Tuesday, September 13, 2005


As she opened her gown, my heart sank. I knew when I first saw her lesion that this was advanced breast cancer and there was absolutley no chance that the tumor was confined only to the breast. Given the size, it probably had already spread to her other organs. Brain. Lungs. Bone. Liver. Who knows where else. Her axillary lymph nodes were matted and hard. This woman had almost no chance at survival.

I felt her breast again. Partly out of disbelief at the size of her mass. Partly out of morbid curiosity. With our advanced technology and imaging capabilities, we rarely see tumors bigger than an inch in diameter anymore. Most are caught early on with mammograms.

Her lesion easily measured at least 7 inches across. And about 5 inches deep. The cancer had grown so much that it ulcerated through her nipple and areola. In fact, she no longer had a recognizable nipple. It was just an ulcerated, bloody, oozing mess. And it smelled like rotting meat.

I looked up at my patient. "How long has it been like this?"

She looked down at her hands, which were folded in her lap, "About a week or so."

I knew that was a lie. This lesion must have been growing for months. A year or more, most likely. I looked at my patient. I could see the fear in her eyes, but more frightening to me was the denial I saw behind her fear.

I looked her straight in the eyes, "Ma'am. This is breast cancer. Unfortunately it's at an advanced stage and I think-"

"No, I don't," she interrupted.

"I'm sorry?"

"I don't have breast cancer. That's impossible." She shook her head and looked off to her left. She wouldn't maintain eye contact.

I tried to explain her condition and prognosis. I tried to explain to her what medical treatments she needed and what surgery I needed to perform. I tried to explain to her the consequences of refusing any medical care.

I tried. But she wouldn't listen.

Arms crossed and gaze shifted, she didn't want to hear her diagnosis. Her level of denial was so strong that I could not even elicit an emotion or reaction when I explained her grave prognosis. "How could that possibly happen when I don't have cancer?"

"But ma'am, you do."

She dismissed me. Chastised me for trying to scare her. Told me that all she needed was antibiotics and her breast would heal. "You are obviously poorly trained and have no idea what you're doing. I don't even know why I wasted my time coming here."

And with that, she got off of the examination table, buttoned up her shirt, and walked out of the clinic.

"Should I go after her?" my medstudent asked.

No. There was nothing we could do. She was in denial. And until she came to terms with her condition and came back for medical treatment, there was nothing we could do.

I let out a slow deep sigh, closed her chart, washed my hands, and walked into the next room. There were more patients waiting to be seen.