DYING WORDS.(increasingly, oncologists must deal with discussions of death with patients)(Brief Article)

Not long ago, I had an appointment with a patient who was likely to die within a year and a half. Maxine Barlow was a twenty-eight-year-old teacher in Boston. The only child of a middle-class family, she had recently become engaged to a financial analyst, Peter Wayland (all names have been changed). One morning in the shower, Maxine found a small lump in her breast, a little larger than a pea. A biopsy showed that it was breast cancer. Further tests revealed that the cancer had spread to Maxine's spine and liver, which meant that surgery could not fully remove it, and Maxine's surgeon referred her to me for chemotherapy.

Maxine and I met on a brisk autumn afternoon. Her appointment was my last of the day, since our conversation was likely to extend beyond the hour usually allotted to new patients. I had to explain the gravity of her condition and the possible choices she could make.

After I had examined Maxine, we were joined in my office by her parents and by Peter. They sat in a semicircle facing me, with Maxine between them. I moved my chair out from behind my desk.

"Let's review what was found at surgery," I began. Maxine reached for Peter's hand. Although I addressed Maxine, I also briefly met the gaze of her parents and of Peter, in order to engage everyone. "The cancer in the breast measured one and a half centimetres, about half an inch, and under the microscope the cancer cells were actively dividing," I said. "They should be treated aggressively. The tests we did on the tumor showed that it is not sensitive to hormones"--which ruled out Tamoxifen, a common hormone-blocker. "The scan showed that several deposits of tumor had spread from the breast to the bones in the neck. There also are four deposits in the liver. We can treat them with chemotherapy, which destroys the cancer cells wherever they might be lurking. The good news is that you stand a very strong chance of going into remission."

"So that means that she'll be O.K.?" Maxine's mother asked.

My stomach tightened in a familiar way. This part never got any easier.

"Remission does not mean cure," I said. "Remission means that all the cancer we can measure disappears. Therapy is palliative."