Clinicians identify two distinctly different types of locally advanced breast cancer that involve the skin: “inflammatory breast cancer” and “cancer of neglect.” Inflammatory breast cancer grows like wildfire. A young, vigorous and health-conscious woman may notice some discomfort in one breast and a week later see the telltale pink overlying skin discoloration and even enlargement of that breast. This is a fast-growing cancer that needs prompt and aggressive treatment, which most women quite appropriately seek out. In contrast, women like Mrs. Helversen in my story “Christmas Rose” have carefully noted and concealed their slowly growing tumor, sometimes for years. During that time the tumor, if close to the skin, will grow through the skin and fungate and ulcerate.
In the nonfiction piece “Wind Tunnel” (Intima, Spring 2017) by Kenneth Weinberg, an experienced Emergency Medicine physician deals with neglected disease that fortunately proves benign. In fact, I would argue that both pieces also illustrate that the disease is not actually neglected by the patient, but rather carefully cleaned, dressed, and hidden from others until concealment is no longer possible. Often the patient has spent far more time, effort, and cognitive energy hiding the tumor – and endured significantly greater pain and discomfort – than would be required for humane and careful medical treatment.
What has been neglected, or perhaps deliberately rejected, is the possibility of professional medical care. It seems to me that the tragedy lies in lack of trust – the patient does not trust that our treatment will help, or that it will be tolerable, or that life afterwards will be better than it was before.
And, perhaps, he or she fears chastisement by family or physician, who may well ask (but should not, I believe), “Why didn’t you show me this before?” I believe that we clinicians also miss opportunities. In my story, the nice young doctor doesn’t ask Mrs. Helversen to disrobe. When we listen to the heart or lungs through a layer of cloth, we miss the chance to spot a breast cancer, a melanoma or a basal cell carcinoma. And the question then should not be “Why didn’t you show me this before?” but rather, “You seem to have a sore place here. How may I help you?”
We, as physicians should go beyond “Why do they do this?” to ask, “Where did trust break down?” and, “How may I make myself a worthy recipient of my patient’s deepest, darkest fears?”
Carol Scott-Conner is Professor Emeritus of Surgery at the University of Iowa Carver College of Medicine, where she is a member of the Humanities Council and serves on the editorial board of The Examined Life literary journal. Her monograph, "Medical Writing: Creative Writing for Clinicians", clarifies the distinction between technical writing and creative writing. Her creative work explores the intersection between surgeon and patient, and hopes to illuminate the lives of women in surgery. Her short stories have appeared in numerous small literary journals and she has published two short story collections: A Few Small Moments, and Beachcombings. In “Christmas Rose,” she gives voice to an elderly woman with neglected breast cancer.
© 2017 Intima: A Journal of Narrative Medicine