In what medical circumstances might someone with a terminal cancer diagnosis not appear obviously sick?

April 18, 2010 11:35 AM

In what medical circumstances might someone with a terminal cancer diagnosis not appear obviously sick?

In a story I'm writing, I'd like a character facing death by cancer in 6 months or less to be able to conceal that fact from a new acquaintance. So their current circumstances should include neither startling gauntness nor chemotherapy recent enough to interfere with a normal female hairstyle. Surgical scars covered by clothing or sudden bathroom visits for vomiting would be OK.

posted by Joe Beese to health & fitness (21 answers total)

An inoperable brain tumor.

In such a case it's not so much that the tumor in early stages is causing trouble, as that it cannot be removed or directly treated (e.g. with radiation) without causing intolerable damage to the healthy parts of the brain.
posted by Chocolate Pickle at 11:41 AM on April 18, 2010 [1 favorite]

Lung cancer has few or no symptoms for a very long time. That's one of the reasons it's so deadly; it doesn't even cause pain.
posted by Chocolate Pickle at 11:43 AM on April 18, 2010 [1 favorite]

In a lot of cases the obvious outward signs (weight loss, hair loss, skin damage, etc) are the result of the treatment (chemotherapy, radiation) rather than the disease. So if your character refuses treatment then depending on the particular cancer she might go precipitously from visibly healthy to deathly ill after a few months.

One off-the-cuff example might be a tumor that eventually closes off the airway. So long as she wasn't especially physically active she might not have any outward symptoms until near the very end when breathing would become extremely difficult and finally impossible.
posted by jedicus at 11:46 AM on April 18, 2010 [1 favorite]

Sort of depends how you want to frame it. I'm not a doctor person but I'm related to someone with incurable cancer. And she doesn't look sick. When her medicine stops working -- which it will eventually but we don't know when, could be months, could be a decade -- she'll likely go downhill quite quickly. However, until that point she looks like anyone else with the exception of a small rash which is a symptom of her medicine's general toxicity. She also has other symptoms like some neuropathy and I'm not sure what else. Her last chemo was a long time ago. Modern medicine can mean that people live with cancers that would have killed them dead even five years ago.

So I'm not totally sure what your scenario is. Does she know she'll be dead because her cancer is not just incurable but also untreatable? Like some sort of brain tumor or something? Do you know she's dying but she doesn't? Could she not know she has cancer? Because the easiest way for this to go down is for her to have some sort of cancer she doesn't know about [not that much of a stretch] and have it metastasize and spread through her system before she knows she has it.
posted by jessamyn at 11:48 AM on April 18, 2010 [2 favorites]

It is entirely not uncommon for people with many forms of late-stage cancer to not know it themselves until the last 6 months of life. If this weren't the case, we'd be catching more cancers and treating them successfully before the prognosis became so grave. This is one of the many awful things about cancer.
posted by drpynchon at 11:49 AM on April 18, 2010 [1 favorite]

Some people choose not to continue with chemo when they know it will only make their remaining time alive more painful, and a good deal of the visible "cancer symptoms" (hair loss, nausea) are really symptoms of chemotherapy. I've never known someone with terminal cancer who chose to stop chemo until they already looked very emaciated, but if your character chose to stop or never undergo chemo, she could at least reasonably have hair. People who are regrowing hair lost due to chemo tend to have coarse, frizzy, fluffy hair for a while, so you might want to take that into consideration.
posted by oinopaponton at 11:51 AM on April 18, 2010 [1 favorite]

jessamyn: "Does she know she'll be dead because her cancer is not just incurable but also untreatable?"

I was thinking maybe she'd had chemo a few years earlier and wasn't willing to go through it again now that the cancer had recurred. But the particulars of the certainty are less important than the certainty itself.
posted by Joe Beese at 11:53 AM on April 18, 2010

My father-in-law had a terminal brain tumor. After they discovered it, he lived for another 10 years or so. The only difference towards the end was behavioral, not physical.
posted by lizjohn at 12:01 PM on April 18, 2010 [1 favorite]

Quite easily. The daughter of someone I know was diagnosed on November 25th last year with lung cancer (she didn't smoke) and died on December 14th. Her initial symptoms were a pain in her shoulder. She wrote a blog.

