I can forgive the snowplow almost anything if it comes while I still have my boots on. There is something particularly offensive about hearing that blade go by when you have one boot off and the other one half unlaced. You could have been in the house ten minutes ago, except that on the way in you noticed a little crescent of snow where the sidewalk meets the driveway and went back to tidy it up. You may care to remember that crescent when you go outside again. It was the last time today you had any say in the appearance of your property.

Most Canadians know what I mean, as do Americans across the northern states. Readers in Vancouver may consult a relative in Winnipeg. For everybody else, a snowplow has a long steel blade set at an angle. As the truck goes forward, the snow rolls along the blade and spills off the curb end. This works beautifully as long as you are looking at the road. If you turn ninety degrees, you can see where the snow went. There are now five feet of compacted ice and snow between a perfectly clear driveway and a perfectly clear street. A car would be quite handy on either side.

The first shovelling was almost pleasant. Fresh snow lets you get a rhythm going. You push a strip down the driveway, tip the shovel onto the lawn and go back for the next strip. The sidewalk requires a little more thought. A person on foot can turn sideways to squeeze through a narrow bit. A person pushing a stroller has to take the baby along at its original width. So you take another pass, right out to the edge of the concrete, and carry on a few feet past your property line because stopping exactly at the line looks petty. How far past it is a delicate question. Two feet is neighbourly. Halfway to the front steps suggests you have formed an opinion about the people who live there.

When I use the snowblower, I like the lines straight and the same distance apart. The first pass matters because if you wander a little to the left and then follow that line on the way back, by the time you finish you have reproduced the same mistake across the entire driveway with considerable precision. My wife Sharon, who is a psychologist, has her own thoughts about this. I would be quite interested to hear them, although preferably after she has told me whether the third line from the garage looks a little off to her, too.

By the time the plow arrives, you have done quite a nice job. You are entitled to look at it for a minute. This is also your best chance to see the driver coming, which puts you under a peculiar social obligation. A man operating a large piece of machinery on your behalf looks down from his cab. You raise a mitten. He raises a hand. For a second you are two fellows out early getting things done, and then, without either of you breaking eye contact, he bricks you in.

Try putting the same shovel into what he leaves behind. The blade goes in about an inch and the rest of the movement takes place inside your coat. There is gravel in there, grey slush packed around slabs of ice and, of course, salt, since they pickle the road with tons of it. Most of the salt appears to have come home with you in one lump, which is too heavy for the shovel, so you put it down and get both mittens underneath. The lump holds together just long enough to reach your chest. By the time you get back inside, the front of your coat is drying out nicely and you can see exactly how much of the municipal salt budget you’re wearing.

There is always somebody who suggests waiting until the plow has gone by before clearing the driveway. I admire the domestic arrangements that make this possible. Apparently these people can go to work whenever the street looks promising, and the fellow walking his dog will be happy to hold the animal at the corner until the municipality and I have agreed on a sequence of operations. Besides, which plow? The first one opens the road. A subsequent one may come along to widen it. From inside the house they make much the same noise, although the second sounds considerably more expensive if you have just paid somebody forty bucks to clear the first one.

I can even see the driver’s side of it. Put me in that cab after a decent snowfall and I would want to get the whole street done in one pass. I would have very little patience with some retired bastard standing at the end of his driveway explaining where he would prefer the snow to go. Ask him to point to a suitable spot and he will discover strong principles about his neighbour’s property, the public sidewalk and the section of lawn where he has already piled the snow about as high as he can throw it. Give him another minute and he will point to Vancouver.

Eventually you chop an opening wide enough for the car. From the garage it looks a little narrow on the passenger side, so back you go and knock another foot off, taking care to put the pieces well clear of the sidewalk you have now shovelled twice. You put the shovel away and stand just inside the door, listening. Nothing up the street. Nothing down the street. This time you keep your boots on and make the coffee.

If I May… My daughter Ashley is a nurse in the neonatal intensive care unit at or local little hospital. I keep this Substack free, partly because I’d have some nerve charging people to hear what I think of the snowplow. If you enjoyed the read and have a few dollars to spare, please consider putting them toward two bassinets and other critical equipment for Ashley’s unit. Of course they have those today, but they’re 30 years old and need renewal. I’m quite happy to work without a subscription fee. I’d rather the money bought somewhere for a very small person to continue being unreasonable about leaving.

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

https://gofund.me/a0fc0777e

In this imagined return visit, Mr. Mortality arrived with his husband, Arthur, whom the Republican Party still knew as Mrs. Mortality, and Patrick Stewart, whom I had rather hoped to meet under circumstances that involved less concern about why he was standing beside Mr. Mortality. Arthur wore pearls and carried a handbag. Patrick wore the expression of a man who had agreed to one small favour and was beginning to understand the full extent of the mistake.

“We thought you might find this reassuring,” Mr. Mortality said, ushering him into our living room. “Someone you admire. Someone who can explain that the transition needn’t be quite so upsetting.” Patrick looked at him. “You said we were going out for tea.” Arthur took off his coat and handed it to me. “He often leaves out the purpose of an outing. I once thought we were going to Venice. We were collecting a pope.”

Sharon brought another chair. I asked whether I was supposed to call him Sir Patrick, Patrick, or Captain, because under the circumstances I would happily accept instructions from anyone who had successfully dealt with a hostile vessel. “Patrick will do,” he said. Mr. Mortality settled beside him with the pleased expression of a salesman whose satisfied customer had finally arrived to put the difficult prospect at ease. “I think Hans would benefit from hearing about your experience,” he said. “Would he?” Patrick asked. “Particularly the peace.” Patrick waited while Sharon poured his tea. Earl Grey. Hot. “I had plans,” he said.

Mr. Mortality adjusted his cuff. Arthur smiled into his cup. We had been seated for less than a minute and already I was enjoying the visit more than its organiser. “People generally do,” Mr. Mortality said. “There’s rarely a convenient moment.” “Then perhaps you should stop presenting the inconvenience as an improvement,” Patrick replied. He thanked Sharon and reached for his cup. Mr. Mortality watched him with the quiet alarm of someone whose celebrity endorsement had started asking about the product.

I explained that this was a recurring disagreement between us. Mr. Mortality believed my resistance came from insufficient understanding. I believed I understood perfectly well and that this explained the resistance. There were things I wanted to do, people I wanted to remain with, and a Newfoundland who had invested considerable effort in training me. I wasn’t inclined to abandon the arrangement because a man with no pulse considered my objections emotionally immature. “Hans can be very difficult,” Mr. Mortality told Patrick. “Hans has been married to me for thirty-one years,” Sharon said. “You’re getting the visitor experience.”

Arthur crossed his legs and unfastened his pearls. Mr. Mortality glanced towards the window. His husband noticed. “Relax. ICE and the Republican Party goons are unlikely to be patrolling Kitchener looking for a man whose necklace has come off.” Patrick looked from one to the other, and Arthur explained that maintaining his public identity as Mrs. Mortality allowed his husband to retain his standing in the republican party, among people who would be appalled to discover they had been approving a marriage between two men. “They know what he does for a living?” Patrick asked. “Oh, yes. They’ve never objected to the deaths.”

Mr. Mortality asked whether we could return to the reason for the visit. Arthur put the pearls in his handbag. “By all means. Tell the man whose life has ended how grateful he should be. That’s going splendidly.”

Patrick stirred his tea. For a moment nobody spoke, and I found myself waiting for the voice. That familiar authority. Some measured observation that would sort the room into manageable proportions and leave me feeling that a competent man had taken command. It was an embarrassing thing to want from a visitor, particularly one who had apparently been brought here without being told he was the entertainment.

“You played a man who always seemed to know what to do,” I said. “Picard had writers,” Patrick replied. “And another take.” Sharon sat down beside me. Mr. Mortality looked disappointed, as though access to the workings of television had spoiled an otherwise useful spiritual intervention. “I thought you might offer him some wisdom,” he said. Patrick put down his spoon. “About what?” “Accepting what cannot be changed.” Arthur leaned back. “Careful. He uses that one at home.”

I said I had no objection to facts. I objected to the supplementary expectations. Apparently, once I had acknowledged that I would die, I was also supposed to acquire serenity, sort out my relationships, become grateful for small things, and stop making everyone uncomfortable by pointing out that I would prefer to continue having large things. Years, for example. Whole bloody years in which I might waste an afternoon without someone describing it as precious. “I don’t want to spend the rest of my life demonstrating that I’ve come to terms with losing it,” I said. “That sounds like another job.” Patrick nodded. “And who would you be doing it for?” Mr. Mortality reached for a biscuit. Arthur moved the plate just far enough that he had to ask. “There is comfort available,” Mr. Mortality said. “Then offer it,” Sharon replied. “You keep asking him to provide it.”

That seemed to trouble him. He looked at Patrick, who had been hired, apparently for no fee, to make departure attractive. Patrick looked back without helping. There was something almost indecent about watching Mr. Mortality wait for reassurance from someone he had collected. “At least the uncertainty is over,” he tried.

I told him that getting rid of uncertainty by getting rid of the person experiencing it struck me as a rather aggressive approach to patient satisfaction. Arthur laughed hard enough to spill his tea. His husband passed him a napkin without looking at him.

Patrick asked whether he could have another cup. Mr. Mortality checked his watch and said they ought to be going. It was a small, ordinary exchange, and for some reason it made me angrier than anything else he had said. Even here, in my own living room, the man was trying to end somebody else’s afternoon. “We have time for tea,” I said. Mr. Mortality began to answer, but Sharon had already picked up the pot. Arthur held out his cup. Patrick settled back into his chair, and I passed him the biscuits. When Mr. Mortality reached for the plate, I told him he could have one when he took his coat off.

If I May… I give Mr. Mortality a hard time in these essays because I can. My daughter Ashley works in a NICU, where asking for more time involves considerably more work than arguing over tea. I keep this writing free; if you’d like to contribute something, please consider helping our fundraiser to buy bassinets and other critical equipment for the babies in her care. I’m quite happy to work without a subscription fee. I’d rather the money bought somewhere for a very small person to continue being unreasonable about leaving.

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Leave a comment

Working in a kitchen taught me the simple elements of life, although “simple” is an odd word for an education conducted beside boiling stock while somebody needs six things immediately and one of them is physically impossible. Anticipation, patience, perseverance, judgment, tolerance, creativity, communication. Also indulgence, exhaustion, and a God-given ability to curse. The curriculum was extensive. There was seldom time to sit down and admire how much character one was acquiring.

I suspect professional cooking is among the hardest ways to earn a living, partly because everyone eats and a remarkable number of people assume this qualifies them to assess the ease with which food can be produced for eighty other people. They have made a lovely dinner for friends. They enjoyed themselves. They opened wine. Try giving each friend a different arrival time, a different main course, and authority to send it back. Then invite another seventy-two people and have someone announce that the dishwasher has stopped working.

A kitchen teaches anticipation because waiting until a problem has arrived is an expensive way to discover that it was coming. You learn to look at what remains in a container and think about what is about to be ordered. You notice the cook who is falling behind before he admits it, which may be some considerable time after everyone else has worked it out. There is a particular kind of optimism that believes a nearly empty tray will somehow last through service. It tends to be held by the person who will ask you to refill it.

Predicting is slightly different. You can prepare for what usually happens and still find yourself ambushed by a dining room that has collectively decided on the same fish. People who have never met will independently choose to ruin your evening in precisely the same way. You adapt. You also learn that a forecast is useful right up to the moment somebody mistakes it for a promise.

Communication becomes wonderfully specific. “Behind” means someone is behind you. “Hot” means that whatever is coming past your elbow will remove your interest in most other subjects if you touch it. There is something refreshing about language that still has work to do. Nobody needs to circle back on the hot pan. They need to get out of its fucking way.

That brings us to cursing, a God-given ability for which a professional kitchen provides continuing education. There are moments when “Oh dear” is an inadequate description of the relationship between your hand and a metal handle. A properly placed curse tells everyone within hearing that something has gone wrong and that discussion can wait. If the Almighty intended more restrained language, He could have made the handles less conductive.

The allowance has limits. A burnt hand may justify a vigorous assessment of the universe. It does not grant a chef permanent permission to humiliate an apprentice. Some kitchens have confused the ability to frighten people with the ability to teach them, and television has helped sell the confusion as entertainment. If your authority depends on throwing something, perhaps put it down and learn to explain yourself. The food was already under enough pressure.

Mentoring requires the patience to watch someone do slowly what you could do quickly, while resisting the urge to snatch it away and prove the point. You have to explain the reason for a cut, a temperature, a sequence. “Because I said so” will produce obedience for as long as you are standing there. Understanding has a better chance of surviving your departure. Eventually the person you taught starts noticing things you missed, at which point you can either be pleased or become an arsehole about it.

I include “somewhat following direction” among the things a kitchen taught me because complete obedience has its practical shortcomings. A recipe cannot see what is happening in the pan. The instruction may say another five minutes; the food may already be cooked. You need enough discipline to understand the method and enough independence to recognise when continuing would destroy dinner. This can be an awkward combination for people who enjoy issuing instructions more than they enjoy eating the consequences.

Creativity lives inside those limits. There is the pleasurable business of finding what belongs together, of getting an ordinary ingredient to taste more fully of itself. Then there is the creativity required when something has failed, something has run out, and the replacement must be ready before a customer discovers there has been a discussion. Inspiration becomes considerably less precious when it has a collection time.

Tolerance develops because the person beside you may have habits, opinions and a personality you would prefer to encounter from another postal code. You still need to work together. A busy service gives disagreement some useful boundaries: you can settle your views on human civilisation later; at present, the vegetables are ready and the meat is not. You learn to appreciate competence in people you might never choose as friends. They may be making the same concession about you.

Inclusion becomes practical too. The person washing the pans belongs to the operation as completely as the person arranging the food. Let the pans stop coming back and watch the hierarchy reconsider itself. Appreciation begins with noticing whose work allows yours to happen. It ought to extend to how people are treated and paid, although a surprising number of establishments prefer to express gratitude in speeches.

Exclusion requires more care. There are behaviours a kitchen cannot afford: concealing mistakes, leaving another person to carry your work, treating a new employee as an available victim. People need room to learn. Persistent carelessness is another matter, especially when someone else keeps paying for it. Tolerance becomes exploitation when the reliable person is expected to absorb everyone else’s failures with a pleasant expression.

