The Unreal World: ‘The Big C’

“The Big C,” “Summer Time,” Showtime, Monday, Aug. 23, 10:30 p.m.

The premise: Cathy Jamison (Laura Linney) is a Minneapolis schoolteacher who has stage IV melanoma: a lesion on her back has spread to distant parts of her body (metastases). Dr. Todd Miller (Reid Scott), her oncologist, tells her she probably has 12 to 18 months to live, though he adds that one can hope to live for three to five years. She responds to the news by declining treatment with radiation or chemotherapy. (“I’ve always loved my hair,” she says.) Instead, she smokes cigarettes, says what’s on her mind, eats desserts instead of balanced meals and takes to sunbathing naked. She asks for compliments on her breasts from Dr. Miller, and walks out on a therapy session with her estranged husband, Paul (Oliver Platt). She keeps her cancer secret from Paul as well as from her son, Adam (Gabriel Basso).

The medical questions: What is stage IV melanoma, and is it fatal within 18 months? Does it respond to chemotherapy or radiation therapy? Are these treatments so poorly tolerated that refusing them is a reasonable choice in an advanced case of melanoma? Is melanoma on the back worse than other parts of the body? Is it considered therapeutic to exercise new freedoms when faced with a terminal diagnosis? Is keeping the cancer a secret from family and friends a method of coping, or is it maladaptive? And finally, are oncologists generally that candid about telling cancer patients how long they may have to live?

The reality: Stage IV melanoma involves spread beyond the original cancer site and associated lymph nodes to distant organs. The median survival is about a year but there is tremendous variation, says Dr. Adil I. Daud, director of the melanoma program at UC San Francisco. For this reason, a good oncologist generally would not provide the kind of finite time frame Dr. MIller does. “I’ve had patients diagnosed 10 years ago who are still alive and some who don’t survive four weeks,” Daud says. About 10% to 20% of patients respond to standard chemotherapy, according to Daud. But, adds Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute, many newer drugs, including ones in clinical trials, are much more effective, don’t cause you to lose your hair and frequently allow a patient to live two to five years or even a normal lifespan. Pavlick considers it “insanity” for the show to portray a patient who refuses standard treatment (in part because of potential side effects) but isn’t urged to participate in promising clinical trials on treatments that don’t make people nearly as sick as standard chemo. “This portrayal is very detrimental to patients,” she says. She points to several cutting-edge therapies: Ones that target mutations found in 50% of melanomas have a 70% response rate; immune drugs (such as Ipilimumab) can trigger the body to attack the melanoma and cause complete remissions; state-of-the-art radiation can help control widespread cancer and decrease symptoms, including pain; gamma knife radiation helps manage brain metastases in 85% of cases.

Melanomas on the back and chest tend to be more problematic than those on the extremities, Pavlick says, because they often go unnoticed because of coverage by hair or clothes and (in the case of the back) the inability to directly inspect them. Thus, they often are found at a later stage.

It is therapeutic to exercise new freedoms and decide to live even more fully when faced with a potentially terminal illness, says Boston psychiatrist Dr. Keith Ablow, author of the 2007 book “Living the Truth.” He encourages patients in these circumstances to change everything they consider inconsistent with their true core selves. However, he agrees with Pavlick that this decision can co-exist with treatment and need not include self-injurious behaviors such as smoking. Ablow also notes that isolating onself or refusing to participate in activities previously enjoyed, together with hiding the diagnosis from others, could indicate depression. “Hiding a diagnosis from family and friends is hiding from that diagnosis yourself,” he says. “It shows weakness in the face of adversity, or feelings of shame about being ill. I recommend telling everyone and also voicing your commitment to living fully for as long as is humanly possible.”

Siegel is an associate professor at New York University’s School of Medicine.

marc@doctorsiegel.com