Christ, it's just as sad reading it again.
posted by MuffinMan at 12:23 PM on April 18, 2010 [4 favorites]

My father had leukemia and went through chemo and aside from tiredness and a port installed in his chest there was no other outside indications. Even at the end he looked relatively healthy. His hair did thin some but not enough that you would automatically think OMG cancer death! I imagine you could write the character's reaction to chemo in anyway you wish as it seemed to me effect each person individually at the cancer clinic.
posted by kanata at 12:43 PM on April 18, 2010 [1 favorite]

When my daughter was diagnosed with brain cancer, up until the moment the brain tumor was found they said "She's fine, she has no symptoms, can't be cancer." On the day it was discovered, she was smiling at her pediatrician, who had just given her the "all clear" at a well baby visit. Had we not caught it that day and scheduled surgery, the neruosurgeon later said, she would not have survived the weekend. Shortly after recovering from her first brain surgery, she was given a 6-weeks or less prognosis, during none of which time did she appear sick. During the majority of the following 8 month battle with brain, spine and kidney cancer, you may not have known she was sick.

Many times cancer diagnoses that are ultimately terminal go unnoticed by doctors (google results page). Some cancers are treatable if caught early, and terminal once metastatic or otherwise advanced. Accordingly, I think there is a very wide range of circumstances that could result in someone receiving a 6-months-or-less survival prognosis while not appearing ill.
posted by bunnycup at 12:50 PM on April 18, 2010 [1 favorite]

I was thinking maybe she'd had chemo a few years earlier and wasn't willing to go through it again now that the cancer had recurred.

This is fairly credible. Some cancers respond only to a limited number of chemotherapeutic agents. Resistance develops, meaning that the drug that worked the first time, usually will not the second time. If new drugs to which the cancer response are not available, your character may have exhausted the chemotherapy choices available to her. This was the case with my daughter, where a combo of Methotrexate, Vincristine, Cisplatin, Cyclophosphamide and Vinblastine worked well, and we got her cancer down to almost nothing. We could only do that so long, however, and when the next phase of drugs was tried, which was a combo of Topotecan and Cyclophosphamide, the cancer came back quickly. On December 19, she had a good MRI - not clean, but close. On December 26 we started that second phase. On January 17, we had to do an emergency MRI and found out that it was not working. We asked to go back to the first phase - the first group of drugs I mentioned - but could not do so. The new cancer growth would be forming from the cancer those drugs hadn't killed off, meaning it was resistant to them. So that was that, we were out of options.

Further, there are lifetime maximums on the number of times radiation - particularly full craniospinal radiation - can be given. So, if someone had aggressive brain radiation in the first treatment cycle, they might not be able to have it again years later. Exceptions abound, especially now with the gamma knife and different kinds of radiation that spill less excess doses into healthy tissue, but in general you could create a credible case where the cancer returned and either (a) no more realistic treatment options existed, or (b) the individual felt the cost - in quality of life - and benefit - if chance of success were very, very low - didn't warrant the attempt at treatment.

All I ask is that you treat this subject with grace and respect. Of course I have no reason to believe you plan to do otherwise, but nevertheless I ask it. If you don't intend to do so, I would ask that you not use my comments, and consider others' suggestions instead.
posted by bunnycup at 1:02 PM on April 18, 2010 [1 favorite]

Assuming that your character has chosen palliative care over chemo, the only noticeable sign might be things like a bit of difficulty breathing (assuming it's lung cancer, which is where a lot of cancers that start elsewhere seem to metastasize), a general lack of energy, and lots of powerful painkillers lying around the house (fentanyl lolipops, fentanyl patches, liquid morphine in the 20oz bottle, etc).

A friend of mine had a soft-tissue sarcoma that he didn't know about until he got a DVT on a long flight, which was really unusual for a guy in his 20s who wasn't more than 30-40 lbs overweight. The cancer was about the size of a tennis ball, and had already metastasized into the lungs. When he was diagnosed, the doctors said ~3-6 months without treatment, maybe. As it was, he got two and a half years after operations, radiation, and 18 rounds of chemo. Had he chosen palliative care from the beginning I doubt anybody would have been able to tell that he was dying (modulo the effects of the DVT), and other than the DVT the chemo was far more painful and draining than the disease was until the last couple of weeks. I was one of his primary caregivers, so if you've got any questions about specifics, there's an email address in my profile.
posted by hackwolf at 1:05 PM on April 18, 2010 [1 favorite]

I have direct experience with people who were not diagnosed with skin, lung, breast and ovarian cancers until they had reached stage 4. All were essentially asymptomatic until their diagnoses. As others have said in this thread, most of the symptoms we are familiar with from popular media come from treatment, not the cancer itself.
posted by zarq at 1:16 PM on April 18, 2010 [1 favorite]

bunnycup: "All I ask is that you treat this subject with grace and respect."