Indulgence belongs here, because spending your working life making things delicious while regarding pleasure as a moral weakness would be a peculiar occupation. Butter has a purpose. So does the last spoonful of sauce lifted from a pan with a piece of bread. There is pleasure in tasting something and knowing it is right, without requiring a photograph, an explanation, or a declaration that you have earned it. I have little interest in a philosophy of eating that makes satisfaction sound like an administrative error.

The difficulty is finding time for your own pleasure while producing it for everyone else. A dining room can be full of people taking a welcome break while the people feeding them cannot stop. You learn perseverance because orders continue to arrive after enthusiasm has gone home. Patience means doing the thing properly again, even when you are tired of it, tired of the person asking for it, and beginning to have reservations about the entire institution of dinner.

Making a living in a kitchen is pleasant until it isn’t. There is satisfaction in good ingredients, a service that runs well, and working beside people who give a damn about what leaves the stove. Then somebody decides the butter costs too much, the stock takes too long, and a supplier has a powder that produces something approximately brown for considerably less money. The trouble begins when the person responsible for the food loses the authority to decide what goes into it. Ingredients, quality and the time required to do the work properly belong in the price of the meal. If the business cannot afford them, it should serve something simpler. An honest omelette is preferable to a fraudulent lobster bisque.

I have no appetite for corporate kitchens. Those are feed factories, where someone who has never peeled a shallot can decide how many seconds it ought to take, and quality becomes whatever survives the purchasing department. The cook is expected to care passionately within a budget constructed by people who regard that passion as free labour. Everything must be consistent, which is a splendid ambition until it means consistently mediocre. Once the sauce arrives in a bag and the instructions require scissors, I would prefer that we stop calling the operation culinary and give the person opening it a decent pair.

I am wary of turning that exhaustion into something noble. Being unable to feel your feet is a poor employee benefit. A profession can demand skill and stamina without making suffering its entrance requirement. Admiring people for enduring unreasonable conditions is very convenient for whoever has decided to keep the conditions unreasonable.

Working in a kitchen taught me how much effort can disappear into somebody else’s pleasant evening. A plate leaves, a conversation continues, and a person who may never know your name takes a bite. There is satisfaction in getting that right, even when you are too tired to be eloquent about it. Then the last order goes out, and everyone would like to believe the work is finished. Someone still has to scrub the stove.

If I may… I spent my first professional years in kitchens making sure people were properly fed. These days, I’m asking you to help babies who have arrived before they are quite ready for the dining room. My daughter Ashley is a NICU nurse at our local little hospital, where the need for equipment is considerably less amusing than anything I write here. If this essay brought you some pleasure, please consider contributing to our NICU equipment fundraiser. Think of it as leaving a tip, except I won’t get it, the babies need it, and nobody will ask whether you’d like to make that eighteen, twenty or twenty-five per cent.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. Always. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

I was born on 31 October, a date that seemed perfectly reasonable until I moved to Canada in 1979 and discovered that it came with a compulsory joke. Tell someone your birthday was Halloween and they would ask whether your mother had been scared when you were born. They appeared pleased with themselves. I failed to see the connection until a few years later, which meant I had crossed the Atlantic only to become the unpaid custodian of a joke I had yet to understand.

I could see several reasons why a woman giving birth might be frightened. There was the birth itself, followed by the prospect of raising whatever had just emerged. A child represents a considerable commitment to someone whose references you cannot check. You know nothing about his character, his political opinions or whether he will eventually explain cryptocurrency at Christmas. Asking whether my mother was scared struck me as a reasonable question, although an oddly intimate one from someone who had only just learned my birthday.

Eventually I understood that they were suggesting I had frightened her with my appearance. This improved my grasp of Canadian humour without improving my opinion of the joke. Apparently, you could imply that a man had been born looking like a small domestic emergency, provided you did it on the appropriate date. I had assumed immigration would involve adapting to different institutions and customs. I had overlooked the need to recognise when a stranger was politely calling me ugly.

Being born on Halloween also means sharing your birthday with people who dress as corpses for pleasure. Someone born in June can expect flowers. I have to compete with a plastic skeleton hanging from a gutter. There is something discouraging about reaching another year of life while the neighbourhood puts considerable effort into depicting the alternatives. A gravestone on the lawn is festive. Mention that your knee hurts and suddenly you are bringing down the mood.

The church calendar offers little relief. In the Catholic calendar, 1 November is All Saints’ Day, honouring those in heaven, and 2 November is All Souls’ Day, when prayers are offered for the faithful departed undergoing purification in purgatory. So the sequence is my birthday, the successful dead, then the dead whose admission still requires some work. I arrived immediately before the annual review of the entire operation.

That distinction between saints and souls has a familiar administrative smell. Even after death, there are people whose affairs are in order and people who need somebody else to intervene. The saints are comfortably inside. The others have been assured that their destination is heaven, although an assurance about your destination is of limited comfort when you have already died and still cannot get into it. I can imagine a soul asking how long purification takes and receiving a leaflet.

If I had arrived a day later, my birthday would have coincided with All Saints’ Day, which would have placed an unreasonable burden on everyone who eventually got to know me. Two days later, I would have fitted more comfortably among the souls requiring assistance. Instead, I came on the evening before the holy people, apparently while the admissions staff were busy preparing for them. There may have been a moment of distraction. Someone opened the wrong door and I got through.

Halloween itself is a shortened form of All Hallows’ Eve, the evening before All Saints’ Day. This is a rather respectable origin for an occasion now capable of putting a grown adult in a rubber horse’s head outside a liquor store. Somewhere between the saints and the seasonal merchandise, the evening acquired other priorities. I cannot claim to have improved its reputation, but I would like my contribution assessed separately from the inflatable spider.

What bothers me about this arrangement is the speed with which the calendar loses interest in my being alive. On 31 October I am entitled to cake and congratulations for having remained here. By the following morning, attention has moved to people who have left. There is barely time to wash the plates before the dead take over. I appreciate that they have waited patiently, in some cases for centuries, but they do get two consecutive days. I get one, and a substantial part of it belongs to children demanding chocolate.

At least the dead are spared the birthday question. Nobody approaches a grave, notices 31 October on the stone and asks whether the deceased’s mother was scared. Or perhaps they do. There are people whose commitment to a familiar joke survives every warning the circumstances provide. Having waited several years to understand it myself, I would hate to think I might have to spend eternity listening to it from someone who believes death has given him a fresh audience.

As I get older, the proximity of those dates feels less like a coincidence and more like someone has put my name beside a booking they expect to confirm. Every year I remain on the October side of the page, while November waits with its prayers and flowers. I object to the presumption. Being born before the commemoration of the dead does not mean I agreed to provide them with an opening act indefinitely.

There is also the business of candles. On a birthday cake, they stand for the years you have accumulated, and you are expected to extinguish them. For the dead, people light candles and leave them burning. A remarkably small change in procedure separates the two occasions. I would therefore appreciate close supervision of the cake. If anyone starts arranging the candles around my photograph, I want the knife put down and an explanation.

This year, on 31 October, I shall turn sixty-nine. Anyone tempted to ask whether my mother was frightened is welcome to consider how long that joke has already been in circulation and whether it needs another outing. The saints can have the following day, and the souls can have the day after that. While I am still able to hold a fork, the flowers belong in a vase and the cake comes to me.

If I May… My birthday requires no gifts, although the NICU could use some equipment. If you enjoy these essays and would like to contribute, we are continuing to raise funds more generally for equipment the neonatal intensive care unit needs, or needs to replace. Thank you to everyone who has already donated. I can manage with cake; the nurses have a rather more demanding shopping list.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. Always. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

October 31 is my birthday, and in case a millionaire or billionaire reads these blogs, I thought I should make myself useful by explaining what to do with some of that money. People with substantial fortunes are forever being asked to invest, diversify, protect their assets and consider their legacy. This must become exhausting. I have a shorter proposal involving neonatal equipment and a Morgan Plus 8, although I should establish immediately that these are separate purchases. Nobody should be delivering a premature baby in a British sports car because I was insufficiently clear.

First, I would like the NICU to have the equipment it needs. My daughter Ashley works in neonatal intensive care, and I would like the people doing that work to have something better than the continuing expectation that thirty-year-old bassinets, and other ageing equipment, should keep putting in a full shift. There is a point at which getting another year out of something stops being thrift and starts being an institutional refusal to buy the bloody thing. A bassinet should not need a retirement plan before the person sleeping in it has a birth certificate.

This is the part of the birthday list where money can do precisely what money is supposed to do: pay for something needed. Ask the unit what it needs, help buy it, and let the nurses get on with their work. I keep these essays free, and if you have enjoyed them enough to consider giving something, that is where I would like it to go. You do not have to be a billionaire. I am merely trying to avoid a situation in which a billionaire reads this and assumes I meant someone else.

Then there is the Morgan Plus 8. I recognise that moving directly from neonatal intensive care to a car for myself could raise questions about my moral seriousness. I considered inserting a paragraph about world peace to create some distance, but that would have been dishonest. I want the equipment for the babies, and I want the Morgan for me. The presence of one decent wish does not require the surgical removal of every selfish one.

The Morgan can be a used specimen. I am quite comfortable with that, being used myself and increasingly familiar with the maintenance implications. I do not require the indignity of a brand-new vehicle making the driver look like the oldest component in the transaction. A well-kept Morgan Plus 8 would be perfectly acceptable. Please do not substitute something sensible because you think it would suit a man of my age. I have medical appointments for that kind of unsolicited correction.

I would also like Isabel to grow into a wonderful Newfoundland dog, which is the item on the list I am actually working on. Money might buy the car, but it cannot do my share of raising the dog. That involves patience, consistency and persuading a very large puppy that affection need not leave the recipient requiring assistance. I want her to have a good life, and I want to be able to walk beside her rather than arrive wherever she has decided to take me. We are working on the distinction.

For Sharon, I want her brain tumour to stay put. No growth. No fresh reason to rearrange our lives around an image on a screen. I have no useful sarcasm to attach to that wish, and I am not going to manufacture some to keep the tone consistent. I want my wife well. I want us to be able to spend a perfectly ordinary morning drinking a latte and eating an edible croissant (I know, an effort here in Waterloo), together without something inside her head deciding it deserves more of our attention.

My own contribution to the medical wish list is a great PSA test result on November 15. There is something faintly insulting about reaching an age when a laboratory number can compete with a sports car for your enthusiasm, but here we are. I would like a result that lets me return to what I was doing before cancer made itself a standing item on the household agenda. I am enjoying being alive without constantly supervising the possibility that I might stop. I would like to continue with that arrangement.

And yes, I would like the Republican politicians who enable Trump to be voted out of office. Consider it the public-service portion of the birthday celebrations. I would take considerable pleasure in watching people who have excused his conduct discover that their constituents have declined to excuse theirs. They could spend more time with their families, who would then be entitled to ask what the hell they had done to deserve it.

If you are a Republican millionaire or billionaire, however, please understand that I would still accept the Morgan. I would thank you sincerely and continue wanting your Trump-enabling politicians removed from office. You would be buying a car for an ungrateful political opponent, which strikes me as a much healthier transaction than buying a grateful politician. Help the NICU first. Then, if you still feel inclined, send the keys. I will remove the bumper sticker myself.

If I May… For my birthday, I would like the NICU where my daughter Ashley works to have the equipment it needs, without asking thirty-year-old bassinets to postpone retirement again. These essays are free, and they will stay that way. If you would like to give me something, please put a donation towards equipment for those babies. Whatever happens with my absurd request for a Morgan, this part of the wish list is serious. Nurses should be able to ask for what they need without the rest of us having to organise a small financial miracle to get it. The little dudes also deserve a fair chance, although the nurses usually pull them through whatever crap they’re enduring.

Thank you, all the nurses!

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Leave a comment

My next PSA blood test is due on November 15. At the moment, I am doing something rather irresponsible by the standards of a man with a cancer history: living without thinking about cancer very much. There are other things to occupy me. There is Sharon. There is Isabel. There is dinner, which somebody has to cook even when the cook has already made a substantial contribution to the oncology department’s workload. Cancer has slipped out of the centre of the room, and I am reluctant to pull up a chair for the bastard again.

The test itself is simple enough. A needle, some blood, a small dressing. The laboratory measures a protein, and then I am supposed to receive this information as though somebody has told me the temperature in Sudbury. Except this particular number can enter the house without taking off its shoes. It can sit through dinner, come to bed, and have something to say at four in the morning. The blood draw takes minutes. The result has no agreed departure time.

So I find myself considering a possibility that sounds appalling if said within hearing distance of a responsible adult. Perhaps I could skip it. Remain blissfully unaware. Live the rest of my life, however much of it there is, without periodically asking a laboratory whether I have permission to enjoy it. There is something attractive about declining an appointment with information that might ruin a perfectly serviceable afternoon.

I have already had brachytherapy, radiation and hormone deprivation. I have participated. Nobody can reasonably accuse me of treating this as a minor disagreement between myself and my prostate. There were consequences, and I got to take those home. After enough treatment, the wish to be left alone acquires a certain force. A person can become tired of having his willingness to undergo the next thing treated as the most reliable measure of his desire to remain alive.

I want to live. I also want some say in what the living consists of. Those wishes can become awkward companions when medicine offers additional time at a price payable in the body I have to inhabit. My heart has its own history. My experience of hormone deprivation belongs in the discussion. If further treatment were ever proposed, I would want to know what it might do for me, how uncertain that benefit was, and what I would spend to obtain it. “We can do something” would be the beginning of that conversation. I would still need to hear a reason.

But I have to be honest about what I am proposing when I consider avoiding the test. This is follow-up after a known cancer, after treatment intended to control it. Not cure it, mind you. Arguments about screening healthy people cannot simply be dragged into this room and made to testify on my behalf. I already know there was a fire. Refusing to check the building afterward is a different decision from questioning whether every house needs an alarm in the cutlery drawer.

Nor does my current lack of worry tell me what the cancer is doing. And really, do I need to know? It tells me something about how I am living, which deserves respect in its own right. It cannot supply the blood result. I would like peace of mind to have diagnostic authority, but wishing has already contributed quite enough to human medical history.

