When the Patient Says No

I was recently consulted in the hospital about abnormal computed tomography (CT) scan findings showing concern for metastatic disease. I have learned that this doesn’t always mean cancer, but findings must be very suspicious for a radiologist to say those words. Before seeing the patient, I reviewed the chart and looked at the images. I agreed—the scans did not look good; I called the radiologist, and he stated that it looked like it was coming from the kidney or the lung. Before entering the room, I first discussed with the nurse to check if I was the bearer of bad news, as I often am. When I went into the patient’s room, I saw a man who was relatively young and very healthy. He had multiple family members by his side, and as it turned out, he had already been briefed on the results of his CTreport. I reviewed his history with himandwhat hadbrought him to the hospital. I reviewedhis risk factors—he had never smoked. I reviewed the scans and then ordered a biopsy of the rib lesion. All that time, I was talking tohim,tryingtosearchforaclueastowherehistumorcamefrom. As all oncologists do, I hope for the best. I close my eyes every time I open a positron emission tomography (PET)/CT scan, as I hope to see a response to treatment. I am not ashamed to say that I wanted an easy path for him, the drug that gives the best response with the fewest number of side effects. In this case, after hearing hewas a never-smoker, I was hoping radiologywas right. If thiswas lungcancer, hewasmore likely to have EGFRor ALK-mutated disease. These patients have three, even four, linesoforal treatmentavailable to them, evenbeforebeing exposed to cytotoxic chemotherapy and the infusion center. I felt like we connected as we talked.We shared a favorite sports team and discussed stories about the legends on that team. He toldme about his kids, his career, and his life. He had amazing stories and a supportive family at his side. When I talkedwith him, hemade it clear tome that hewasn’t ready to die. I kept asking questions, and then I came to this one: Me: “So you never have had any surgery? Nothing?” Him: “Oh yeah, I did have a melanoma removed from my left arm about 12 years ago.” Me: “Oh.” There itwas. It’smelanoma, Ikeptrepeating inmyhead.Still, I didn’t want to lead the patient down that path, not without a pathology report. So I departed the room with a smile and a promise to see him tomorrow after the biopsy was performed. I returned to his room the nextday andwe talkedmore. He was alone this time and showed some fear. I told him this was normal. A cancer diagnosis is a life-changing event, and I was going to be with him every step of the way. It was at this point that I told him therewas a chance this wasmelanoma that had spread and becomemetastatic. I told him that therewas hope and that cytotoxic chemotherapies were no longer the drugs of choice. I explained that immunotherapy has been around longer than I have been alive and that, nowadays, some of the best responses are being seen in melanoma. I called the pathology department that afternoon—the pathologist suspected melanoma. I asked him to add BRAF, a marker for targeted therapy, to the sample so we could have a treatment plan in the next few days. The patient was discharged in stable condition, with a diagnosis pending and an appointment to see me in 2 days. I explained to him that we would plan what to do next when I saw him as an outpatient. He came into the office like any other new patient. He was no longer at a hospital but in a cancer office.The diagnosis was looming. I didn’t mince words or beat around the bush—I told him that it was metastatic malignant melanoma. He seemed stunned, as if he were hoping I was wrong. The truth is, I was hoping I was wrong, too. However, now was the time to start making decisions and moving forward. He told me he wanted to fight, so we discussed treatment options. I recommended immunotherapy, but his BRAF status was still pending so we had time to change our minds. I recommended further workup to complete staging and then planned to start treatment in the comingweek. I sat and answeredquestions, performedmy physical exam, and asked again,“Do you have any questions or concerns?” The answer was no, and we planned his return to clinicnextweek.Hewasagreeable;weshookhandsandhe left. That would be the last day I would see him. He disappeared. He called to cancel his PET/CT. When I heard that, I was concernedbut knewhewas claustrophobic. I spoke to himand told himwe could start treatmentwithout it, although itmight make it slightlymore difficult to follow his disease without the baseline. I suggested we reschedule it, but he was reluctant. I learned later that he did not show up to his treatment teaching session. My office called a few times, and he would answer. Soon he stopped answering; his wife would answer and tell us, “He is not talking to anyone right now.” Then she