‘Big C’ consultant Dr. Vijay Trisal
Cathy Jamison lived four TV seasons with cancer, a stage 4 melanoma diagnosed at the start of “The Big C” on Showtime; “The Big C: hereafter,” a four-part series, airs Mondays. With Laura Linney in the lead role, Cathy’s reactions, and those of her loved ones, ranged wildly as she learned to live whatever life remained. In the following Q&A;, Dr. Vijay Trisal, a surgical oncologist at City of Hope and the show’s medical consultant throughout the process, talks about some of the personal and social issues surrounding cancer.
What’s the difference between palliative care and hospice care?
When you look at end-of-life care, hospice is more like you are not doing an intervention. You are not doing a surgical intervention; you are saying nothing medically needs to be done. We’re mainly going to focus on pain control … whether hydration is needed or not. And it is toward the latter end of palliative care. Palliative care includes hospice, but palliative care does not mean just hospice.
You can do palliative chemotherapy; you are giving some chemotherapy. You don’t think it will extend life, you don’t think it is going to improve survival, but it may improve appetite. It may improve fluid collection in the body. It might improve mental status.
One of the pillars of palliative care is hospice care, but hospice care does not encompass all of end-of-life care.
Is it common for people to do what Cathy tried to do in the beginning of the story? Keep her diagnosis hidden from people, including her children?
It doesn’t depend on the cancer. It depends more on the personality of the person. I think that there are some personalities — you will notice this not only with what they do with their cancer treatment, it’s what they do with their jobs, how they drive … how they approach their children. The caveat is when you look at how a diagnosis of cancer changes your perception of things, how it impacts people … everybody deals with it very differently.
There is a clear sense in Cathy’s situation that facing her mortality or dealing with cancer made her a better person. Is that also based on personality?
No. I think that’s a common thing. But it can go to extremes. I have patients who when they get diagnosed the whole family comes together. They feel [it], even if they have two years. At the end of those two years, they say, “These two years were worth 15 years with my mom. I’ve really lived a full life with my mom in these two years.” And I have patients who have terrible diagnoses and their husband suddenly divorces them [saying], “I don’t want to deal with it.” It depends on the strength of the connections you have. If the connections are based on truth, morals and love, you come together. If the connections are frayed, it becomes an excuse to separate. Sometimes I feel really angry at that: This is the time you choose to abandon your friend, this is the time you choose to abandon your spouse?
Cathy also got really angry at one point about people using the words “fighting” or “battling” cancer. What do you think about those verbs?
I think it is a lot of pressure. The pressure is that if the patient is not getting better, they’re not trying hard enough. Look at [Lance] Armstrong. Armstrong had a cancer that has a 98% survival rate. … Put that with someone who has even stage 1 pancreatic cancer, and eventually has a 90% mortality rate ... it is not based on whether they are trying hard enough, it’s based on the disease.
We have this belief that death is a failure. Death is not a failture. It is inevitable. How we go is much more critical than when we go.
We’ve come a long way, as a society, from hiding cancer and death from cancer. Are we where we need to be?
No, we are not. You might have heard of this book, “The Emperor of All Maladies: A Biography of Cancer.” Siddhartha Mukherjee wrote this remarkable book. … [In it] he mentions this New York socialite who in the 1950s wanted to take out a full-page ad that she wanted to focus on breast cancer. So she said, I am willing to pay double the money, please write that breast cancer is a scourge, or something like that, and we need to fight it together. And the newspaper said no, we can’t use either of those two words. We can’t use breast, and we can’t use cancer. We will write something like chest wall diseases. To do clinical trials on breast cancer, we had to go to Europe. So that conversation has changed. But to your question, have we gotten there? Nowhere close. Even [among professionals], hospice and palliative care are just beginning as an open, robust conversation.