There is another complication. A PSA result after radiation needs interpretation. The American Cancer Society explains that normal prostate cells can still produce PSA, that levels can take years to reach their lowest point, and that a small rise can be temporary. Doctors look at the pattern over time. A number moving upward does not, by itself, establish recurrence or demand immediate treatment. This is useful to remember before allowing a decimal point to appoint itself executor of my estate.

Which means there are decisions here that I have been squeezing together. I can agree to a blood test and still ask questions about the result. I can agree to further investigation and still refuse a proposed treatment. Giving a tube of blood does not give anyone permanent authority over the rest of me. The laboratory has a sample. It does not have power of attorney.

The conversation I would want before November 15 is therefore quite specific. If the number is low and stable, when would we check again? If it has risen a little, what would justify repeating it rather than drawing conclusions? If the pattern becomes concerning, what choices would actually be available to someone with my treatment history and heart problems? I would want that explained before the result arrives, while I can still listen without mentally measuring myself for a coffin.

There may come a point when I decide that further cancer treatment asks more than I am willing to pay. I can imagine choosing comfort and accepting the consequences. That would deserve a serious conversation about whether continued testing would help me, including with planning and symptom care. It would be my decision to make with a clear account of what I was accepting. For now, I have said that I am enjoying my life. I have not established that there is no possible information, or no possible treatment, I would ever want.

The temptation is to buy permanent peace by cancelling one blood test. I am sceptical of that offer, including when it comes from me. I might enjoy the afternoon. I might then spend the following month wondering about the result I had arranged never to receive. Ignorance can be expensive considering how little information comes with it.

I suspect I will get the test, after discussing how the result will be reviewed and what would actually warrant action. I would like the information handled with the same care as the blood, rather than dropped into my life for me to interpret alone. Then I intend to go back to the things that have made cancer less interesting lately. November 15 can have a space on the calendar. I am reluctant to give it the adjoining weeks. But I know I will.

If I May… I would prefer that nobody needed an oncology ward or a neonatal intensive care unit. Medicine has declined to accommodate me on either count. My daughter Ashley works in a NICU, and I’m raising money to help buy equipment for the babies in her care. This Substack stays free. If you can spare something, please consider donating to the fundraiser. I can supply the opinions without charge; the hospital equipment people remain stubbornly attached to being paid.

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

Thank you very much.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Leave a comment

I am not a medical professional, but I do know how to research a subject, read the evidence and notice when a conclusion has wandered beyond what the study actually found. I also happen to inhabit the body receiving the treatment, which gives me a considerable interest in the footnotes. I am asking for explanations, including an honest account of what remains uncertain. That should require neither a medical degree nor permission.

Somewhere among today’s medical commandments are tomorrow’s revised guidelines, and the patient has the privilege of swallowing them until the distinction becomes clear. Thou shalt take this drug, endure its consequences and avoid irritating the priesthood with questions about whether you need it. Years later, the advice may change, and you are invited to celebrate science correcting itself, preferably without mentioning what the earlier certainty cost you. Clinical trials can miss rare harms, delayed effects and problems in people taking several other medications.

Approval cannot establish that every patient needs a drug indefinitely. Those limitations are real; they deserve to be explained before the prescription acquires the authority of scripture. Under accelerated approval, a drug can also reach the market before its anticipated clinical benefit has been confirmed. There may be sound medical reasons for earlier access, but the financial arrangement is exquisite: the benefit remains under investigation while the invoice is ready for payment. That does not prove regulators deliberately protected shareholder value. It does make unquestioning obedience an outrageous thing to demand from the only person in the arrangement required to swallow the uncertainty.

The Warburg effect is real: many cancer cells consume unusually large amounts of glucose and ferment it even when oxygen is available. It is extensively researched, but a biological observation is not a ready-made cure. Tumours can use alternative fuels, healthy cells need energy too, and removing sugar from breakfast has not been shown to make cancer disappear. The bastard is metabolically more resourceful than the diagram suggests.

Repurposed medicines deserve proper trials, and here the financial criticism has teeth: the NIH acknowledges that companies have little incentive to investigate new uses for drugs already available as generics. Affordability can be a commercial handicap. Cheap drugs still have to work: the large MA.32 breast cancer trial found no significant improvement in invasive disease-free survival from adding metformin in the patients studied. I want evidence, whoever owns the molecule. I also want a research system in which “people might survive” can justify an investigation without first demonstrating that the survivors will be sufficiently profitable.

The tablets have an expiry date. The certainty with which they were prescribed generally does not. That is left in the patient’s custody, somewhere between the instruction to take them with food and the warning that failing to take them could kill him. Years later, a study may arrive suggesting that people in his particular circumstances did not need quite so much of the treatment, or quite so many years of it. The pharmacy can dispose of unused medication. There is no little bin beside the counter for the years spent believing there was no reasonable alternative.

I have cancer and a cardiac history, which gives me an interest in this arrangement beyond the academic. I would quite like medicine to work. My objection begins when a recommendation acquires the authority of a commandment and the person expected to swallow it is permitted approximately the same theological freedom as a medieval peasant. Take this. Continue taking this. We will let you know if the thinking changes, although you may have to discover that yourself while looking up why you feel like a damp carpet.

Imagine an honest prescription label. Under the dosage, it might say that this treatment helped patients with certain characteristics, that the size of the benefit varies, and that nobody can promise you will be among those helped. It could say when the prescription should be reviewed. There might even be room for the expected benefit in actual numbers. We somehow find space to explain how to open the bottle, despite having designed the lid specifically to prevent an elderly person from doing so.

Instead, the phrase “standard of care” can arrive with the conversation-closing weight of a bishop placing his ring on the table. It sounds final. It suggests that somewhere, behind doors unavailable to ordinary people, the matter has been settled. The frightened patient hears survival. The recommendation may contain qualifications about which patients were studied and how uncertain the benefit remains. Those qualifications have had the good manners to remain in the journal.

Beta blockers offer a useful example. A 2025 analysis of five randomized trials found no reduction in death, another heart attack or heart failure among patients who had suffered a heart attack, retained normal pumping function and had no other indication for the drugs. Every qualification in that sentence matters. Beta blockers still have other uses, including controlling heart rate in atrial fibrillation. The discovery concerns a particular group of patients. Nevertheless, it is a substantial revision to the idea that having had a heart attack automatically earns you an indefinite subscription. Apparently “for life” can sometimes mean “until we properly investigate this particular population.”

Aspirin has undergone its own reduction in ecclesiastical rank. The US Preventive Services Task Force recommends against starting it routinely to prevent a first cardiovascular event in people aged sixty or older, because the balance of benefit and bleeding does not justify it. Someone who has already had a heart attack presents a different question. Again, the distinction matters. The trouble begins when “good for the heart” becomes a general blessing, broad enough to cover anyone who owns one. A drug that can prevent a clot can also cause bleeding. Both activities take place in the same customer.

Cancer makes the obedience problem particularly ugly because the word itself does much of the persuading. A discussion about a possible benefit takes place with death apparently sitting just outside the consultation room, checking his watch. Under those conditions, “we recommend” can sound very much like “you would have to be a fucking idiot to refuse.” A signature obtained from a frightened person establishes that a form was signed. The quality of the conversation still has to be earned.

I know androgen deprivation therapy from inside the body receiving it. The hot flashes, the fog and the changes to a body one was already having enough trouble operating give the question of duration a certain personal urgency. ADT has evidence behind it in appropriate prostate cancers. That makes the next question more pressing: how much additional benefit does the next stretch of treatment buy, and at whose expense is that purchase being made?

A large analysis published online in late 2025 found that additional benefits from longer ADT varied by cancer risk and diminished with increasing duration. Longer exposure was also associated with more deaths from other causes. This does not produce a universal stopping date. It makes individual judgment unavoidable. In the TRIP trial, thirty months of ADT failed to show better biochemical cancer control than six months when combined with external radiation and a particular form of brachytherapy. That trial did not prove the durations equivalent, and its brachytherapy differed from mine. Even with those qualifications, the presumption that more months must be worth having deserves a considerably less comfortable chair. for more info: JAMA Network

Then there are oestrogen patches, another way of delivering ADT that deserves considerably more attention than a patient having to discover it himself. The 2026 PATCH/STAMPEDE results found them noninferior to standard LHRH agonist injections for three-year metastasis-free survival in men with locally advanced, non-metastatic prostate cancer, with fewer hot flashes but more breast enlargement. In plain English, comparable cancer control on that measure, less spontaneous combustion, and a greater likelihood that the tits get bigger. That trade-off deserves a conversation with the man expected to wear the breasts. Yet when UCL announced the findings in March, the patches remained unlicensed for prostate cancer in the UK, requiring off-label prescribing while work continued towards a licence application. They are not automatically suitable for everyone, and individual risks still require assessment. But once credible evidence supports an alternative, patients deserve to hear about it while they still have treatment choices to make. I would prefer to discuss the possible expansion of my chest before the paperwork achieves its own.

The patient has to live through every month that the prescription covers. If the extra benefit is uncertain, he still experiences the treatment in full. There is no reduced rate on side effects to reflect the confidence interval. Nor can the lost months be credited towards a later illness. When a paper eventually proposes a shorter course, the person who endured the longer one cannot present his receipt and ask for the difference back.

Chemotherapy supplies another awkward amendment. TAILORx and RxPONDER helped identify groups of women with particular breast cancers who could avoid chemotherapy. In RxPONDER, postmenopausal women with hormone-sensitive, HER2-negative disease, one to three affected lymph nodes and a genomic recurrence score of twenty-five or less gained no demonstrated benefit from adding chemotherapy to endocrine treatment. Premenopausal women with similar findings did benefit. The detail is essential. “Cancer requires chemotherapy” is a much easier sentence to deliver, but ease of delivery is a poor reason to leave the detail out.

There is something indecent about demanding that patients regard such findings only as good news. They are good news for the people spared treatment. Someone who underwent it is also entitled to sit with the possibility that better information might have spared her. She need not provide a cheerful testimonial about the progress of science while privately counting what the earlier certainty cost. Gratitude is a feeling. Hospitals should stop short of treating it as another discharge requirement.

Sometimes the mistake is the assumption that improving a number must improve a person. In the ACCORD trial, an intensive strategy to drive blood sugar towards normal in people with type 2 diabetes and high cardiovascular risk increased mortality. That part of the trial was stopped early. The lower target had an appealing logic. The bodies were less cooperative. There is a rather final limit to how pleased we should be with a laboratory result when the patient attached to it is doing worse.

Then there are patients with ME/CFS, for whom NICE’s 2021 guidance rejected programmes based on fixed increases in exercise, including graded exercise therapy. The guidance also rejected approaches built on theories that deconditioning and exercise avoidance perpetuated the illness. Consider what is at stake when the patient reports that the prescribed activity makes them worse. A treatment theory that allows the complaint to be interpreted as evidence of the patient’s resistance has furnished itself with an excellent escape route. The patient remains in the room with the symptoms.

I expect doctors to change their minds when the evidence changes. I would be alarmed if they refused. What we should not and cannot accept is a system in which uncertainty is available to the institution as a defence afterwards but unavailable to the patient as a subject for discussion beforehand. If the recommendation depends on probabilities, let us hear the probabilities while there is still a decision to make. Do not deliver the commandment on Monday and introduce the philosophy of scientific uncertainty after the damage has been done.

Nor does any of this make the fellow selling an alternative cure on the internet a prophet. He has simply noticed that frightened people who feel dismissed are available for further exploitation. I am keeping my medication until it has been properly reviewed. I am also keeping the right to ask what each drug is doing there, what evidence supports its continued presence and whether “we have always done it this way” has been allowed to renew a prescription.

The next time I am handed a treatment plan, I would like the review date written as clearly as the dosage. If the evidence is uncertain, the uncertainty belongs on my copy too. The doctor can retain the original, along with the signature. I am the one taking the contents home.

If I May… I keep The Oncology Underground free because being ill is expensive enough without having to subscribe to someone being annoyed on your behalf. If these essays give you something worth reading, please consider a voluntary donation to our fundraiser for NICU equipment. My daughter Ashley works in neonatal intensive care, where babies and their families depend on skilled people having the equipment they need. Any amount you can comfortably spare is welcome. I supply the indignation free of charge; you can help buy something considerably more useful.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

No, I wasn’t always a writer of essays about cancer, getting older and the silliness of daily life. I used to write assessments for companies that had convinced themselves they were on the right track because a vice president had said so, and the CEO had been convinced. This is understandable. The moment a person becomes a vice president, their mental and intellectual capacity increases by at least 75 percent. Nobody has ever explained how the promotion accomplishes this, but the people sitting around the boardroom table generally seem to accept it.

The vice president would announce that everything was going well, and everyone would nod. Some had helped prepare the presentation, so they knew what had been left out. Others had questions but also had mortgages. By the time the assessment landed on a desk, the people who most needed to read it had already agreed with one another that there was no particular problem. A consultant could be useful in those circumstances, provided he knew when to stop talking and send the invoice.

I now write for three reasons: to make sense of things that don’t, to engage with other cancer patients who are struggling to make sense of things that don’t, and to raise money for NICU equipment at our local little hospital, so newborn babies can one day have a go at making sense of things that don’t make sense. I still encounter plenty of people who are convinced they have the answers. The main difference is that I no longer have to put their opinions into a report.

Cancer has a way of taking an ordinary life and filling it with appointments, unfamiliar words and decisions you would rather somebody else had to make. You can ask sensible questions and still come away with answers that need further explanation. You can be grateful for the people looking after you and furious that you need them. Those things fit together quite comfortably, even if the rest of your life suddenly doesn’t.

Before cancer, I might have assumed that a serious diagnosis came with a clear set of instructions. Here is what we know, here is what we don’t, and here is what happens next. Instead, you learn how much can depend on a scan, a test result, an appointment that hasn’t been scheduled yet, or a question you only thought to ask after the person who could answer it had left the room. The paperwork, at least, is dependable. There is always more of it.

You also become acquainted with the peculiar language of medicine. A finding can be described in terms so measured that you are unsure whether to breathe a sigh of relief or start making a list of people you should call. A report may contain six words you understand, four of which are your name and date of birth. Somewhere in the remaining paragraphs is information about your body, written for people who have spent years learning how to read it. The patient is left to admire its thoroughness while wondering what the hell it says.

