A fellow entered the physicians' work room and presented me with the story of our new patient in room 4, a case of "indolent" cancer. The patient was worried, he told me, but he said he gave the patient the good news: "the cancer is indolent." The fellow smiled at me.
By many metrics the fellow was right. Among all cancers, this was generally slow growing. The median life expectancy was measured in years, and the average age of onset was in older Americans. Because of these two facts, many patients lived so long with the cancer, they died of heart disease or a car accident or something else entirely. That is why the textbooks called it "indolent."
But I didn't like to use that word. I didn't try to forecast the future. Particularly for someone with cancer whom I had just met. Yes, I had a world of information -- PET scans, CT scans, biopsies, and molecular testing -- but I didn't have the most important thing of all: time. I hadn't yet followed the person. I hadn't yet observed the behavior of this cancer. I hadn't seen how it responded to treatment. While the cancer might be generally indolent, for the person in my room, I did not yet know if his cancer was.
Like the fellow, I was young once, and I learned my lesson the hard way. A man presented to my clinic years before with an indolent cancer. He told me he was afraid of dying, but the moment I saw the pathology and the scans, I was optimistic like the fellow: the cancer was indolent! Good news. The patient's wife was reassured, but my patient stared off into space. I promised to take care of him as best I could, and tried to help him feel the hope that I felt.
But months later, the cancer had progressed and progressed, and the optimism drained from my face and body. I discussed his case with colleagues and experts, and recommended the best treatments proven with randomized trials. Six months later, my patient was dead. His wife, a widow.
After his death, I spoke to his wife. A long conversation about who he was in sickness and health. Gently, I reminded her of the first visit. I told her that I regretted how optimistic I was. It radiated from my skin. I asked for her forgiveness.
She told me that her husband always appreciated my enthusiasm and the months we came to know each other better. He trusted me. She told me that privately, he knew he was dying. He told her that first night in bed. He felt it in his bones. And my enthusiasm could not shake him from what he knew inside. After we spoke, she forgave me, but I didn't forgive myself. And I became more cautious with my language and demeanor.
So, I told the fellow to sit down, and I pulled up a survival curve for the disease, and I pointed out that he was correct, the median was indeed long, but I asked him to follow the entire curve. In the beginning, right there, you could see it: there was a quick dip. That dip was more precipitous than the survival function for age-sex matched controls, I explained. Yes, most people had indolent cancer, but a few people did not have "indolent" cancer. He said, "I see."
Then I told him the story of my patient. I told him the diagnosis and the series of treatments I recommended. I told him the exact moment when I knew that my patient's cancer was not going to be indolent, and how the optimism drained from my face, and how I felt pain in the pit of my stomach, and I told him what the patient's wife had told me. I told him my regrets.
I saw the blood drain from his face, and he sat up straighter in his chair, and he said, "I see." We walked back into the room and talked to the patient more. The fellow led the conversation, and I could tell he did see.
is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .