Cases: Afraid of the Worst

One day on hospitalist rounds, I saw the ER had left me an admission from 2am. The sign-out read: "63 year old woman with large breast mass." I wasn't sure what that meant. Perhaps a breast abscess?

The truth was a bit more complicated. I could tell when I entered her room and introduced myself. She emitted an odor I can only describe as living decomposition. A syrupy, cloying smell reminiscent of rotting meat, only worse.

I asked her why she came to the hospital. She said she'd been feeling tired. A quick peek at her labs revealed a likely cause of her fatigue: a hematocrit of 18. This morning she was feeling much better, after having received four units of blood.

Why did she think she'd lost so much blood? She had no idea. Had she noticed any blood in her stool, or tarry stools? No. Any blood in her urine? No. Had she recently started menstrual-like bleeding again? Oh no, that ended years ago.

I took a deep breath before I asked about the breast mass. I knew this was going to be bad. "I understand you have a lump on your breast," I said. "May I look at it?" She agreed.

I undid her hospital gown and removed several layers of dressings. Underneath was a fungiating breast cancer that was weeping bloody fluid. The entire breast was hard and immovable. I could feel firm, lifeless tumor extending up and beyond her clavicle and laterally to her axilla. Even her shoulder and upper arm felt hard, as though replaced by plastic under the skin. The skin itself was dark, florid purple.

I redressed the tumor and sat back. I looked at her for a moment. She was an extremely well put-together older woman, rather distinguished looking, with white hair swept neatly into a chignon. "Do you see a doctor regularly?"

"No."

"Have you ever seen a doctor about this lump?"

"No."

"Did it ever occur to you that this might be something that needed medical attention?" I asked. Now that I'm writing about this, the question seems mean-spirited, but I really, really wanted to know.

"Well, yes, it did," she said matter-of-factly. "But I still decided not to go."

"Why?"

"Because I was afraid of the worst."

"I see."

She was a very private person, she explained to me. She didn't want anyone to know. Her entire family, including adult children, didn't know until today. She didn't think it was troublesome to have a tumor erupting from her chest. The only problem it caused was how long it took to cover up every morning after she took a shower. Forty-five minutes to cover it up with gauze and sanitary pads and tape.

I returned to her room later with one of the surgeons. He confirmed my suspicion that the cancer had extended locally into the axilla and most of the upper extremity. To resect the tumor, he'd have to amputate her arm at the shoulder, and this was unlikely to be curative because--he suspected--she probably had distant metastases.

Her husband was weeping in the hallway. "I didn't know," he told me. "I know she...had a smell, but I thought it was the herbal tea she's been drinking."

I was lightheaded for several hours after being in her room so long, faint and nauseated from the smell of her wound. I thought: She was afraid of the worst, and she found it.

Comments

[Doc]

Poignant story!
I'm not sure if this is as much denial as ignorance. She acknowledged being "afraid of the worst", and is probably unwittingly correct about the likelihood of any curative treatment once the tumor was protruding from the skin. I suspect her ignorance was regarding understanding available palliative treatments and what the end result would be like without any such care.
Not wanting to be a burden is also a powerful motivating factor in this demographic when it comes to not seeking treatment.
Families should encourage those of this generation to have routine care, and that they are not a burden for doing do, even if their worst fears are realized.

[enrico]

I had a similar olfactory experience with a pt w/a maggot-infested venous statis ulcer, and he too didn't think it was a big deal because it "didn't hurt." There is a commonality women of that generation have especially about not bringing up things for fear or embarrassment or having to be the recipient of attention (as if that was a bad thing!) I suppose borne out of an era of expected total self-sacrifice. I know it's generalizing, but I've heard so many stories in this exact same way, sometimes presenting for something else (a fall, then breast="Oh, that's nothing")

I hope the time she has left is made comfortable for her and is easier without the burden of secrecy.

[Eric]

Denial is remarkably powerful. Even smart, insured women can end up in straits like this.

What's really tragic is that we've changed 'the worst' into what, in many cases, is a pretty manageable chronic condition. When my mom was diagnosed, five-year survival was about 5% for her histology and staging. Now, it's 95%. A reversal in 25 years. Many, many women are laboring under a tragically dated image of what it means to survive breast cancer, and that saddens me.

[Leigh Ann]

My gosh. How devastating. Her poor husband.

The things you doctors see are just astonishing.

Leigh Ann Hubbard
Managing Editor
James Hubbard's My Family Doctor

[Jessica Bond]

Wow and I thought that I had seen it all when I managed a county, teaching hospital ER. Denial is a powerful emotion.

Powerful story!

Jessica Bond
Medical Careerist