I understand why doctors use precise language. I would rather have a careful answer than a cheerful guess. But precision has limited value to the person in the chair if nobody takes the time to translate it. “We’ll keep an eye on it” sounds reassuring until you get home and start wondering what “it” is, how often the eye will be applied, and who is responsible for making sure the appointment happens. By then the office is closed, and your imagination has opened for business.

Writing gives me somewhere to put all of that. The questions, the anger, the absurdities, and the occasional thought I would probably have been better off keeping to myself. Once a sentence is on the page, I can look at it, argue with it, and sometimes discover that what I thought was bothering me was only the polite version. This does not make cancer any less serious. It gives me something to do while serious people discuss it in words that require a second appointment to understand.

There is a certain pressure on patients to be agreeable. Medical staff have difficult jobs and crowded days, and most of us know it. We also know that the person across the desk may have information we need, so we try to be reasonable. We apologize for asking another question. We thank people for calling us back. We hesitate to mention that the instruction we were given on Tuesday bears little resemblance to the one we received on Thursday, in case there is a perfectly good explanation and we have missed it.

Sometimes there is a good explanation. I would still like to hear it. Being ill does not make me incapable of understanding a problem, and being polite does not mean I have agreed to sit quietly while everyone else sorts it out. If I am expected to keep track of appointments, medications, symptoms and the contents of several conversations, I would appreciate instructions that do not require a committee, a dictionary and a séance.

Then there is the matter of attitude. Cancer seems to make some people uncomfortable enough that they reach for the nearest uplifting phrase and offer it to you like a biscuit. Stay positive. Keep fighting. Everything happens for a reason. I know these things are often said kindly, by people who wish they could help and cannot find the words. I have also noticed that the person receiving the advice is expected to nod appreciatively, even when the advice is about as useful as a bicycle with one wheel.

I do not believe a bad day needs to be corrected before it can be discussed. Sometimes you are frightened because there is something to be frightened about. Sometimes you are angry because a situation is infuriating. Sometimes you are tired and would like to be left alone without having that interpreted as a failure of character. A person with cancer has enough work to do without also being appointed chief morale officer for everyone around him.

Other patients recognize parts of it. They have their own diagnoses, their own families, and their own ways of getting through a day that may include waiting for a phone call nobody wants to receive. Some write back. They tell me what they are dealing with, or they tell me I have put words to something they had been trying to explain. I value those exchanges. A person living with cancer has enough people telling them what they ought to feel; it is a relief to hear from someone who understands that you can feel several contradictory things before breakfast.

We do not have to agree about everything. One person finds comfort in a phrase that makes another want to throw a shoe at the wall. One wants every detail; another would rather hear the essentials and go home. Both are entitled to their way of dealing with it. Cancer is already taking liberties with our lives. I see no reason to let it dictate our personalities as well.

And then there is the rest of daily life, which continues to demand attention regardless of what is happening inside your body. The bills arrive. Passwords expire. A website informs you that your account has been locked for your own protection and invites you to sign in to find out why. Somewhere, a vice president is looking at a presentation about improved customer experience and congratulating everyone involved.

Getting older adds its own entertainment. Objects remain exactly where you put them, which would be useful if you could remember where that was. You walk into a room with a purpose and stand there waiting for it to come back. Meanwhile, the companies that sell you things have decided that every appliance, account and service must be operated through a phone. The washing machine may soon know more about me than my doctor, although I doubt it will call with the results.

The absurdity is not confined to technology. You can buy a product in packaging that requires a weapon to open, then find a warning inside telling you to be careful. You can call a company for help and spend twenty minutes listening to a recording explaining how important your call is. By the time someone answers, you have heard it often enough to suspect that the company and you have very different ideas about importance.

I write about those things because they are part of living, too. A cancer diagnosis does not excuse you from dealing with a forgotten password or a package that refuses to open. The day still expects you to get on with it, even when you have more pressing matters on your mind. Sometimes the small stupidity is the one that finally makes you swear, and sometimes writing it down lets you see how funny it was. A few years of listening to vice presidents had already given me some practice.

There is also the matter of those babies. My daughter Ashley works in a NICU, where very small people arrive needing equipment and skilled hands before they have had a chance to complain about either. I keep my writing free and ask anyone who wishes to contribute to help fund bassinets for our local hospital. The people who care for those babies do the difficult work. The bassinets are something the rest of us can help provide.

I am aware that connecting cancer patients, vice presidents and newborn babies makes for an unusual explanation of why I sit at a keyboard. Most writing advice would probably suggest choosing a subject and sticking to it. Fortunately, nobody has asked me to run a writing school. I am interested in what happens when people find themselves in situations they did not choose, in the people who turn up to help them, and in the impressive amount of nonsense we manage to produce along the way.

I like the thought that, years from now, one of those babies might be a fully grown adult staring at a medical form, a government website or the instructions for assembling a piece of furniture, wondering who the hell wrote it. They may even become a vice president and explain it to the rest of us. First, though, they need a bassinet.

If I May… Our little local hospital has a NICU, and that NICU obviously does have the equipment it needs, except, it’s 30 years old. And getting older myself, I feel the need for rejuvenation. While that equipment works most of the time, most of the time isn’t what little people need. They need all of the time. That is why I am fundraising for that NICU, to allow them to get the up-to-date equipment they need to be effective.

If something I write makes you laugh, swear or feel a little less alone, I’m glad. I keep these publications free. If you’d like to contribute, I’m raising money to help buy bassinets and other critical equipment for the NICU at our local little hospital, where my daughter Ashley works. Those babies have a lifetime of human nonsense ahead of them. I’d like to help them get there.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Ontario held municipal elections yesterday, and here in Kitchener’s Ward 7, the incumbent, Bill Ioannidis, has been returned to city hall. Nikki Rollick, who ran against him, did not win. The city’s results are still unofficial, but the outcome is clear enough for those of us who had hoped to see someone else in the chair.

I have a suggestion for Nikki, and I hope she takes it in the spirit in which it is offered. Please don’t disappear for four years and then reappear on a lawn sign with a promise of “change.” Everybody promises change. The word has been worn smooth by politicians who use it to cover everything from a new bus shelter to the complete reorganization of civilization. You can promise change without committing yourself to a single thing that might change. It is political bubble wrap: light, entertaining for a moment, and mostly air.

What I would like from a candidate is something more demanding. Tell me what you think should happen before the vote at city hall, not afterwards when there is nothing left to do but complain about it. Tell me what the decision will cost, who asked for it, who benefits, and what objections you have heard. If you disagree with a council decision, explain why. If you agree with the incumbent, say that too. I would rather have an honest alternative than a permanent objection looking for a subject.

And if you run again and win, promise to communicate with the people you represent between elections. Hold regular meetings, send out a plain-language update, and ask residents what they think before major decisions. Call them mini referendums if you like. They would take more work than sending out a photograph of yourself standing beside a freshly painted curb, which is precisely why they might be useful.

That does not mean every council vote should be decided by whoever has the time to click on a survey. A poll that attracts the angriest fifty people on Facebook is not necessarily the considered opinion of an entire ward. Renters, seniors, parents with young children and people working shifts should have a chance to be heard too. But a councillor could at least tell us what is coming, make a decent effort to hear from us, publish what people said and then explain the vote, including when the councillor chooses differently. Apparently that is a rather ambitious proposal for a person whose job is to represent us.

As for our incumbent, I have found myself wondering what it takes to lose a municipal election. I have been frustrated by decisions at city hall and by the feeling that residents are expected to pay attention only after those decisions have been made. I cannot claim to know what a majority of Ward 7 residents thought about every vote, and an election result alone does not tell us. It would help if there were a reliable way to ask people before the next consequential vote instead of inviting all sides to declare afterwards that they speak for the majority.

Incumbents have an obvious advantage. Their name is familiar, they have held the office, and voters who do not follow every council meeting may reasonably assume that the person already doing the job knows what it involves. Challengers have to introduce themselves, explain why the job needs doing differently and persuade people to take a chance on them. They generally have a few weeks and a limited budget to accomplish this, while the incumbent has had years to become a name people recognize.

A photograph on an election sign may be all some voters see of either candidate. Some incumbents appear to have selected their photograph immediately after discovering that their campaign manager has locked the bathroom. That is their business, I suppose. I am less interested in whether a councillor can smile for a camera than in whether the same councillor can explain a vote in a way that does not require a resident to spend an evening deciphering a 300-page agenda.

Nikki, if you are considering another run, I can understand the temptation to wait until the incumbent retires. Municipal politics can resemble an exclusive parking lot where the spaces become available when the current occupant decides to leave. It is difficult to tell people that you offer an alternative when the name on the ballot has been familiar to them for years.

But I hope you keep in touch with Ward 7, whether or not you decide to run again. You don’t need a council seat to read the agenda and tell us what you would have done. You could build a record in public: here is the proposal, here is how the councillor voted, here is how I would have voted, and here is why. Residents could agree with you, disagree with you, or tell you what you missed. By the next election, they would have something more useful to judge than the word “change” printed beside your face.

Bill Ioannidis has the seat, and with it comes the chance to do the same. Tell us what is coming up. Ask us before the decision. Explain the vote afterwards. If residents disagree, give us the reasons and let us argue with them. The election sign can come down now. The job of keeping the people who live here informed is still waiting.

For F%^&* sake…

I object to the amount of preparation now required to do something I do not particularly want to do in the first place. Going outside, for example. There was a time when the distance between deciding to leave the house and leaving it was occupied by finding my keys. Now the body would like advance notice. There are shoes to negotiate, a bladder whose assurances cannot be trusted, and the question of whether the destination has chairs. I have reached an age when the availability of seating can improve my opinion of an entire establishment.

People describe this as slowing down, which makes it sound voluntary. As though I had reviewed the pace of my life and decided that putting on trousers deserved a more contemplative approach. I am quite capable of appreciating a quiet moment without having one imposed on me halfway through dressing. The mind has already gone downstairs. The rest of the organisation is still trying to get a foot through an opening it has used successfully for decades.

What annoys me is how much experience has become useless at precisely the moment I have accumulated a decent supply. I know how to cook. I know how to manage complicated work. I have lived through enough human stupidity to recognise it before it has finished introducing itself. None of this improves my ability to read pale grey instructions printed on a white packet. Somewhere, a designer has been paid to make the word “OPEN” visible only to a kestrel. Then we are told that older people struggle with everyday tasks. Give the fucking kestrel the packet.

There is a particular insult in being advised to keep the mind active while surrounded by objects that appear to have been designed by people whose minds were elsewhere. I am still Sharon’s technical support. I can deal with the phone, the settings and whatever fresh inconvenience an update has introduced. Yet my date of birth apparently qualifies me for an explanation delivered slowly enough to permit translation into a language I already speak. Being helped by someone who has mistaken age for concussion requires a degree of restraint for which there ought to be a separate pension payment.

Of course, one must remain active. I walk. I exercise. I am doing my part. What I resent is the conversion of ordinary existence into homework. A walk used to be a walk. Now it can be entered as evidence that I am taking appropriate steps, literally, to prevent deterioration. Sitting down afterwards feels faintly incriminating. There is always some cheerful bastard in a photograph hanging off a mountain at eighty-seven, making the rest of us look negligent because we would prefer to eat lunch on reasonably level ground.

The public face of ageing has become unbearable. Everyone in the advertisements is silver-haired, lean and laughing on a bicycle. Their trousers fit. Their knees have apparently signed something. They are discovering Tuscany, starting businesses and having the sort of sex for which a pharmaceutical company would like the credit. I would like to see an advertisement in which a man of my age is looking for his glasses while wearing them, becomes irritated when this is pointed out, and continues to be irritated after accepting the evidence. I could respect that man. I would understand his position on Tuscany.

Cancer treatment has added its own contribution to the proceedings. Hormone therapy gave me weight I had not ordered and a relationship with my own clothes that can best be described as a dispute over occupancy. The clothes have retained their original dimensions with offensive consistency. I am the one expected to explain myself. A pair of trousers can spend months hanging uselessly in a wardrobe and still emerge as the disciplined party. Meanwhile, I have done the treatment, put up with the hot flashes and carried the resulting body around. The trousers have contributed a zip.

Then there is sleep, that modest pleasure which becomes an evening of negotiations followed by several trips to the toilet. People speak warmly of sleeping like a baby. Babies have staff. They can soil themselves, scream and have someone else deal with the consequences. An older man is expected to get up quietly, find his own way and avoid waking his wife. By morning he has completed several small expeditions and is asked whether he feels rested. Rested enough to resent the question, certainly.

Retirement was supposed to remove the need to account for my time. Instead, the calendar acquires appointments for the maintenance of the person who owns it. There is something particularly mean about spending your working life looking forward to having a free Tuesday, then using it to explain your bowel habits to someone who is running forty minutes late. The freedom is technically there. I am free to choose which magazine from 2019 I would like to hold while waiting.

The vocabulary also needs work. “Young at heart” is offered as a compliment, presumably because old anywhere is a defect requiring an exemption. I have had heart surgery. I would appreciate a compliment that leaves the organ out of it. “You’re only as old as you feel” is another generous contribution from people who should have stopped after hello. Some days that calculation would make me eligible for protection as a historic building. There would be restrictions on altering the frontage and a small grant towards the roof.

I am aware that I am expected to be grateful. Someone always arrives with the observation that getting old is better than the alternative, as though I were taking bids. I understand the alternative perfectly well. Understanding it has not made nocturia delightful. When a restaurant serves a bad meal, nobody suggests that I should appreciate having avoided starvation. Yet complain about ageing and suddenly the only acceptable comparison is a coffin. It is a very effective way of winning an argument against a man who merely wanted to discuss his knee.

Nor do I especially want to be young again. I have been young. The evidence includes decisions, marriages and trousers that nobody needs to revisit. I would, however, like to keep the judgment acquired at considerable expense and recover a few of the physical arrangements under which it was purchased. I see no reason why wisdom should require getting up in the dark to urinate. There is no educational connection. I have learned everything that bathroom has to teach me.

