It looked like the skin of an orange--peau d'orange, in medspeak. My fellow interns and I had heard about it in medical school; some had even seen it before. As our attending physician undraped Mrs. Durante's breast one sunny morning during our first month as interns, we knew that what we were seeing was bad.
Mrs. Durante wore a hospital gown and a brightly colored head scarf. She looked like a child lying in the bed: small, delicate, demure. Her face was pretty, her voice soft and deep. By contrast, the mass rounding out the side of her right breast bulged aggressively. It was firm to the touch, reddish against her olive skin. When asked, she said it hurt.
Timidly, we interns explored its edges with gentle, over-extended fingers. In Mrs. Durante's armpit we felt a nest of firm nodules--lymph nodes nurtured on a diet of cells growing out of control.
Cancer often hides. Here it was thriving in plain sight. To my surprise, Mrs. Durante had an air of calm detachment, as if the breast we were examining belonged to someone else, as if the pain were not her own.
What became evident that morning was not just the power of cancer but the power of denial. Mrs. Durante knew something was wrong, but had hidden it from her siblings, her husband and three children. She'd watched the lump grow under her skin until the stretching and inflammation became too uncomfortable to ignore. Then she'd sought treatment--for pain. Now, her pain relieved, she lay in bed watching TV, calling her friends and family and never mentioning her cancer.
Her hospital stay was short. We made her an appointment with an oncologist, found her a primary-care doctor and sent her home.
Near the end of that year, I arrived at the hospital one morning to find that Mrs. Durante had returned. Reviewing her chart, I learned that despite several readmissions for pain, she'd never visited the oncologist. She'd gone to her primary-care doctor only for pain medicine and had come to the hospital because it was no longer effective.
I was struck by her appearance: At first glance, she looked much as she had at our first meeting. But her bright, multicolored head scarf and shy smile belied the destruction beneath her hospital gown. Examining her, I saw that her cancerous breast had grown larger, more firm and red. Her neck skin was taut with underlying cancer, her belly swollen with metastases.
Why, I wondered, had she not sought treatment? I found her passivity maddening and puzzling. Our initial treatment plan had formed a simple picture of hope--that medicine could conquer her cancer, could restore her. Her denial--of it, of us--had shattered that hope. I could barely hide my frustration.
"Mrs. Durante," I asked, "what do you think will happen if you don't get treatment for your cancer?"
"I just won't be here anymore," she said.
Could dying be as simple as that? I wondered, then pressed on: "And how do you think that will be for your family?"
She only shrugged, with a glimmer of sadness.
I pleaded with her to meet with the oncologists to discuss her treatment options.
"I just want to get my chemotherapy and go home," she said. "I don't want to have to meet first to talk about it."
In my short career, I'd worked with hospice patients. I'd held people's hands as they took their last breath. But never had I felt so acutely that I was watching someone die right before me. I could practically see her disappearing. I wanted to yell at her to come back to reality.
Finally Mrs. Durante agreed to meet with the oncologists. We arranged to discharge her the next morning directly to her appointment in the oncology clinic, downstairs in the same building. I asked her if I could tell her family her diagnosis, and she consented.
They were shocked--and galvanized: They promised to accompany her to the appointment. Relief flooded through me.
The next morning, Mrs. Durante's brother called: they were late, but en route. Mrs. Durante declined my offer to escort her downstairs, so I told her that her family would meet her at the oncology office. Watching her leave, I wondered if I had done enough to corral her into therapy--or if that was even the right thing to do....
Ten minutes later, her sister called. "We just saw Stella walking away from the hospital. Is she finished with her appointment?"
"No," I said. "Can you get her and bring her back?"
Five minutes later, another call. "She says she went to the appointment already and got her chemotherapy."
"No, she didn't!" I said incredulously. "Can you try to convince her to come back?"
Frantically, I called the oncology clinic to say that Mrs. Durante was on her way. They said they would still see her....
The other day, a young lady of sixteen years walked into my clinic room complaining of a sore throat. Her name was Flora. Tall, thin and shy, she wore a head scarf. She had all the symptoms of strep throat: fever, white patches on her tonsils and swollen, tender lymph nodes. While waiting for the strep test result, I asked her who she lived with.
"My stepfather and my brother and sister. You may have known my mother, Stella Durante? She died in September."
For a moment I caught my breath. The image of a bright head scarf and white, sunlit hospital blankets flashed through my mind.
"I did know your mother," I said. "I'm sorry to hear that she died. How have you been since that happened?"
She shrugged. Suddenly, I felt her mother there in the room.
Despite a normal test result, Flora's symptoms convinced me that she should be treated with antibiotics. Because of her age, or because of my memories of her mother, I feared that she might not complete ten days of pills. I recommended a penicillin shot.
Minutes later, the nurse knocked on my door. Flora was refusing the injection for fear of the pain.
I went to where she sat. Seeing her familiar, somewhat blank expression, I felt a surge of alarm.
"I'm sure it won't hurt as much as you think," I said, mustering authority. "Not as much as the sore throat."
I reflected uncomfortably that I wasn't sure this was true.
"If you absolutely cannot do it, I'll give you the medicine by mouth," I finished. "But I really think you should take the shot."
She finally agreed, and I shut the door behind me, praying she wouldn't change her mind.
Later, while writing my notes, I felt the adrenaline rush fading away. A penicillin injection had never felt so urgent. An image of Flora's mother came to mind. She was walking down the street, untreated. I didn't ever want that to happen again.
About the author:
Justin Sanders is a family medicine resident in the New York metropolitan area. "I've always loved writing as a means of expression, but I've sharpened my pen further by writing letters to a long-distance love, who is soon to make me a lucky and grateful husband. When not working, I like looking at contemporary paintings, cooking pizza and reading The New Yorker."