When Breath Becomes Air(20)

“Did anyone tell you what the MRI showed?” I asked.

“No.” The buck had been passed, as it often was with difficult news. Oftentimes, we’d have a spat with the oncologist over whose job it was to break the news. How many times had I done the same? Well, I figured, it can stop here.

“Okay,” I said. “We have a lot to talk about. If you don’t mind, can you tell me what you understand is happening? It’s always helpful for me to hear, to make sure I don’t leave anything unanswered.”

“Well, I thought I was having a stroke, but I guess…I’m not?”

“That’s right. You aren’t having a stroke.” I paused. I could see the vastness of the chasm between the life she’d had last week and the one she was about to enter. She and her husband didn’t seem ready to hear brain cancer—is anyone?—so I began a couple steps back. “The MRI shows a mass in your brain, which is causing your symptoms.”



Silence.

“Do you want to see the MRI?”

“Yes.”

I brought up the images on the bedside computer, pointing out her nose, eyes, and ears to orient her. Then I scrolled up to the tumor, a lumpy white ring surrounding a black necrotic core.

“What’s that?” she asked.

Could be anything. Maybe an infection. We won’t know till after surgery.

My inclination to dodge the question still persisted, to let their obvious worries float in their heads, unpinned.

“We can’t be sure until after surgery,” I began, “but it looks very much like a brain tumor.”

“Is it cancer?”

“Again, we won’t know for certain until it is removed and examined by our pathologists, but, if I had to guess, I would say yes.”



Based on the scan, there was no doubt in my mind that this was glioblastoma—an aggressive brain cancer, the worst kind. Yet I proceeded softly, taking my cues from Mrs. Lee and her husband. Having introduced the possibility of brain cancer, I doubted they would recall much else. A tureen of tragedy was best allotted by the spoonful. Only a few patients demanded the whole at once; most needed time to digest. They didn’t ask about prognosis—unlike in trauma, where you have only about ten minutes to explain and make a major decision, here I could let things settle. I discussed in detail what to expect over the next couple of days: what the surgery entailed; how we’d shave only a small strip of her hair to keep it cosmetically appealing; how her arm would likely get a little weaker afterward but then stronger again; that if all went well, she’d be out of the hospital in three days; that this was just the first step in a marathon; that getting rest was important; and that I didn’t expect them to retain anything I had just said and we’d go over everything again.



After surgery, we talked again, this time discussing chemo, radiation, and prognosis. By this point, I had learned a couple of basic rules. First, detailed statistics are for research halls, not hospital rooms. The standard statistic, the Kaplan-Meier curve, measures the number of patients surviving over time. It is the metric by which we gauge progress, by which we understand the ferocity of a disease. For glioblastoma, the curve drops sharply until only about 5 percent of patients are alive at two years. Second, it is important to be accurate, but you must always leave some room for hope. Rather than saying, “Median survival is eleven months” or “You have a ninety-five percent chance of being dead in two years,” I’d say, “Most patients live many months to a couple of years.” This was, to me, a more honest description. The problem is that you can’t tell an individual patient where she sits on the curve: Will she die in six months or sixty? I came to believe that it is irresponsible to be more precise than you can be accurate. Those apocryphal doctors who gave specific numbers (“The doctor told me I had six months to live”): Who were they, I wondered, and who taught them statistics?



Patients, when hearing the news, mostly remain mute. (One of the early meanings of patient, after all, is “one who endures hardship without complaint.”) Whether out of dignity or shock, silence usually reigns, and so holding a patient’s hand becomes the mode of communication. A few immediately harden (usually the spouse, rather than the patient): “We’re gonna fight and beat this thing, Doc.” The armament varies, from prayer to wealth to herbs to stem cells. To me, that hardness always seems brittle, unrealistic optimism the only alternative to crushing despair. In any case, in the immediacy of surgery, a warlike attitude fit. In the OR, the dark gray rotting tumor seemed an invader in the fleshy peach convolutions of the brain, and I felt real anger (Got you, you fucker, I muttered). Removing the tumor was satisfying—even though I knew that microscopic cancer cells had already spread throughout that healthy-looking brain. The nearly inevitable recurrence was a problem for another day. A spoonful at a time. Openness to human relationality does not mean revealing grand truths from the apse; it means meeting patients where they are, in the narthex or nave, and bringing them as far as you can.



Yet openness to human relationality also carried a price.

One evening in my third year, I ran into Jeff, my friend in general surgery, a similarly intense and demanding profession. We each noted the other’s despondency. “You go first,” he said. And I described the death of a child, shot in the head for wearing the wrong color shoes, but he had been so close to making it…Amid a recent spate of fatal, inoperable brain tumors, my hopes had been pinned on this kid pulling through, and he hadn’t. Jeff paused, and I awaited his story. Instead, he laughed, punched me in the arm, and said, “Well, I guess I learned one thing: if I’m ever feeling down about my work, I can always talk to a neurosurgeon to cheer myself up.”