What I want is an ordinary afternoon in which the body has no announcements. I would like to do something foolish because I have chosen it, rather than because a knee has withdrawn its support during an otherwise sensible activity. I would like people to stop congratulating me for doing things “at your age,” a phrase that manages to turn buying a cucumber into a small victory over the grave. And I would like the right to be bad-tempered without someone wondering whether I have had enough fluids.

And I resent the speed at which the remaining years are discussed. When you are thirty, ten years is practically a separate civilisation. At sixty-nine, someone can casually suggest doing something in ten years as though asking you to keep a Thursday free. I may be available. There are several departments to consult. I dislike the assumption that time remains an uncomplicated resource, particularly when so much of it is being spent on hold.

The worst part is the pressure to make peace with all this. Acceptance is admired, especially by people who find your objections inconvenient. They would like an agreeable old man who takes his pills, appreciates the sunset and causes no difficulty during the disposal of his possessions. I have no intention of becoming easy to dispose of. There are things in this house that I have kept for no defensible reason, and I expect to extend the same courtesy to myself.

If someone eventually has to write an account of my final days, I hope they resist the temptation to say I slipped away peacefully. Check with Sharon first. There is a reasonable possibility I was arguing about something, and I would hate to have death credited with winning a discussion merely because I stopped answering.

If I reach a hundred, there will probably be a request for my secret. Someone will want a quotation about staying curious, eating properly or greeting each morning with gratitude. I shall have had another thirty-odd years to consider the question, provided nobody has hidden the answer in pale grey print. They can put the cake within reach and bring me a chair. If they want me to stand for the photograph, they can come back tomorrow.

If I May… I have had nearly sixty-nine years to become this difficult. Some babies need help getting through their first few days. My daughter Ashley works in a NICU, and I keep this publication free while asking anyone who can contribute a little to help us buy bassinets and other critical NICU gear. If the writing gave you a laugh, please consider a donation. The babies have yet to form an opinion about me, which makes them a particularly deserving audience.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

I have discovered a remarkably effective way to meet women in the street. You allow a very large dog to put his nose in their crotch, then step forward to apologise. The dog receives affection. You receive permission to explain that he is friendly. Within seconds, two strangers are having a conversation that neither would have started otherwise, and the animal responsible for the intrusion is being told what a lovely boy he is.

This was Oliver’s method. He had a habit of sniffing the crotches of people we met on the street, which I suspect did more for my social life than anything I could have managed through ordinary conversation. I might have tried a pleasant greeting or a remark about the weather. Oliver went straight to the part of the acquaintance most of us leave entirely unexplored.

It was extraordinarily effective. A stranger could be walking along, occupied with her own affairs, and suddenly find that her affairs were of considerable interest to a Newfoundland. There would be a reaction, some rearrangement of bodies, and then we would be talking. I cannot recommend it as a technique for men. Oliver had permissions that I have never possessed, even in the more permissive periods of my life.

The remarkable thing was how readily he was forgiven. Here was an animal conducting an unsolicited investigation at groin level, and somehow I was the one left looking awkward. He could remain quite composed while I attended to the social consequences. Then a hand would go down to his head, the voice would soften, and the interview would continue on terms more acceptable to everyone.

Women were particularly susceptible to his charms. “You’re gorgeous.” “What a handsome boy.” “Look at that face.” I would be standing close enough to hear every word, holding the leash and trying to remember whether anyone had ever been that pleased to meet me. Oliver had contributed no wit, asked no thoughtful questions and arrived without trousers. Apparently I had been overpreparing for social encounters.

He also had the advantage of being male, which made the comparison difficult to ignore. A woman could admire his beautiful eyes while I stood beside him with a face I had taken the trouble to shave. He had made no effort. He had no intention of making an effort. If the encounter required any improvement in presentation, I would be the one removing something unpleasant from his fur.

There were no conversational expectations, either. Nobody asked Oliver what he did before retirement or waited for him to say something interesting. He could breathe heavily while a woman stroked his head and be considered excellent company. Were I to stand in the street panting while a stranger rubbed my ears, the gathering would become larger and somebody would eventually ask whether I knew what day it was.

What I find especially impressive is that all these conversations failed to establish my name. People knew Oliver. They recognised him, greeted him and stopped for him. I was “the man with the big black dog.” Decades of existence, employment and assorted complications had been reduced to a description that would also have worked perfectly well for whoever happened to be holding his leash.

I was identifiable, certainly. If someone mentioned the man with the big black dog, people knew whom they meant. But there is a difference between being known and being located. I had become a useful point of reference attached to a much more interesting creature. My name would have added very little to the conversation, rather like learning the first name of the person who delivers your favourite wine.

Now Isabel has taken over the public position, and I have been given a new title. I am “the man with the wonderful puppy.” There was no discussion about whether, after all these years, we might try Hans. The dog changed, so the description changed. I remain the man. Apparently that part of the information has been sufficient throughout.

With Isabel, the enthusiasm begins well before anyone reaches us. There is a particular expression women get when they see a Newfoundland puppy coming towards them. Their faces soften, their pace changes, and they begin speaking in a voice suggesting that something wonderful has finally happened in a day otherwise occupied by adults. For a brief and wholly unjustified moment, I can enjoy the sensation of a woman being delighted by my approach. Then she bends down.

The conversation reaches me when information is required. How old is she? What does she weigh? What is her name? I provide the facts, after which Isabel is addressed personally. “Isabel! What a beautiful name!” Mine is Hans, should the interest ever extend this far up the leash. So far, nobody has asked my age with any intention of following it with a cuddle.

I understand the attraction. There is a great deal of Newfoundland to admire, and the fur offers a much more rewarding place to put a hand than anything I am wearing. I am simply observing that the standards are generous. Hair on everything, dampness around the mouth, very little concern about personal space: these qualities have done nothing for the reputations of men I have known. On a dog, they encourage people to come closer.

Nor is there much opportunity to compete. If Isabel leans against a woman’s legs, it is affection. If I tried it, I might be forgiven on the assumption that my knee had given way. If she rolls over, someone may rub her belly. Were I to follow her example, the encounter would probably involve a person kneeling beside me and asking whether I was taking blood thinners. The best I could hope for would be a blanket.

I do have some sympathy for the women. A dog allows them to be affectionate without having to hear a man explain his views on something. They can stroke Isabel without discovering that she has been waiting all morning to discuss a disappointing contractor. Oliver could make his interests apparent within seconds. Mine would require several paragraphs, and there is always the danger that I might ask whether they had read the essay.

Still, I cannot pretend I mind people loving them. I know what there is to love. Oliver could bring a stranger to a halt with a method that would have got his owner arrested, then turn the encounter into an exchange of affection. Isabel can make someone’s face change before a word has been spoken. I am there for the mud and the less flattering discoveries under bushes, so I am happy to stand beside the public admiration and hold the leash.

It would be pleasant to have a name, though. Perhaps I should introduce myself more firmly, while Isabel is being admired and before everyone moves on. “Hans,” I could say. “My name is Hans.” A woman might look up, smile and say how lovely it is to meet me. Then she would turn back to Isabel and tell her what a clever girl she is to have brought him along.

If I May… My dogs get strangers to stop in the street. I’m hoping to get a few readers to stop here and consider a donation for NICU equipment, supporting the work my daughter Ashley and her colleagues do. The writing stays free. If you can spare something for the smallest patients, thank you. A polite appeal will have to do; Oliver’s methods are unavailable to me.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. Always. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share

I have become rather cynical about the pharmaceutical industry and the medical-industrial machinery surrounding cancer, particularly when an encouraging statistic arrives with no explanation of what, exactly, improved. Earlier detection, yes. Find the bloody thing while something useful can still be done. But finding it earlier does not, by itself, mean I will live longer. It can improve the recorded survival rate simply by giving the record an earlier starting date. Diagnose me five years sooner, let me die on precisely the same day, and suddenly I am a much more impressive survivor. I have gained five years of knowing I have cancer, which strikes me as a peculiar benefit to advertise without qualification. If a treatment buys me more life, I want it credited honestly. If somebody has merely started the stopwatch sooner, I would prefer they stopped congratulating themselves while I am still paying for parking.

There is a way to give a cancer patient another five years of survival without giving him another afternoon. Find his cancer five years earlier, keep his date of death exactly where it was, and count from the new starting point. The arithmetic is impeccable. The funeral remains on Thursday. I find this an unsettling arrangement, particularly when the person being congratulated on his improved survival might be me.

Imagine two versions of the same man. In one, his cancer is diagnosed at 68 and he dies at 72. Four years of survival. In the other, it is found at 63 and he still dies at 72. Nine years of survival. We have more than doubled the number without extending his life by the time it takes to butter toast. He crosses the five-year survival threshold in the second version and misses it in the first. Same man, same disease, same lifespan. Much better presentation.

Medicine calls this lead-time bias. The American National Cancer Institute explains it quite openly, which rather spoils any ambition I might have had to expose a secret medical conspiracy. The information is available. The trouble begins when “longer survival after diagnosis” arrives in ordinary conversation wearing the clothes of “longer life.” Those phrases sound interchangeable until you are the poor bastard whose remaining years are being measured.

And yes, catching cancer early can save lives. Earlier treatment can sometimes cure disease that would become much harder to treat after it spreads. Nothing in this argument is an invitation to ignore symptoms or postpone an investigation because a retired Belgian has become suspicious of a graph. Equally, a late diagnosis does not automatically mean you are toast. Some people live for years with controlled metastatic cancer. The type of cancer and its behaviour matter, and the toaster is a poor instrument for individual prognosis.

What bothers me is how easily a sensible proposition, that finding certain cancers earlier can help, becomes a universal claim that finding anything earlier proves we have helped. The first requires evidence. The second requires a sufficiently reassuring voice. As a patient, I would prefer that the evidence arrive before the reassurance, although I appreciate that this complicates the appointment.

The statistical advantage can attach itself to whatever happens after diagnosis. Operate, irradiate, prescribe medication, or monitor the patient: if you begin counting earlier, the recorded interval before death can lengthen even when the intervention adds nothing. That does not mean every treatment result is false. It means the calendar can contribute to the apparent achievement, and someone should separate its contribution from the surgeon’s before we order the commemorative plaque.

Even “wait and see” can acquire a magnificent record under these conditions. Find a cancer earlier, observe it for years, and the patient accumulates survival time while everyone watches. Those years are real. Whether finding the cancer created any of them is a separate question. I would like that distinction kept visible, preferably in lettering at least as large as the claim of success.

There is another advantage hiding in the patient list. Screening tends to find slower-growing cancers because they remain available to be found for longer. This is length bias. A disease that moves slowly gives a scheduled test more opportunity to catch it than one that develops and causes trouble between appointments. The screened group can therefore have better prospects before anyone has demonstrated that the screening improved them.

Then there is overdiagnosis: finding a cancer that would never have caused symptoms or death during that person’s lifetime. Add these cases to the survival figures and the percentages improve. The disease did not need to be defeated for the patient to avoid dying from it. Nevertheless, once you have diagnosed him, his continued existence becomes available for inclusion in the results.

I can imagine the annual report being very pleased with this man. He has supplied a diagnosis, attended his appointments and remained alive. An exemplary participant. His own contribution to the apparent success may have consisted largely of having a cancer that was never going to kill him, a qualification he would probably have preferred to enjoy without knowing about it.

That is also why sensible observation deserves more respect than the phrase “doing nothing” allows. For selected prostate cancers, active surveillance means monitoring for changes and retaining the option of treatment; watchful waiting generally places more emphasis on treating symptoms if they arise. Choosing surveillance can spare or delay treatment harms. But its results still need to be interpreted in light of which patients were selected and how their cancers were found.

I have had radiation and hormone treatment. I would very much like them to have bought me time, and I have no interest in dismissing that possibility to make a sarcastic paragraph work. My scepticism is directed at the ease with which a patient can be handed an encouraging number without being told precisely what it measures. Once the word “survival” appears, asking about the calculation can feel indecent, as though you are checking the price tag on your own rescue.

A fair test of screening follows comparable groups from a common starting point and asks whether fewer people die of the cancer. Randomized trials help make that comparison. Treatment trials can likewise compare strategies among comparable patients; starting diagnosis earlier does not automatically erase a real difference between their outcomes. We should also care about the harms incurred along the way. A longer entry in a cancer registry is a poor substitute for evidence that people benefited.

I want medicine to succeed. I am personally invested in the matter to an extent that would disqualify me from chairing an impartial committee. But if someone tells me I have gained five years, I would like to know where they put them. I already owned the years before my diagnosis. They cannot give those back to me and call it treatment.

If I May… My daughter Ashley works in a NICU, where premature and seriously ill babies need equipment that costs considerably more than a hospital bake sale is likely to raise. I keep this publication free because I don’t believe every thought needs a subscription attached to it. If you would like to support something through these essays, please consider a voluntary donation to our NICU equipment fundraiser. You owe me nothing for reading. Helping Ashley and her colleagues get the equipment they need would mean far more to me than a paid subscription.

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Leave a comment

I am not a medical doctor. What follows grew out of having to make decisions about my own cancer, drawing on years of consulting work in which I used principles from game theory, chaos theory and risk analysis to help companies make decisions when the variables were uncertain and the consequences could be expensive. Applying that thinking to my own body made the consequences considerably less abstract. It did not qualify me to prescribe treatment. These decisions are highly individual: what makes sense for me may be entirely wrong for you, and following your oncologist’s “standard of care” recommendation comes with no guarantee, just as rejecting it comes with no exemption from the consequences. Cancer care has made real advances, although a longer survival curve deserves examination: diagnosing someone earlier can lengthen the time measured from diagnosis without postponing their death.

Starting the stopwatch sooner is not the same as buying more time. Some people have years in which to consider the implications; others can be dead within eight weeks, before the family has finished insisting that everything will be fine. Shit happens, and it does not consult the reassuring literature first. Meanwhile, you are expected to decide with incomplete information about how the disease will progress, how your particular body will respond, and how much treatment you can bear, accompanied by frightened relatives whose love occasionally expresses itself as relentless whining. I developed this guide to help me think under those conditions. It cannot tell you which treatment to choose. It can help you examine what you are being told, identify what remains unknown, and recognise when “standard of care” is explaining a recommendation and when it is being used to avoid explaining one.

