The 'C' word — cancer. That word hits like a lightning bolt to the heart in every patient. “As long as I don’t have that,” they say. During my in-patient rotations as a third-year medical student I’ve reflected on how to break this bad news to patients, especially when we as physicians have a strong suspicion, but not diagnosis, that a patient may have cancer.
While on general medicine, I took care of a woman who was admitted for gross hematuria with severe abdominal and back pain. The first morning I saw her, we had already obtained CT imaging that showed an 8 cm mass in her kidney that was the likely culprit for her symptoms. The radiologist had noted it was “highly suggestive of renal cell carcinoma.” The intern, senior resident, attending, and I all discussed her as a “kidney cancer patient” and proceeded to consult the urology service. Ultimately, it was up to the intern and me to update the patient on the imaging results. We stood outside her door and the intern said, “Now, I don’t want to say it’s cancer just yet because we don’t have a biopsy yet proving that it’s cancer.”
“OK,” I said haltingly, “so should we defer to the urologist in case she asks?”
“Yeah that seems reasonable,” the intern said as we walked into her room. Halfway through the intern’s explanation to the patient and her family, his pager went off and he exited the room. I was left to finish the conversation. I reiterated again what the imaging showed — “a mass” — as well as our team’s next steps for the day. “Do you have any questions for us?” I said, dreading what she would inevitably say next.
She asked some questions about her pain and tried to show a calm demeanor, but her eyes betrayed her. She was scared, but she didn’t want to say it. The 'C' word.
I was still alone, and so I stammered my way through an explanation. “I know you may be worried whether this mass could be a… cancer, or something else, and I’m sure you have lots of questions but I’m afraid I’m going to have to defer to our urologists who can give you a better answer–"
Just then, a resident walked in, his white coat labeled “Urological Surgery.” Grateful, I excused myself and stepped out. Why did that feel so wrong? I thought. We all think it’s cancer. Why couldn’t I have just said it? For the rest of the morning, I went back and forth in my head. Perhaps it was better to keep the patient’s hopes up. Plus, if we were wrong we would have unnecessarily caused distress and anxiety for the patient, not to mention her family. But isn’t that another form of medical paternalism, to deny patients the right to know what we’re thinking?
A few months later on my urology rotation, I watched as a resident finished a cystoscopy on a black American man and asked her whether she would tell the patient and his family that his findings could be bladder cancer. She said almost immediately, “Of course I would say that I’m concerned about cancer.” She further explained, “When my grandfather had pancreatic cancer it took me at least a year to figure out that the doctors thought it was cancer. It was so frustrating to feel in the dark.” I found myself nodding in agreement.
The next day, I met with a patient and her husband who were referred to my preceptor — a urological oncologist — for an 8 cm renal mass. The chances of it being malignant were 99.99%, of course, but without a biopsy there was no way to know for sure, which was why she was referred to the clinic. She conversed easily with me as I gathered her history. Unlike my other patient, she did not have any signs that anything was wrong. “I just get a little bit of pain in my back and side, but it comes and goes.”
After I finished the interview, I said, “I’m sure you have questions about the next steps. In general there are several options we have for your kidney cancer, such as taking a biopsy or doing surgery to remove it.”
She and her husband looked shocked. “Wait, this could be cancer?”
Oh no, am I the first one to tell them? I replied, slowly to make sure not a word was missed, “Well, you were referred to us by your kidney doctor because they were concerned that the mass could be cancer. And indeed, there are a couple concerning findings like the size and how it looks on the CT scan that are consistent with a cancer. However, we don’t know for sure whether it’s cancer because we don’t have a biopsy yet.”
I finished the conversation, reassuring them that my preceptor and I would be back to discuss in greater detail. She sat in her walker trying hard not to cry, and I exited quietly to give them space to take everything in. That didn’t feel right either, I thought, to catch a patient by surprise like that. Could I have done anything differently?
I presented the patient’s case to my preceptor and added, “They seemed pretty surprised that this could be kidney cancer.” I paused, waiting expectantly.
“I’m not surprised,” he responded, “You won’t believe the number of patients who get all the way here — to a cancer hospital — and are totally shocked about the reason why they’re there. She unfortunately has a lot of comorbidities and is not a great surgical candidate, so we’re going to do a biopsy first just in case it’s benign.” We went into the room together and I watched as my preceptor gently broke the news again, extending tissues and reassuring the patient as she started crying.
Perhaps this was the most important lesson I’ve learned in my third year of medical school —our responsibility to patients is ultimately to guide them, to use our knowledge and training to lead them through difficult diagnoses and to wade through the uncertainties of life. Telling bad news is never going to get easier, but my hope is that I will not shy away from these difficult conversations.
Image by April Brust
