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Uttering the ‘C’ word

Part of my job, too large a part of it really, is performing endoscopy on patients referred ‘straight-to-test’ with symptoms suggestive of cancer, including dyspepsia, dysphagia, weight loss, iron deficiency, anaemia or chronic diarrhoea. This means, among other things, that a couple of times a week I have to tell a complete stranger that they have cancer.

The lists are usually attended by a medical student or two, armed with a little blue booklet of things they need to get ‘signed-off’, which they chase with the voracity yet ultimate pointlessness of my 10-year-old self trying to fill my Panini Italia ’90 sticker album. One of the little boxes to be ticked, signed, dated, etc, is whether or not they have observed a clinician tell a patient that he or she has cancer.

So she trots in behind me.

“I can’t be sure until we have the biopsies back, but I am greatly concerned that what we have seen today looks like a cancer.”

Alone, people are sadder and more circumspect. If a relative or friend is there, the thing that strikes me is how quickly the language becomes martial. All sorts of declarations are made about fights, battles and vows to beat it. I always wondered whether that was a good or bad thing, but really it’s more of a polite thing.

The harsh yet eternal truth is, he will never forget this moment and you won’t remember it next week 

I think the patient is somehow trying to alleviate the extreme awkwardness of the third person (fourth, if you count the medical student — which nobody does) in the room when such leaden news is being imparted. Sometimes, it feels like you should temper some of the bombast, but it’s not possible.

None of the worthy articles on how to break bad news mention what you should do when you have found an obstructing oesophageal tumour and someone looks you in the eye and tells you they are going to ‘beat this bloody thing’.

I bet if they had, it wouldn’t say: ‘Do a sort of grimaced smile and nod your head a few times’, but I haven’t been able to think of a better way. We do have a duty of candour. Being true to that would involve saying ‘you know, you probably won’t’.

“Unfortunately, with this particular type of cancer, the majority of people do not survive it, but at this point, there’s no way of knowing who will and won’t survive it.”

Cancer advocacy organisations of various hues do truly wonderful things for people at a very low ebb in their lives. They should be supported at every opportunity but I do wonder if some of the tag-lines used in various campaigns are universally helpful things. All sorts of grand promises are proferred about ‘making cancer history’, ‘ending cancer in our lifetimes’, and so on and so forth. Whether such claims are biologically plausible is questionable and could probably be better debated by someone smarter than I, but I doubt if it can be reduced to a sound-bite. Nor do I have a clear idea of what a world without cancer might look like, or if it would definitely be an improvement on the one we live in.

My beloved dad is in the earlyish stages of both cancer and dementia. Every time I go home, less and less of him is present and I curse how unfair it seems and what he has to endure at the end of as honest and decent a life as anyone could have lived. If I could make some sort of twisted Faustian pact to make one of these conditions history for him, I wouldn’t have to think too long over it.

Death was described as “nature’s masterstroke, albeit a cruel one, allowing genotypes space to try on new phenotypes” in my first and still most well-thumbed textbook of medicine, the Oxford Handbook. If we accept death as necessary, there are far worse ways to die than cancer. Yet the word ‘cancer’ is the nuclear warhead of the doctor-patient interaction and nothing can ever be the same after it is used, such are the overwhelming connotations it has attached to it.

Are we okay with that?

“I’m going to leave you now. You will be hearing from the x-ray department and the nurse specialist in the coming days about your scan and next appointment. If there’s anything you’d like to ask me, here is my secretary’s number.”

You leave the room. It’s never nice. Never. But it could have gone worse. And now the list is running behind schedule and you’re getting all sorts of passive-aggressive glances from the nurses’ station and the waiting room, which will be nothing compared to what you get at the nursery. It never gets easier. A sharpish little intake of breath and time to get back on the horse. The harsh yet eternal truth is, he will never forget this moment and you won’t remember it next week.

She turns and says to you: “Can I get that signed off please?”

Sure, why not.

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