Only Patients Can Decide When It's Time to Talk

"Inside every patient, there's a poet trying to get out. My ideal doctor would 'read' my poetry, my literature." - Anatole Broyard

"When did you first notice the sore?" I ask the newly diagnosed cancer patient. I was taught in medical school that a thorough history includes information on the "duration of symptoms." Over the years, I have been amazed how often the answer is: "Doc, I first noticed something about six weeks ago."

Whether the cancer appeared large or small, locally confined or widely metastatic, barely symptomatic or agonizingly painful, the answer was frequently "six weeks."

Early in my career, I didn't believe the "six weeks" response from patients with advanced disease and tended to trust the answer only from those with small cancers. After getting the same reply from so many people, however, I began to wonder which types of patients were most precise. Certainly, cancers can grow at different rates and it takes time to move through the medical system. Still, I often suspected that denial was delaying evaluation and cancer care.

Danielle Ofri, MD, in her wonderful book of medical essays, Singular Intimacies: Becoming a Doctor at Bellevue (Beacon Press, Boston, 2003), tells the story of a prominent psychoanalyst with an unnamed cancer. Over the course of several months, the disease had ravaged his body, destroyed his liver, and had finally landed him, reluctantly, in the hospital. He steadfastly refused to admit that he might have cancer; he was certain that he had a viral infection that would soon resolve.

A few weeks later, he died from the cancer and the zealous attempts to make a diagnosis. Suddenly, Dr. Ofri realizes that this intelligent psychiatrist might have shrewdly used denial to his advantage. He had maintained control for as long as he possibly could by delaying the inevitable hospitalization and medical interventions until he was finally unable to resist.

A short list of explanations for exhibiting denial might include the fear of cancer, a lack of knowledge, legitimate concern about potential medical costs, a sense of guilt, prior experiences with medical interventions, and a host of family and work responsibilities.

Until reading Dr. Ofri's story, I had forgotten that denial could also provide a continuing and powerful sense of control. For some, the decision to relinquish that control marks the end of denial. By the time a patient reaches my office, there has been a transformation. Now, six weeks later, it is time to talk about cancer.

Bruce H. Campbell, MD, FACS
Professor of Otolaryngology and Communication Sciences
Chief, Division of Head and Neck Oncology
Interim Director, Froedtert & Medical College Cancer Center

"Reflections" is a collection of essays by the health professionals of the Medical College of Wisconsin.