Don't Mention It

DOI: 10.1200/JCO.2008.17.7238 Off our starboard beam, Beavertail Light beats its perpetual reassurance, blinking through twilight and swirling mist. At the sight of its flashes, my friend and I relax for the first time in hours. Even though salt spray still pecks at our skin, wind still shrieks through shrouds and strains sails, and our boat’s heavy keel heels sharply despite reduced canvas, we are almost safe. My friend and I are pushing his sailboat hard into the mouth of Narragansett Bay, but we are not racing in out of recklessness. The sea is vast and tireless. We know its power well, and are hoping to avoid a sleepless night offshore, pounded by the squalls of a rising gale. Like careless children, we’ve spent this day of brisk winds and growing swells enjoying weightless plunges into wave troughs, taking turns sprawled across a bouncing foredeck. The ride was so much fun that we stayed out later than planned. Now, the sea is catching up to us, its wild foam menacing in the gathering dark. This is not the first time my friend and I have courted trouble by coming home after hours. When we were boys growing up in the same small town, extra-inning sandlot ballgames often brought us back to our kitchens long after supper had gone cold. Once we were grounded for building boulder forts in the woods, because we stayed out until the darkness was so thick that we couldn’t find the trail back home. Despite differences of temperament that became clear over time, we still enjoy each other’s company enough to meet regularly, to catch up, and to indulge in grown-up adventures like this sailing trip. He works in tall buildings in Manhattan, moving money and making money in ways I’ve never quite grasped, despite his patient explanations. Whatever he does is lucrative enough to fund an offshore cruising sailboat with all the trimmings. For almost 20 years he has been married to a witty woman with piercing green eyes, who (unfairly) looks just as fair as she did the year we graduated— the year when I was the third to ask her to a school dance, meeting the same fate as the first two while she held out for him. And to my great sadness, I have just learned from another old friend—a reliable gossip—that he has incurable cancer. We have spent the past 2 days together in close quarters on his boat, but the topic of his diagnosis has not come up. He shows no signs of being ill. His forearms are still thick with muscle, which bulges whenever he grinds at a winch or pulls a line taut. I’ve seen no tell-tale biopsy scars, no bloody sputum quickly concealed in a handkerchief. He has not mentioned his disease; I have not probed. Could my informant have been wrong? No, there is no precedent for that—and any doubts were erased by the dullness in his wife’s eyes and by her half-knowing, half-pleading glances when we all met at the airport. Later, when I thanked my friend for allowing me to enjoy a few days on his boat, he looked me straight in the eye and said, “Don’t mention it,” which I heard as more than a pleasantry. Does he suspect that I know? Why hasn’t he said anything about his cancer? Some people might answer this by burdening him with a label cribbed from the jargon of psychology. And perhaps the labelers are technically correct: maybe my friend truly is “in denial,” “avoidant,” or “displaying immature coping mechanisms.” But there seems no need to judge him so. This trip seems as valid and healthy a coping mechanism as my writing about it. My friend knows perfectly well what I do for a living. He knows that I could marshal experts, steer him toward the most promising clinical trials, or at least listen in the practiced way of one who does not panic when cancer is mentioned. But he has his own resources. This weekend he has trusted me to be his sailing partner, not his doctor. Today he wants his sails trimmed properly and a steady hand on the helm, not an unsolicited medical opinion. His silence is not because we are not close. Nor have we skirted this difficult subject because we are locked into macho expectations—devotees of the Neanderthal school of male-male interactions. We have talked honestly and openly about many awkward or painful matters over the years, the worries and sorrows of modern life—overdue promotions, impossible coworkers, fears of betrayal, relentless work demands. The unspoken rule is that we bring these things up on our own time. Every doctor faces difficult, awkward times when friends and relatives become ill, especially JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 18 JUNE 2