. But the last few weeks have brought a grim procession of cases where I've been the one that's had to break the news.

Two of these patients have been very elderly, very frail, and while a cancer diagnosis is always devastating, they and their families have met the news with a sense of resignation mellowed by dementia.

But two of these patients have been fairly young (in their fifties), otherwise healthy and brought into the doctor's office by fairly minimal symptoms. In both cases, I initially pursued a conservative work-up, but through a mixture of clinical intuition, defensive medical practices, and plain old blind luck, I ended up ordering special imaging studies. Both patients ended up having particularly large and aggressive tumors; both now face a horrifying gauntlet of major surgeries, radiation and chemotherapy, all of which appear unlikely to prolong their lives.

Ugh. It's enough to make me want to do an MRI of my whole body, just to be sure there isn't something sinister simmering in my tissues.

It's a little bit like hearing about a plane crash: when you see something so horrific, you suddenly feel vulnerable, even though your odds of suffering the same fate are exceptionally small. (Unless, of course, you fly on Great Lakes Airlines.) Compound that by paranoia by witnessing first hand the disaster several times in a short span.

When I'm faced with an x-ray report that reveals a likely cancer diagnosis, I feel devastated for my patients as well. I dread having to be the messenger, though I do appreciate the importance of my role in reliably and empathically conveying the information. Knowing I will have to answer a deluge of panicked questions once I break the awful news, I go do as much research as possible to try and educate myself and be prepared. But oncology is such a specialized field now with such specific diagnoses, treatments and prognostications, that whatever meager information I impart will be utterly insufficient. This is especially true when I am breaking the news of an as yet unconfirmed cancer, as you never diagnose cancer off of an x-ray, but rather under a microscope once you get a tissue biopsy. It's all a very hopeless feeling for me; usually the best thing I can do is convey the information, offer compassionate solace, extend an invitation to hope for the best, and then expedite a referral to an oncology center. It's not like treating an ear infection: easy diagnosis, excellent prognosis, concrete remedy.

It's more like dredging a lake for drowning victim: emotional paralysis until the awful discovery confirms your worst fears.

I guess that's why I've had a Tim McGraw song humming in my head all week:

He said, "I was in my early forties, with a lot of life before me
When a moment came that stopped me on a dime.
I spent most of the next days, looking at the x-rays
Talking 'bout the options and talking 'bout sweet time."
I asked him when it sank in, that this might really be the real end.
How's it hit you when you get that kind of news?
Man, what'd you do?

He said,
"I went skydiving
I went rocky mountain climbing
I went two point seven seconds on a bull named Fu Man Chu
And I loved deeper
And I spoke sweeter
And I gave forgiveness I'd been denying
And he said, some day I hope you get the chance
To live like you were dying."