I hesitated to ask the question out of concern for what were bound to be people's painful memories on the subject. But the answers have confirmed my suspicion that I knew even less about cancer than I thought I did. So I sincerely thank all the contributors for making it an educational experience - especially if any chafing of old wounds was involved.
posted by Joe Beese at 2:31 PM on April 18, 2010

My cousin's wife had stage IV bowel cancer which has spread to her liver and lungs (that we know of). She was married for about one month before she died and she was in her early 30s.

Apparently the main reasons it wasn't discovered is that young bodies hide the symptoms for a long time so when its' discovered it's more advanced, and because she was also pregnant they had attributed the symptoms to that.
posted by holloway at 2:32 PM on April 18, 2010

Just to expand on something that bunnycup mentioned: for certain kinds of cancer, doctors may expand their chemotherapy repertoire to drugs that work on others. This is extremely common in the treatment of ovarian cancer. For a variety of reasons, despite the fact that ovarian is quite a bit more deadly than breast cancer, it gets only a small percentage of the funding that goes to breast cancer research. This has meant that more drugs have been developed in the pursuit of attacking breast cancer tumors than ovarian.

If the standard handful of drugs developed to fight ovarian cancer prove ineffective - either due to resistance buildup over time or other reasons, patients with ovarian cancer are often given drugs which were originally developed to fight breast cancer, to varying effect. The chemotherapy drugs may be given in combination, or with other drugs (steroids, etc,) to help absorption. (Not all chemotherapy drugs are easily absorbed by the body.)

Also, patients with recurring tumors may be put on a chemotherapy maintenance dose regimen for the rest of their lives even if they are asymptomatic. This would entail taking a certain amount of a given chemotherapy drug or cocktail daily, weekly or monthly.

I may be able to expand upon these points (or even others) a bit if you have more specific questions.
posted by zarq at 2:55 PM on April 18, 2010

Brain cancer. Once tumors are removed new ones can grow in their place, and the patient can live years without any obvious symptoms except perhaps behavioral changes like lizjohn said.
posted by vincele at 4:45 PM on April 18, 2010

Randy Pausch had terminal pancreatic cancer when he gave his last lecture, but didn't appear obviously sick to me.
posted by cosmic.osmo at 10:15 PM on April 18, 2010

One of my clients is dying (6 to 9 months) of cancer. When I first met her 2 months ago I would never have guessed it. She was wearing a wig but I didn't even notice it until she wore a pink one. Her cancer was stage 4 and metastasized through her abdomen when it was found in the fall. The hair loss is from the radation but is hard to spot. Sometimes I even forget that she's dying when we are together. So, yes someone could be dying and not look it.
posted by saradarlin at 10:29 PM on April 18, 2010

All I ask is that you treat this subject with grace and respect.

I hope this isn't a derail, since the secondary topic is Joe Beese's character, but I guess I'm not sure what sort of grace and respect you could treat cancer with that you wouldn't (or shouldn't) treat dying in general with. Dying young from cancer is still dying, and I don't think there's anything about cancer that makes it more deserving of respect than other terminal diseases. In my experience, it's the dying that matters more than what you're dying from - the mechanics differ but the end is the same and suffering is suffering is suffering. I like to see characters treated as people, with all of the warts and fears and neuroses and sexual hangups and inappropriate laughter that come with being human, cancer or no cancer. My friend didn't become a cancer victim when he was diagnosed; he was still my friend, just with cancer and a lot less hair. He hated cancer, and he never treated it with respect. Denial - boatloads. Anger, yup. Later on, lots of humor; he had some wicked funny cancer jokes. Plenty of fear and insecurity and more than a few regrets too, and occasionally he could be a more than a bit of a dick. When he went into home hospice care, he wasn't a cancer victim either; he was my friend, one who wasn't buying any calendars for next year and who had some outrageously good drugs. Now that he's dead, he's still my friend, but he doesn't tell many jokes, and he sits in a box in a little shrine instead of in the second bedroom.

I don't have the gumption to edit that, so I suppose I'll throw it against the green and hope some of it sticks. If treating cancer with respect means treating people with cancer like people, with cancer, then I'm all for it, and my apologies for the mawkishness.
posted by hackwolf at 3:54 PM on April 19, 2010 [1 favorite]