There is a pleasantly upholstered version of cancer care in which the patient sits down with a thoughtful team, considers several treatments, weighs the evidence, and chooses the approach that best suits the life they hope to continue living. Then there is the appointment in which someone tells you what is going to happen and asks whether you consent. You may say yes. You may say no. The brochure calls this participation.

For a Canadian patient facing that second version, advice about “weighing your options” can sound almost insulting. Which options? The surgeon recommends surgery. The radiation oncologist recommends radiation. The pastry chef recommends a cherry tart. Professional expertise has a field of vision, and the patient has to discover whether anything exists outside it. Nobody should need to become an amateur oncologist while also trying to sleep, arrange transportation and explain to the family why the word “fine” has been temporarily withdrawn from service.

“Standard of care” ought to mean that a recommendation rests on evidence and accepted clinical practice. It can be an excellent reason to recommend treatment. It becomes a poor answer when used to end the explanation. Which standard, for which cancer, at which stage, with which features, and with what adjustment for the person attached to it? A guideline can support a recommendation. It cannot answer a question nobody has bothered to hear.

The first decision, then, is whether the apparent lack of choice is medically justified. An alternative may be less effective or unsafe for you. It may be reasonable but unavailable locally, or outside provincial funding rules. Or it may simply not have been discussed. These are different problems. “We do not offer that here” and “that would be inappropriate for your cancer” should never be allowed to pass through the same sentence wearing each other’s clothes. The useful question is direct: “What alternatives did you consider, and why have you ruled them out for me?”

Game theory is useful here because information and influence are unevenly distributed. The clinician knows the treatments; the institution controls access; the patient knows what consequences they are willing to live with. Their interests overlap without being identical. The patient wants an individual judgment, while the service must also work within staffing, capacity and rules. None of this requires a conspiracy. A rushed system can produce a thoroughly inadequate conversation with everyone behaving quite respectably. In decision theory, recognising the actual limits on your choices comes before comparing them. An option you cannot obtain is not yet an option.

Start with prostate cancer. A biopsy can establish the diagnosis and provide the Gleason score or Grade Group, but that finding needs to be considered alongside PSA, the extent of cancer in the samples, imaging where indicated, and the person’s health. The Canadian Cancer Society describes several accepted approaches for localized disease, depending on risk. Suitable low-risk disease may be monitored; other situations call for treatment, with surgery or radiation-based approaches among the possibilities. The word “prostate” does not supply enough information to decide which.

If a surgeon presents removal as the only reasonable course, the productive request is a radiation-oncology assessment before an irreversible decision, where time and clinical circumstances permit. If radiation is recommended, ask why surgery is unsuitable or less attractive, whether hormone therapy belongs in the plan, and what supports its proposed duration. The question is not whether you can assemble a more appealing treatment out of spare parts. It is whether the comparison has actually been made for your disease. Sometimes both specialists will support the same approach. That agreement is useful. Two disciplines reaching a conclusion after examining the case offer more reassurance than one discipline pointing at its own equipment.

Lung cancer introduces a different difficulty: “lung cancer” can conceal distinctions that change treatment substantially. Small-cell and non-small-cell disease are different categories. Stage matters, and in appropriate non-small-cell cancers, molecular findings and PD-L1 testing help guide systemic treatment. The Canadian Cancer Society describes biomarker testing as part of this assessment. A biopsy may therefore provide information beyond confirmation that the suspicious patch is malignant.

Here, a patient offered an immediate drug regimen can ask whether the relevant pathology and biomarker results are complete, and whether any pending result could change the first treatment. That question must come with another: is it medically safe to wait for those results? A stable patient awaiting information and a patient deteriorating rapidly do not have the same decision. For early-stage disease, surgery and stereotactic radiation may enter the discussion differently depending on fitness and other features; they are not automatically interchangeable. If surgery is ruled out, ask what makes it unsafe and whether another treatment offers a realistic chance of control. Precision about the constraint is more useful than being told there are “no options.”

Breast cancer exposes how easily a major decision can be presented as though its scale proves its wisdom. Removing more tissue feels, to many people, like removing more danger. Yet the Canadian Cancer Society states that, for eligible patients with certain early-stage breast cancers, breast-conserving surgery followed by radiation has survival outcomes comparable to mastectomy. There can be medical reasons to favour one approach, and there can be practical or personal reasons. The patient deserves to hear which reasons apply.

If mastectomy is presented as the only path, ask whether tumour extent or another specific finding rules out breast conservation. If conservation is offered, ask about the radiation usually accompanying it and whether access is feasible. Before the sequence of treatment is settled, ask how hormone-receptor and HER2 findings affect the plan, including whether drug treatment should come before surgery. Those biological details can change treatment recommendations. Choosing which operation to have is a very different decision from assuming that an operation is necessarily the first step. A consent form for surgery should not quietly become consent to an entire treatment sequence nobody has explained.

Colon cancer supplies an example where the recommendation may be fairly definite without making every subsequent decision automatic. Surgery is commonly central to treatment of resectable colon cancer. The tissue removed can reveal how deeply the tumour has grown and whether lymph nodes contain cancer, information a small biopsy cannot always provide. After surgery, the discussion about further treatment depends on the final stage and other findings. Stage III disease commonly leads to a recommendation for chemotherapy to reduce recurrence risk.

Even then, “chemotherapy” does not describe one fixed package. The regimen and duration matter, as do fitness and the risk of lasting nerve damage. BC Cancer’s guidance distinguishes treatment approaches by recurrence risk and includes shorter courses for selected lower-risk stage III disease. This does not mean every patient should receive less treatment. It means a patient can reasonably ask why this regimen, for this duration, fits their pathology. A bowel obstruction may make the immediate decision urgent; a postoperative chemotherapy discussion has a different clock. Neither situation is improved by borrowing the other’s urgency.

Across these cancers, the useful request is often less grand than “give me more options.” It is “show me the reasoning.” What is the goal: cure, reduced recurrence, disease control, or symptom relief? What benefit is expected for someone sufficiently like me, over what period, and how uncertain is that estimate? What happens if I decline, and what care will still be provided? If possible, describe benefit in absolute numbers using the same outcome and time period for both comparisons. There is no requirement that the answer be cheerful. There is a requirement, if we are to call this a meaningful discussion, that it be intelligible.

Bayesian reasoning belongs here in ordinary clothes: new evidence should change the assessment when it is strong enough to do so. A pathology review, a staging scan or an applicable biomarker result can change the recommended treatment. Another search result chosen because it agrees with us may change nothing except our mood. The value of further information depends on whether it could alter care and whether obtaining it is worth the delay or risk. This is a better basis for requesting another test than the understandable wish to keep testing until something reassuring turns up.

Chaos theory offers a limit on our expectations, not a replacement treatment plan. In some nonlinear systems, small differences in starting conditions can produce large later differences. That does not prove that a particular tumour’s course is chaotic, or make established evidence irrelevant. The practical lesson I take from it is to leave room for reassessment when biology behaves differently from the forecast. A protocol should have ways to respond to progression or harmful side effects. “We started this, therefore we finish it” is a description of stubbornness, not a sufficient clinical argument.

But sometimes, after proper review, the honest choice really is the recommended treatment or declining it. A second opinion cannot manufacture an equally effective, painless substitute. Then the decision concerns whether the likely benefit is worth the burden to you, with as much help managing that burden as medicine can offer. Accepting can be reasonable. Refusing can reflect a person’s considered priorities. Neither becomes more informed because someone has decorated it with the word “brave.” What matters is understanding the consequences, including the uncertainty, and knowing that refusing one intervention does not make the need for care disappear.

When the explanation remains inadequate, ask for review by the relevant multidisciplinary team or an independent second opinion, with a clear answer about how long it is safe to wait. The Canadian Cancer Society recommends asking the treating doctor or family doctor for a referral, including to someone not closely connected with the first clinician. That is a route to request, not a promise of immediate access. A cancer-centre navigator or patient-relations service can help pursue an unanswered referral or communication problem, although they cannot invent capacity or guarantee a different treatment. The unfairness is that a frightened, exhausted person may have to chase the process. Calling this “empowerment” does not make the phone calls any less theirs.

If you have just been diagnosed, begin by obtaining the pathology report and asking what has actually been established. A biopsy usually supplies the first firm identification of these cancers, often with a grade or biological features that help guide treatment. It does not necessarily establish the full stage, and an inadequate sample may leave questions unresolved. Ask what is confirmed, what remains provisional, and whether more imaging, tissue testing or review is needed before treatment is chosen. You need a plain-language explanation alongside the report. Handing someone a collection of abbreviations is not the same as informing them.

A biopsy should usually be taken seriously when the result is needed to confirm cancer or choose treatment, but it still requires consent and a judgment about benefit and risk. It is not automatically necessary before every intervention. In selected suspected early lung cancers, for example, biopsy may be unsafe or impractical, and a specialist team may consider treatment on strong clinical and imaging evidence after careful review. Sometimes diagnostic tissue is obtained during surgery rather than beforehand. Ask what the biopsy would establish, how it would be obtained, and what would change if it were omitted. Refusing it may leave clinicians unable to recommend a treatment confidently; insisting on it regardless of circumstances can also cause harm.

Next, establish the actual deadline and the person responsible for the next step. Ask whether a brief interval for completing tests or obtaining another opinion would affect the prospect of successful treatment. Do not assume that all cancers permit leisurely reflection, or that every appointment marked urgent requires a decision before you leave the room. Bring someone who can take notes if that helps, and ask the team to account for your other illnesses and medicines. State the consequences you most want to avoid. Clinicians cannot include a priority they have never heard, and they should not assume that every patient ranks those consequences identically.

Before agreeing, ask the clinician to connect the recommendation to your findings: “Because my cancer has these features, you recommend this treatment, with this expected benefit and these risks. Have I understood?” Ask what findings or side effects would make the plan change, whom to contact, and when unresolved questions will be answered. You do not need to win an argument, prescribe your own drugs, or charm the department into liking you. You need to understand what you are authorising. “Standard of care” may belong in that explanation. It should not be the point at which the explanation stops.

If I May… If I May… If one made you smile, you might consider leaving the oncology economy briefly and making a small donation to our NICU fundraiser. My daughter Ashley works at the local hospital’s neonatal intensive care unit, where parents face decisions about someone they have barely had time to hold. I cannot offer those families certainty, but I can ask for help buying equipment for the people caring for their babies. This publication stays free. If you would otherwise pay to read my work, please consider putting that money towards our NICU fundraiser instead. Give what you can comfortably spare. The purpose is practical: equipment that nurses can use, for babies who need their care, while their parents wait for news.

There is no obligation, no subscription and certainly no guilt. Just an opportunity to turn a few words on a screen into something wonderfully practical for a very small person who has barely arrived and could use every silver lining we can give them.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

I found that there is a peculiar moment after one tells someone you have cancer when they begin looking for a version of your diagnosis they can enjoy. You can almost see the search taking place. The face tightens, the head tilts, and then something reassuring surfaces from an article they half-read while waiting for a haircut. “Oh, but that’s the good kind.” There we are. You have cancer, but fortunately they have found a way to feel better about it.

I would like to know where this good cancer is being distributed. Presumably there is a counter, somewhere beyond diagnostic imaging, where the more discerning patient can select a pleasant malignancy. Something restrained. Nothing that interferes with sleep, bodily functions, marriage, income, or the ability to hear the telephone ring without wondering who has found what. Perhaps it comes with complimentary parking. I would certainly have asked about the parking.

There is no good cancer. There are cancers with better prospects than others, and hearing that treatment has a good chance of working can be an enormous relief. Those distinctions deserve proper explanation. They do not require the patient to stand there looking pleased to have qualified for the more respectable end of the catastrophe. A doctor explaining why there is reason for hope is doing useful work. Someone announcing that you got lucky before you have even absorbed the diagnosis is hurrying you through an emotion they would rather not witness.

“At least,” they say, and already I want to confiscate the rest of the sentence. At least they found it. At least it hasn’t spread. At least you’re older. That last one has a particularly thoughtful quality, as though you have already had sufficient use of your organs and should be prepared to return them without making a scene. Yes, I have lived for a while. I had also made arrangements for next week.

The trouble with “the good kind” is that it follows you home. Once your cancer has been classified as a minor administrative inconvenience, your distress begins to look excessive. You are frightened, but didn’t we establish that this was the nice one? You are exhausted, but surely you should be grateful. You mention what treatment has done to your body, and somebody reminds you that it could be worse. It could always be worse. This is an extraordinarily low standard for deciding whether another human being is allowed to be miserable.

I have had radiation, brachytherapy and hormone treatment for prostate cancer. I have also had hot flashes, disrupted sleep and a catheter. I am prepared to discuss the purpose of the treatment and be grateful that it was available. I see no reason to provide a favourable review of the entire experience. The catheter, in particular, did very little to persuade me that I had purchased the deluxe package.

Then come the investigators. Having established that your cancer is quite a good one, they would like to determine what you did to acquire it. Did you eat properly? Were you under stress? Did you exercise? There is a tone people use when asking these questions that would be more appropriate if you had driven the car into a canal. Somewhere, they suspect, there is an avoidable mistake. If they can identify yours, they can go home feeling protected by their own superior habits.

I understand the temptation. I would also prefer a world in which disaster arrived with an itemised explanation and could be avoided by eating a different breakfast. It would make shopping considerably more consequential. Unfortunately, having a risk factor does not make cancer inevitable, and having a lower risk does not make someone exempt. Prevention matters. It does not give the rest of us permission to conduct a character assessment at somebody’s bedside.

So, to the newly diagnosed person examining every meal, every missed walk and every difficult year: no, this is not your fault. You have no obligation to assemble a prosecution case against yourself. Even where a past exposure or habit contributed to risk, that is something to understand and discuss with your medical team. It is no justification for shame, and it does not reduce your entitlement to care. You do not have to prove that you lived faultlessly before anyone is allowed to feel sorry that you are ill.

The implied moral ranking is particularly ugly. We seem quite comfortable offering unqualified sympathy to someone who can demonstrate an immaculate history, then adding conditions for everyone else. “Never smoked,” people say approvingly, as though preparing a reference. And if the person did smoke? Are we to send a smaller card? Withhold the soup? I would like compassion to survive the discovery that its recipient has behaved like a human being.

