Cancer. The Big C. No one wants it as a Christmas gift.
Maybe it’s just coincidence, but in the lead-up to Christmas I seem to be delivering this bad news more frequently than usual.
Intriguingly, as with children’s toys, each year there seems to be a particular type that is all the rage. Three years ago, I diagnosed two leukaemias in the week before Christmas. Two years ago it was three breast cancers and, in 2012, it was two invasive melanomas.
Unlike my breast cancer and leukaemia patients, my melanoma patients took the news calmly. Too calmly. They were both unusually blasé, even for middle-aged country blokes.
The first wanted to postpone the treatment of his aggressive desmoplastic melanoma until February, as he wanted to have a knee arthroscopy first.
The second didn’t even want an excisional biopsy until the new year. I had diagnosed his melanoma, with its textbook dermoscopic appearance, clinically.
Understandably, I was keen to remove the little blighter before it got up to more mischief, but the patient had plans to swim at the beach and didn’t want an open wound.
I usually employ a softly-softly approach when breaking bad news, trying to not unduly scare my patients. Wrapped in comforting padding, the “this is serious” message was obviously not being absorbed through either of their thickened, sun-damaged skins.
I was pretty sure neither was in a state of terrified denial; they both seemed genuinely unconcerned.
With the first patient, I worked my way up the scary-statements ladder until he “got it”. It was quite a climb; I even needed to use the word “death”.
With the second, I took an easier route, bringing in his wife from the waiting room and re-explaining the situation. He didn’t stand a chance! The melanoma was excised the following day.
When I saw him after Christmas to do his wider excision, he told me: “You’re too touchy-feely, Doc. You should’ve just said first-up, ‘This mole is deadly. I don’t care what plans you have — it’s coming off right away’. I wouldn’t have argued if you’d put it like that.”
Minutes later, as I sat wondering whether I should be more like Dr House at times, I received a phone call from a very worried daughter of another patient.
“Mum has been beside herself all Christmas. She’s convinced she won’t live to see another one. Getting the cancer diagnosis has completely knocked her for six.”
Puzzled, I reviewed my notes. I’d seen her mother as a new patient a week before Christmas and found a small solid pigmented BCC on the skin overlying L2/3.
I told her that a biopsy would be a waste of time and recommended excision, briefly going through the risks of skin surgery. She didn’t have any questions and the procedure was booked for early January.
I like to think I’m particularly good at reading people but in this case I failed miserably. I had no inkling that what she’d heard was: “CANCER!! On the SPINE! Too urgent to biopsy! Risky surgery!”
I apologised profusely, feeling terrible that I’d wrecked their family Christmas with my careless tossing around of the C word.
The daughter replied, “Oh it wasn’t all bad. Mum finally made amends with her sister after 20 years of fighting, and decided to work through her bucket list, starting with learning how to surf. She loves it!”
So while I’d kept a patient out of the water over Christmas, it seems that I’d inadvertently encouraged another one in. I just hope she slip, slop, slapped.
First published in Australian Doctor on 17th January, 2013: On the Big C