It is not easy for a doctor to tell someone, "It's cancer."
But should the doctor break the news on the telephone?
This is a time when the patient is possibly alone, often completely unprepared and unable to work through the questions and emotions that instantly surface.
Margie Fire, a Washington fitness instructor, says, "I had cancer twice. Cancer of the cervix in 1980 and breast cancer in 1982. And both doctors gave me the news on the phone."
"The first time I was at work" -- she lived in another city in both cases; she was 34. "The doctor called me and said, 'Your Pap test came back positive.' I said, 'Positive what?' He said, 'Positive cancer.' I went into shock."
Then "all I could hear" as the doctor continued to talk was phrases with no meaning. "He started using big words like hysterectomy, and words I didn't understand. I'd always considered myself healthy. This man was telling me I wasn't . . .
"I hung up. I sat there just like a statue for a while."
She felt resentful. "I was called on the phone, the cold phone! I did not even have the right to be called into the doctor's office so he could tell me with sincerity, with emotion. If he called you into his office, at least he could hold a hand and say, 'I'm sorry.' "
Yes, she concedes, she did ask for the test result on the phone, but "he could easiy have said to his nurse, 'Call her and tell her I would like to see her in my office.' "
Two years later much the same thing happened, with another doctor. This time she was at home, she says, when a surgeon told her the biopsy of a lump in her breast was "malignant." "I asked him if that meant I had cancer." He said yes. "And I went nuts. I was just a basket case all over . . . I almost had a nervous breakdown."
The doctor in this case tells the story a bit differently: "I felt we had to act immediately . . . I did not call up and tell her, 'You've got cancer.' I told her I needed to see her at my office that afternoon if at all possible. She managed to put me on the mark and asked, 'Do I have cancer?' "
At first, he says, he tried saying, "We have an unexpected report with bad news," but she answered, "Do I have cancer or don't I?" -- a situation, he says, where "she's over 21, I'm not going to lie about it."
That position seems at least understandable. Still, she understandably maintains, "We shouldn't be told we have a disease over the cold phone. If doctors can read this and realize we are human beings, maybe they'll be more sensitive."
Natalie Davis Spingarn is a Washington medical writer who has made an outstanding new medical training film, "Patients and Doctors," for the American Cancer Society. (The society says its area chapters will have the film for distribution next month.)
Spingarn herself had a breast cancer in 1974. It spread to her spine three years later and, despite treatment, continued spreading. She had another breast cancer and a second mastectomy in 1981.
When she had the second breast cancer -- as she tells the story in the film -- "it was difficult to diagnose" and the pathologists went "back and forth," but "finally my doctor called me up and over the telephone said to me, 'Well, it's decided.
You have another malignancy . . . You have one year, maybe two.'
"You know, over the telephone!"
Of course, she adds, his forecast was untrue. Five years later she is still working and writing.
In the film -- in a sequence shot at Memorial Sloan-Kettering Cancer Center in New York -- she tells the story while sitting in a circle of women, all cancer patients, sharing experiences.
Another woman says: "I was told over the telephone, too. I had gone for a mammogram, and the secretary called and said, 'There's a suspicion of cancer. We want you to come in.' It's not the kind of news you get over the telephone."
How can a doctor handle this problem? Especially when even a tentative suggestion of cancer by telephone can inevitably lead to the patient's demand -- 'Do I have cancer or don't I?' -- and a shocked response when the answer is "yes"?
Some doctors say that whenever they order any test or X-ray that might reveal a cancer, they have the patient make an appointment then and there to return, eliminating the need for a phone call.
Some doctors dissemble a bit. I asked Dr. Milton Seifert, a suburban Minneapolis family doctor who consults with his patients on the whole management of his practice, how he handles this hard problem. "Supposing I have an abnormal Pap smear," he said, "and I think it's a cancer and I can prove it in the lab. I'd have one of the staff call and say, 'The doctor wants to double-check that test.'
"Then, when the woman comes in, I'll say, 'Here is what the result looks like, here's what it means and, right away, here are the next things we are going to do.'
"Then I'll let the emotions explode if they have to. The crying or just being quiet for a while. The important thing for me is just to be there for what happens.
"And then see how else we can be helpful, because curing isn't the only thing we can do."
Of course, he adds, "When a patient says on the phone, 'Was it cancer?,' I've got to tell the truth. I can hedge, but not much."
In the main: "One of the best rules of thumb for me is, 'How would I want my family treated? Would I want my wife told this way?' If it's a close friend, you wouldn't do it on the phone."
There are other circumstances, too, he says, when it can be necessary or acceptable to give bad news on the phone. There is no one way to do anything.
But usually, says Dr. Barry Smith, president-elect of the D.C. chapter of the American Academy of Family Physicians:
"I'd get the patient back in to see me. I'd call and say, 'I have some lab results I'd like to discuss with you. Come in and talk to me.' Then I bring them into my private office, rather than an examining room, and tell them the facts and their meaning.
"I think that's better than telling it on the phone. They may have no one there to help them. And if they're here, they can question me. They can cry, and that does happen. And no matter how much time it takes to talk it through, I'll take the time."
Next Week: Getting along with today's doctors.