Attitude provides another opportunity to make the patient responsible for absolutely everything. You must stay upbeat. You must believe. You must fight. The US National Cancer Institute says there is no convincing scientific evidence linking a person’s attitude to their risk of developing or dying from cancer. Yet the amateur morale department remains fully staffed. Now, on top of being ill, you have to watch your facial expression in case someone thinks you are assisting the tumour.

There is a particular cruelty in telling people they will get through this because they are strong. Think about what that sentence leaves behind for the people who don’t. Think about their families hearing that somebody else survived because they refused to give up. I have no objection to a patient calling themselves a fighter if that language helps them. I object to handing everyone a uniform and then treating death as evidence of poor performance.

If you have just been diagnosed, you can be frightened without apologising for it. You can be angry without adding that you know how lucky you are. You can enjoy an afternoon and then have a dreadful evening without having betrayed either version of yourself. Nobody should be marking your consistency. You have enough appointments without submitting to a daily assessment of whether you are doing cancer attractively.

You can also ask the doctor to explain something again. “What does that mean for me?” is a reasonable question, even when the person answering has somewhere else to be. You can want facts and still find them frightening. You can want someone beside you who writes things down, because you would prefer to leave the appointment with something more useful than a remembered phrase and a parking receipt.

And those of us wondering what to say could begin by abandoning the ambition to fix the situation with a sentence. “I’m sorry. That’s shitty news” leaves considerably less damage than a cheerful announcement about the quality of the cancer. We can ask whether the person wants to talk. We can offer something concrete that we are actually willing to do. Then we can listen to the answer, including when the answer is that they would rather be left alone.

If I bring you dinner, you will not have to earn it by sounding hopeful. You can tell me you are terrified, complain about the food, or ask me to leave it at the door. I will put your name on the container. There will be no space underneath for a grade.

Donations to the GoFunfMe for our local NICU are still very much needed and welcomed!

I once made a pumpkin cheesecake so monumentally awful that it should have ended my obligation to cook. There should have been a brief investigation, a surrender of utensils and a family member gently explaining that I could still contribute by setting the table. Instead, I remained responsible for the next meal. Apparently, once you have been a professional chef, even evidence of your incompetence is dismissed as an isolated incident. I had hoped the cheesecake might establish reasonable doubt. A household willing to eat that and still put me in charge of dinner has made its own decision. Whatever happens afterwards is shared responsibility.

I hate baking. Baking requires a degree of obedience I find difficult to summon for something I intend to eat. It wants exact quantities, exact temperatures and the sort of attention to a clock normally associated with defusing explosives. Cooking allows me to taste something and interfere. Baking asks me to follow the instructions, put it in the oven and spend forty minutes wondering whether my personality has ruined it.

If a sauce needs something, I can add it. If a cake needs something, I generally discover this after it has acquired the structural integrity of a patio slab. By then, adding another egg would create more questions than it answered. The pumpkin cheesecake was an especially forceful reminder that professional experience does not exempt me from reading the bloody recipe.

My difficulty is that I can understand an instruction perfectly well and still feel that it probably does not apply quite so strictly to me. Somewhere between measuring and mixing, I begin negotiating. Does it really need that long? Is the distinction between these two quantities going to matter? Baking answers these questions in public, usually after everyone has been told there will be dessert.

Ordinary cooking suits my temperament better, although “suits” should not be taken to mean that I move through the kitchen with effortless grace. I am clumsy. I am impatient. I can know perfectly well that something needs another few minutes and still stand over it with a spoon, behaving as though my dissatisfaction ought to accelerate the process. The food continues cooking at its own speed, which I consider unnecessarily provocative. There is a considerable gap between knowing how something should be done and being willing to wait while it happens. I have spent enough time in kitchens to recognise that gap. I still occasionally try to cross it by turning up the heat.

Being a former professional chef has nevertheless condemned me to cook every single meal in this house. My qualifications have outlived my employment and now function as a domestic court order. Retirement apparently means I no longer have to cook for strangers. The people who know me can still demand service, and they know exactly where to find me.

Most days, we have something almost edible on our plates. Some days, I make too much, and Sharon gathers whatever remains into little plastic containers, announcing that she will have it for lunch tomorrow. She says this with such conviction that I continue to believe her, despite living in the house where the lunches are supposed to occur. Tomorrow arrives, lunch comes and goes, and the container remains untouched. Six days later, I throw it out. This happens every single day. I cook the food, Sharon grants it a temporary reprieve, and I eventually carry out the sentence.

The quantities are extraordinary. Half a potato. A spoonful of vegetables. Enough chicken to make a sandwich if the bread does most of the work. Each receives its own little container, because apparently separating the survivors improves their prospects. Sharon sees tomorrow’s lunch. I see six things I will eventually have to scrape into the bin before washing the containers so they can be issued to the next intake. We own enough plastic to preserve the contents of a modest hospital, all of it occupied by food she is definitely having tomorrow.

By the sixth day, I can no longer remember what some of it was. The original meal has never been found. Its alleged remains are available for examination, but I am reluctant to disturb them. I lift a lid with the expression of a pathologist who has recognised the shoes. I cooked this. These are my professional qualifications staring back at me from beneath a film of condensation. Somewhere between dinner and Sharon’s proposed lunch, my work has become something I would hesitate to feed to a person against whom I held a serious grievance.

I could throw it away sooner, but that would be interfering with her lunch. For several days, it remains protected by an intention. Eventually, visible deterioration gives me the authority that experience could not. I dispose of it, wash the container and leave it to dry. That evening, Sharon puts another little portion inside and says she’ll have it for lunch tomorrow. I put it in the fridge beside the others, where Wednesday’s lunch is still waiting for her to finish Thursday’s.

My professional response is to make something else out of it. This usually requires adding enough ingredients to produce further leftovers. I begin with a small amount of chicken that needs using up and finish with a dish large enough to require a seating plan. Then I put what remains back in the fridge, having successfully increased the problem and dirtied another pan.

I also use cooking for Ethan’s character development. This sounds more considered than admitting I would like some help with dinner, but I do think there is something useful in having to produce food that other people are waiting to eat. Ethan thinks… well, I don’t know what Ethan thinks. I should probably establish that before claiming to have developed his character.

What I can offer him is practical experience of cause and effect. A potato remains unpeeled until someone peels it. A pan needs watching even when nothing especially entertaining is happening inside it. Dinner does not appear because you have been aware of its absence for twenty minutes. These are useful discoveries, although I am teaching patience while personally resenting the time it takes an onion to soften.

He also has the opportunity to observe an experienced adult making mistakes. I consider this a generous educational service. There is very little value in presenting young people with an elderly man who claims to know everything, particularly when that man has a pumpkin cheesecake on his record. Ethan can learn the correct method and watch me become annoyed by the need to use it, all within the same lesson.

Cooking has been a good way of bringing our blended family together, too. People can work beside one another without being required to discuss the state of their relationship. There is considerable relief in being handed a potato instead of being asked how you feel about the family arrangements. You can contribute, be useful and get to know someone while retaining the right to look down at your hands.

And when things go wrong, everyone shares the experience. The cook has to sit down and eat the evidence. I cannot give a professional explanation of why dinner is disappointing and then leave for a restaurant. I am at the table with the people I have fed, working through the same mistake and hoping nobody asks whether there is more.

When it works, though, I get enormous satisfaction from it. I like taking ingredients that have no apparent business together and turning them into something people want to eat. There is something sensual in the handling and tasting, in making a small adjustment and feeling it work in your mouth. It is very satisfying to get that right, particularly after spending part of the preparation looking for an object that turns out to be in my hand.

Then everyone says it is wonderful, and I immediately begin examining the reliability of the witnesses. They seem pleased. They are eating. Some want more. Meanwhile, I know the sauce could have been better, or I should have waited before doing something I knew I ought to wait before doing. Compliments have to fight their way past a man who was present throughout the preparation and has retained all the evidence.

It must be faintly irritating to praise someone’s dinner and receive a description of its defects. You are enjoying what is on your plate, and the person responsible starts telling you about the superior dinner he failed to make. I can see the problem. Being able to see it has not always prevented me from continuing.

I am trying to let people enjoy their food without requiring them to attend the review meeting. Sometimes good is good enough. Everyone has eaten well, Ethan has had an opportunity to acquire character, and I have managed to feed the family despite being clumsy, impatient and convinced I could have done better. When someone says it was wonderful, I can say thank you and pass the rest. The pumpkin cheesecake remains outside this arrangement. Anyone who called that wonderful owes me an explanation.

If I May… My pumpkin cheesecake proved that professional qualifications offer no guarantee of a satisfactory outcome. My daughter Ashley’s work in the NICU requires rather more dependable skills. Thanks to your generosity, we have raised more than $50,000 CAD so far to help buy two bassinets and other equipment for babies who need that care. These essays remain free. If you enjoy them and can spare a donation, please help us close the gap through the GoFundMe link. Nobody who contributes will be required to eat the cheesecake.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Canada Has Started Sharing. Apparently Nobody Likes It.

I read a headline suggesting that Canadian winters could threaten Europe, and my first thought was that we really ought to have been consulted. We have been trying to get rid of the bloody thing for years. If Europe is interested, we can arrange delivery, although I would recommend being home when the package arrives. You do not want February left on your doorstep.

Apparently, sending smoke into the United States was insufficient. Now we are implicated in the possible refrigeration of another continent. For a country whose international reputation has depended heavily on being pleasant and relatively easy to overlook, this is an alarming expansion of our activities. At some point someone will accuse us of weaponising November, and I will have difficulty providing a convincing defence.

The smoke, admittedly, was ours. In June 2023, and again this year, smoke from Canadian wildfires spread over the northeastern United States, producing dangerous air and the sort of skies normally used to announce that civilisation has fifteen minutes left. Nobody ordered Canadian forest, lightly incinerated, delivered directly to Manhattan. It arrived anyway. We had become the upstairs neighbour whose cooking sets off everybody else’s smoke detector, except our kitchen was enormous and on fire.

Now Europe is being warned that it could experience winters more like ours. Notice how Canada enters the discussion. A beautiful country when photographed in September, a threat to human habitation when mentioned in a European weather forecast. Nobody says Belgium faces the possibility of delightful Canadian autumns. They go straight to the part where your nostrils stick together and opening the front door constitutes a decision.

Having grown up in Antwerp and moved to Canada in 1979, I have lived on both sides of this comparison. Belgian winter gives you ample opportunity to complain about dampness. Canadian winter introduces the possibility that you have dressed incorrectly enough to require medical attention. There is a considerable difference between regretting your shoes and needing to preserve your toes.

The article itself, by Zia Weise, concerns the Atlantic Meridional Overturning Circulation, or AMOC, a system of ocean currents that carries heat northward. Its weakening could alter Europe’s climate; the likelihood and timing of a full collapse remain subjects of scientific debate. Britain’s Met Office reported research in 2025 finding a collapse this century unlikely, while still expecting the circulation to weaken. There is a serious risk to investigate and prepare for. There is no departure board in Halifax showing Winter, destination Brussels, boarding at Gate Four.

But once you put “Canadian winters” in the headline, the ocean’s complicated circulation problem acquires a return address. Somewhere in Europe, a man reading the news over breakfast is liable to conclude that those agreeable bastards with the maple leaves have finally shown their true colours. First they smoked the Americans. Now they are coming for our plumbing.

I can picture the diplomatic meeting. The European delegation wants assurances that Canada will retain custody of its weather. Our delegation explains that we have never exercised meaningful control over it, despite spending extraordinary amounts of time discussing it. The Europeans ask whether we could at least keep the wind chill. We explain that the wind chill is precisely the part we would most like them to take.

The phrase “feels like” will require its own briefing. A newly Canadianised European will look at a forecast showing minus eighteen, followed by “feels like minus thirty,” and reasonably ask why the first number was provided. Canadians will explain that minus eighteen is the temperature, while minus thirty is what happens when you step outside. This will sound like fraud. It sounds like fraud to us, too, but we have learned to put on another pair of socks while the investigation continues.

Then there is the domestic equipment. Imagine explaining the boot tray to someone who has spent years choosing the correct stone for an entrance hall. You have paid considerable money to make the entrance beautiful. You must now place a plastic reservoir beside the door to collect the dirty water coming off your feet. Guests arrive wearing magnificent wool coats above boots that appear to have been issued for inspecting a flooded abattoir. Everyone stands on one leg, pulling, while trying to remain an interesting person.

We could send instructors. A Canadian could stand beside a European driveway and explain that the work is divided into two stages: clearing the snow, and watching the municipal plough return it. The second deposit has different structural properties. You removed snow; the municipality has supplied masonry. Your instructor would then demonstrate the appropriate shovel technique and the language required when the blade hits the frozen ridge.

What troubles me is how quickly our misery becomes somebody else’s unimaginable scenario. People live here. We buy groceries in this. We stand in dark parking lots trying to determine which identical grey lump is our car. Yet when the possibility is raised elsewhere, it acquires the vocabulary of national security. I understand the concern about buildings, agriculture and infrastructure designed for a different climate. Still, it is mildly insulting to discover that your adopted country’s weather qualifies as an emergency planning exercise abroad.

Europe could retaliate by sending us August closures. Ottawa would receive a notice explaining that the entire continent is unavailable until September and that any further meteorological aggression should be addressed to an unattended mailbox. Belgium could escalate by requiring a certificate confirming that each snowflake had been registered in the correct municipality. Within weeks, winter would be backed up at the border, missing a signature.

Meanwhile, the pasted article contains an advertisement for a luxury fountain pen and, farther down, one for cashmere-lined leather gloves. The pen is an ambitious response to potential disruption of ocean circulation. Presumably, when the sea reaches your living room, you can write an exceptionally elegant complaint. The gloves show a better grasp of the material. Journalism has identified a possible catastrophe, and advertising would like to help you accessorise.

There is something painfully familiar about reading that governments are considering how to prepare while scientists need dependable funding to keep watching the system. The ocean is permitted to operate continuously; the people measuring it must periodically explain why they should be allowed to continue. I would enjoy seeing a funding committee ask the Atlantic to suspend circulation until the next budget cycle. At least then we could establish who actually has the power to stop the thing.

