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How Do You Say ‘You Have Stage IV Cancer’?

Angela Harris has been here in the hospital for six hours awaiting the results of her CAT scan. I won’t take responsibility for all of that wait time: complicated CAT scans and labs do take a significant amount of time to perform. But she didn’t need to wait the last hour.

She was waiting on me — her emergency physician — because I needed to confirm her cancer diagnosis with radiology, arrange some oncology follow-up… and find the most appropriate phraseology for, “You have stage IV cancer, but you don’t meet admission criteria.”

I’ve delivered this diagnosis five times this year — and, ironically, always in that room. The cold, narrow one that echoes.

I pause outside of Room 4 and, unseen by anyone, quickly make the sign of the cross. I haven’t been to Mass since Christmas, and my father is Jewish; but for some reason, when I feel overwhelmed, I return to some foundational beliefs to ask for help. I’m about to tell a patient something invasive, painful, and traumatic, so I take a personal time out beforehand as if I were about to place a chest tube.

In situations like this, I fall back on a script. Now, carefully following that script, I walk into the room and intentionally choose my seat. To my right, flush against the wall sits the hospital gurney, a used gown folded neatly over its rumpled white sheets. To my left, in the chair closest to the door, sits Ms. Harris, already dressed.

I head for the empty chair wedged into the corner, murmuring, “excuse me,” as I brush past her in the cramped space. I sit down in the chair and angle it slightly toward her; our knees almost touch.

This is what I say:

“I have the results of the CAT scan. Is it OK to discuss those results with you now?”

Ms. Harris nods.

“When we performed the scan,” I continue, “we saw something that we weren’t expecting to find.”

Her face changes completely. The standard pall of emergency department anxiety disappears; her eyes widen slightly, and her posture becomes perfectly erect. This is what terror looks like.

“The scan showed a mass with a certain pattern,” I say. “I’m concerned that the symptoms that prompted you to come to the emergency department are due to this mass.”

“Is it cancer?” she asks blankly.

I hate the way I say the next part. I haven’t figured out how to be honest without, at the same time, seeming to deliver a death sentence.

“I’m concerned that this mass may be cancer. I can’t diagnose cancer until we have a sample of that tissue and look at it under a microscope. Still, the pattern that we see is a very high-risk pattern.”

Silence. An eternity of silence.

From the corner of my eye, I notice her left hand. It begins to tremble, and she covers it with her right.

It’s at this point, during this kind of conversation, that I become a bit depersonalized. The situation becomes a movie scene to me. It can’t be real: This is too much pain, and the rawness of the situation comes too close to dismantling my appropriate and necessary denial of mortality. It’s human pain, but, for today at least, not mine.

“What do we do now, Doc?” she asks, holding onto her poise. She rapidly blinks her eyes, warding off the possibility of tears.

The conversation continues into territory that’s hard to discuss because of all of the unknowns. I always feel that I’m in way over my head.

“We’re so concerned about the pattern we see today that I’ve called the cancer specialist, who has reviewed the scans,” I say. “We’ve reserved an appointment for you tomorrow so that the next steps can be discussed. Your medical team will go over the tests and treatments with you.”

“So I’m going home today?”

My inner self laments the system. For Ms. Harris, I know, these next days will be full of waiting for results — of having too much time between appointments and no guarantees.

“You don’t need to stay in the hospital,” I say. “Do you have someone at home who can be a support to you? Your sister? I want you to talk this over with her. These next days will be hard, but you have many reasons to be hopeful. Take this one step at a time. Right now, I’ll give you a prescription for some anti-nausea medications and pain medications. Tomorrow, you’ll see the specialist.”

I make myself pause, then say, “You’ve taken in a lot of information. What questions do you have?”

“None right now.”

Feeling embarrassingly relieved, I stand up.

“All right, then; this is the start,” I say. “Please excuse me, I’ll go and get your discharge paperwork.”

She sits still, eyes downcast, waiting for privacy.

Trying not to race for the door, I take an awkward step. Only when I start to lose my balance do I realize that my foot has gotten wedged under the leg of my chair.

I fall forward, and behind me, the chair topples over and hits the floor with a metallic crash.

Ms. Harris laughs. I find myself on my hands and knees directly in front of her, bruised in body and ego.

Bending down from her chair, still smiling, she takes my elbow and scoops me up.

Meghan Gaffney Liroff, MD, is an emergency physician at Henry Ford Medical Center and a volunteer professor at Wayne State University School of Medicine, in Detroit. Her writings can be found in FemInEm, Emergency Medicine News, Annals of Emergency Medicine, and Journal of Emergency Medicine. On Twitter: @gaffmeg.


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