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Don't Mention It

David P. Steensma

From the Division of Hematology, Mayo Clinic, Rochester, MN

Corresponding author: David P. Steensma, MD, Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: steensma.david{at}mayo.edu

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 when that disease falls within our own domain of expertise and authority. Oncology is perhaps unique because of the frequency, complexity, and pace of cancer, and the intense emotions involved. Almost one half of Americans will develop cancer at some point in their lives: half of our friends, half our family, half of our lovers, and—a different challenge entirely—half of us. These illnesses often catch us unprepared. How do we—should we— face them?

There are no simple answers. Every relationship and each situation is unique. It helps to have a good ear, to listen for just what is needed or desired. Some of the people close to us want specific advice, while others seek only reassurance. Most want our support; all need acceptance. We may be sought out for an informal opinion on the basis of the flimsiest of connections—the proverbial friend of a friend of a friend—even as those closest to us never ask for our help. Their reasons are their own, but it may require Zen-like calm not to be annoyed or insulted.

As for my friend, there may come a time when he will need my special skills—when his strength will fade and self-reliance will fail. If that happens, he knows that I will be there for him. Until then, we can share the wind whistling across the sails and the scents of the sea, just as we did before his diagnosis. Until he chooses to involve me in his metaphorical storm, we can focus on dodging real ones.

This weekend, we gave each other a gift. My silence let him put his cancer aside for a few days to enjoy a last adventure with an old comrade-in-arms. In turn, he let me imagine that our friendship will be unchanged, for just a little while longer.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Submitted November 2, 2007; accepted November 12, 2007.

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