None of this makes Canada innocent of the emissions problem, and a friendly national reputation does not purchase an exemption from atmospheric physics. But the headline offers a much more satisfying arrangement than shared responsibility. Canada has winters. Europe might acquire worse winters. Clearly, somebody in Canada left something open. Send a strongly worded letter and ask whether the warranty covers the Netherlands.

I doubt we are becoming the most hated country on earth. The competition has considerably larger budgets and people working at it full-time. We may, however, need to reconsider how we present ourselves abroad. The maple leaf on the backpack used to reassure people. If these headlines continue, they will see it approaching and go inside to cover the tomatoes.

Should Europe need practical assistance, we can send someone who understands frozen locks, wet mittens and the particular betrayal of stepping into slush that is deeper than the boot. I would advise against sending a goodwill delegation in January, though. Canadians who discover that their destination still has green grass may prove very difficult to get back on the plane.

If I May… While Europe contemplates the horror of becoming as cold as Canada, some very small Canadians need help staying warm. My daughter Ashley works in our local hospital's neonatal intensive care unit, and I’m raising money to help purchase bassinets for babies who arrived before everything was ready. These publications remain free. If this one earned a laugh, shiver, cough or gasp, please consider a donation through my GoFundMe fundraiser. I can offer no assurances about the Atlantic, but we have a specific plan for the bassinets.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

I spent enough of my working life managing programs to recognize a badly governed one. Responsibilities become vague precisely where something might go wrong. Everyone has completed their part, yet nothing works. The person who notices this is invited to arrange a meeting. I had rather hoped retirement would release me from these people. Instead, I developed cancer and discovered that they had divided up my organs.

The oncologist manages the cancer. The urologist manages the plumbing. The cardiologist manages the pump. The pharmacist supervises the chemical traffic, and the family doctor receives copies of everything, presumably because someone must eventually explain the wreckage to the insurance company. Somewhere beneath this distribution list is an actual human being. He or she has questions, several prescriptions and trousers that no longer close. He or she has also been appointed program director without being consulted about his or her availability.

The appointment is particularly inspired because treatment has left him tired, fogged and capable of walking into a room with considerable purpose before forgetting what the purpose was. This is the candidate selected to remember which doctor changed which medication, whether another doctor knows, and whether the symptom that appeared afterwards belongs to the disease, the treatment or the department that has just closed for lunch. In most organizations, cognitive impairment would warrant an accommodation. Here it comes with additional responsibilities.

My organs, unfortunately, have failed to respect the organizational chart. They continue sharing blood, nerves and the consequences of decisions made elsewhere. A treatment can achieve exactly what one specialist intended while making life considerably more difficult for the rest of me. The body has this vulgar habit of functioning as one connected thing. You would think medicine might have encountered it before.

Imagine running a construction project this way. The electrician is satisfied. The plumber is satisfied. The structural engineer has issued a reassuring report. The house is underwater and occasionally catches fire, but each contractor can demonstrate that the problem falls outside his scope. The owner is advised to keep a diary of when the flames occur and contact whoever installed the bathtub. This would produce litigation in construction. In health care, the owner is encouraged to become an informed participant.

There is a great deal of enthusiasm for patient participation. I understand the appeal. The patient is already there, knows his date of birth and can be paid absolutely fuck all. Give him access to a portal and he can become the records department as well. He can transport information between professionals who have years of training, institutional email addresses and apparently no reliable way of establishing what the person down the road has just done to him.

Then comes the advice to speak to your family doctor, delivered with the confidence of someone suggesting you consult the instruction manual. In Ontario, this assumes possession of an increasingly coveted item. The family doctor has become the health-care equivalent of a rent-controlled apartment: if you have one, other people look at you with a mixture of happiness and resentment, and you become very nervous when retirement is mentioned.

Ontario’s March 2026 primary-care plan described approximately 1.9 million people who wanted to connect to primary care and put the goal of universal access in 2029. That is the government’s own account of the gap. I appreciate that training and recruiting people takes time. I would appreciate it more if my organs had agreed to the schedule. A pancreas cannot read a budget announcement and decide to hold off until the workforce strategy matures. ontario.ca

Nor do we make particularly sensible use of the doctors we have. In April 2024, the Ontario College of Family Physicians cited an average of nineteen hours a week spent on administrative tasks. Nineteen hours. We train people to diagnose illness and then occupy a substantial part of their working lives processing the documentation generated around it. Somewhere, a form is receiving more sustained medical attention than the person whose name appears at the top. Ontario College of Family Physicians

The shortage also changes how patients behave. When access feels precarious, you begin rationing your own questions. You rehearse them before the appointment, shorten them in the waiting room and abandon half when you see how busy everyone is. You become grateful for being fitted in, as though you had requested a last-minute haircut rather than an assessment of something occurring inside your chest. A publicly funded service starts to feel like a personal favour, and the person seeking care begins apologizing for the demand he creates by continuing to exist.

This suits the machinery beautifully. A patient who is worried about being difficult will undertake astonishing amounts of unpaid work. He will telephone one office, then another, then the first again to explain what the second said. He will learn the distinction between a referral being sent, received, reviewed and accepted, four administrative conditions during which his actual condition may continue doing whatever the hell it likes. He will become fluent in the passive voice. Something has been forwarded. Someone has been notified. Responsibility has left the building without leaving a forwarding address.

And if he cannot manage it, a spouse may be recruited. Marriage acquires a clerical department. Someone who wanted to sit beside the person they love must instead take notes, check dates and reconstruct the discussion on the drive home. The family is praised for its support, which is cheaper than employing enough people to provide it. Those who live alone, struggle with English, cannot take time off work or have nobody willing to sit on hold get to discover how much of the system’s apparent functionality depends on resources it never supplied.

I have enough project-management experience to recognize what is missing. There should be an identifiable person or team responsible for making the pieces fit, with the time and authority to do it. Sending that person a copy of every report is insufficient. In business, copying someone on forty emails does not mean you have appointed them to run the program. It means that when the program collapses, you can search your sent folder for evidence that they were informed.

So what are we supposed to do while Ontario works towards the magnificent future in which seeing a primary-care provider becomes an ordinary event? For now, I would keep a current medication list and a short record of treatment, symptoms and outstanding questions. I would ask who is responsible for following up each test, when to expect an answer and whom to contact if it does not arrive. If two instructions conflict, I would ask the clinicians to resolve them with each other. I am willing to report what happens in my body. I am poorly placed to arbitrate a professional disagreement about what should happen next.

I resent how sensible that paragraph is. It describes the very job I object to having. A sick person should be able to bring his symptoms to an appointment without also bringing the governance structure needed to prevent them from disappearing between departments. Yet refusing the work does not punish the people who designed the arrangement. It leaves you with the missing result, the unresolved question and another week of wondering.

What we should demand from Ontario is equally ordinary: enough primary-care capacity, proper administrative support, records that can be used across care settings and paid time for professionals to coordinate complex cases. A referral should remain somebody’s responsibility until the receiving service has accepted it and the patient knows what happens next. A disagreement about treatment should trigger a conversation between the people qualified to resolve it. We should judge access by whether patients can actually obtain care, and coordination by whether anybody can tell them what the complete plan is.

None of this requires every specialist to attend a committee meeting about my left testicle. I have attended enough committee meetings to know that the testicle could retire before the terms of reference were approved. It requires somebody to notice that the man receiving treatment for cancer also has a heart, takes other medication, needs sleep and would quite like to get through an afternoon without managing an incident. Those are ordinary requirements for being alive. They deserve an owner.

I am grateful to the people who have treated me. That gratitude has never included consent to become their unpaid integration department. I retired from program management, and I would like to spend whatever time treatment buys me doing something other than managing treatment. If Ontario intends to keep me in this position, it can start by giving me authority over the budget and paying my invoices. I already meet its apparent qualification for senior management: I am responsible for a great deal, control very little and cannot get the departments to speak to one another.

If I May… My daughter Ashley works in a neonatal intensive care unit, where the patients arrive before they have had time to develop organs capable of tolerating Ontario’s administrative arrangements. I’m raising funds to help buy bassinets for our local little hospital, for babies who have more urgent things to do than wait for funding. These publications will remain free. If it gives you a laugh, or puts words to something you’ve been too exhausted to explain, please consider a small donation through my GoFundMe. These patients cannot advocate for themselves, and their parents already have quite enough to manage.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Sharon and I watch the BBC in the mornings while we eat our gruel, or an edible croissant when civilisation has something to offer, and drink a latte. Or two, depending on how much encouragement consciousness requires. We watch Escape to the Country, in which prospective buyers are escorted around houses in the British countryside while we inspect other people’s kitchens without having to explain ourselves to the police. It is our version of voyeurism, conducted over breakfast with the full cooperation of a public broadcaster. Sharon’s favourite, however, is Garden Rescue, which invariably leads to suggestions. It was through this programme that I learned a suggestion can be an order whose author is allowing you a little time to imagine it was your idea. Somewhere in Britain, a man installs a raised flower bed, and in Canada I acquire responsibilities before finishing my coffee. I therefore appreciate the relative safety of inspecting houses we have no intention of buying, where I can question the wallpaper without immediately becoming involved in its removal. Then, during a visit to a house dating from the 1620s, someone called the toilet “the thunder box,” and I felt the programme had finally begun providing the sort of architectural commentary I could respect.

I admired the expression immediately. Here was a property programme prepared to acknowledge that, beneath the exposed beams and the tasteful hand towels, somebody would eventually have to have a shit. Usually, everything in these houses has been softened by language. A low ceiling is character. A staircase that could finish you off is charm. But the toilet had been allowed to retain an honest relationship with its work.

I began to wonder what would happen if the same standard were applied throughout the property. Once you have introduced prospective buyers to the thunder box, you can hardly lead them into the next room and retreat to “a delightful space for entertaining.” You have established a level of candour. The house now requires a complete inspection by someone who has actually lived in one.

Imagine the presenter trying it. The couple have come from somewhere expensive in search of somewhere expensive with fewer neighbours. He wants a workshop. She wants light. Both want character, provided it has been rewired. They have already expressed concern about a road on which another human being might occasionally drive, and now they are standing in the kitchen, waiting to be told how happy they will be there. “This,” the presenter would say, “is the Feeding and Recrimination Chamber.”

The husband would look at the range cooker. The wife would open a drawer. Neither would object outright, because both would recognise the room. This is where someone spends an hour making dinner and someone else arrives to ask whether there is anything to eat. It is where a clean worktop attracts a dirty mug from a distance of thirty feet. There is ample cupboard space for ingredients purchased during a brief period of believing you were going to become a different person, and a central island around which two adults can keep moving the same pair of scissors while accusing each other of losing them.

The presenter could point out the refrigerator, also known as the Cold Mausoleum. Inside it, vegetables bought with excellent intentions would be permitted to die in individual bags. At the back would sit a jar whose contents had become independent of the label. The viewing couple would nod approvingly at the size of the room while privately calculating whether it offered enough space to load the dishwasher incorrectly.

Upstairs, we would find the Snore Exchange, formerly advertised as the principal bedroom. The estate agent would probably prefer “Slumber Suite,” but that conceals the nightly negotiation. One person is too hot. The other has taken the duvet. Someone has started breathing as though trying to clear a blocked culvert, and the person responsible maintains, with considerable confidence, that they were awake the entire time.

The bed would be described as having room for two people and all the things they have decided not to discuss until morning. A chair in the corner would hold garments awaiting a judgment that might never come. The presenter would mention the romantic view across the garden, and the husband would test whether he could reach a plug socket without getting out of bed. At a certain point in married life, seduction has to compete with a charging cable.

Naturally, the brochure would insist on calling it an intimate space. “Yes,” the presenter could agree, “you will become intimately acquainted with noises your spouse denies making, and with the precise amount of mattress they require to turn over.” The couple would stand side by side, each silently deciding which side was theirs. Already the room would be doing its work.

The garage would be the Deferred Disposal Depot. There might once have been a car in it, but that would be a matter for the surveyor. Its present function would be to keep objects close enough that you could claim to own them and far enough away that you could avoid explaining why. Paint tins would record earlier mistakes. A broken appliance would be awaiting a repair that now depended on someone returning from retirement or the dead.

“This area would make an excellent workshop,” the presenter would say. The husband would brighten. He could already see a bench, good lighting, perhaps some shelving. His wife would be looking at the same space and seeing somewhere to put the boxes they had paid to move from the previous house, where they had spent eleven years in the garage. They would agree that it had tremendous potential, each relieved that the other appeared to understand.

Then we would enter the living room, which ought to be called the Mutual Irritation Lounge. “Living” promises a great deal for a room in which people sit quite still, watching other people buy houses. The television would occupy the best position. The furniture would face it. A window overlooking open countryside would provide the light required to see a screen showing open countryside.

Here the couple could enjoy a quiet evening in which one person asks what the actor just said and the other pauses the programme to answer, only to discover that the question was about an actor in the previous scene. There would be enough seating for visitors, although the owners would each have one particular seat from which they would resent being displaced. A low table would keep every necessary object just beyond reach. Somewhere beneath a cushion, the remote control would be waiting for a full accusation.

The rest of the bathroom would deserve its own name: the Restoration Works. The thunder box handles a specific departure. Around it stands the equipment required to get the remaining body fit for public inspection. There would be a shower in which you could wash your hair while reading the back of a bottle to establish whether you had just conditioned your elbow. Beside the basin would sit an expensive cream expected to reverse events that had taken several decades.

The mirror would need to be included in the survey. Bathroom mirrors can be vicious, particularly when positioned above lighting chosen by someone with a grudge against the human face. You lean forward to remove a hair and discover a completely new one growing somewhere that has never previously required maintenance. The magnifying side offers further information, all of it unwelcome. By the time you leave, you are clean, mildly injured, and considering a different bulb.

I can see why the presenter might hesitate before adopting my improvements. It would be difficult to maintain the asking price while explaining that the house offered generous provision for eating, hoarding, arguing and inspecting a suspicious patch of skin. The thunder box is safe because it sounds quaint. Apply the same honesty elsewhere and the buyers might begin wondering whether a move would change quite as much as they had hoped.

At the end of the imaginary viewing, the presenter would ask the couple how they felt. They would love the beams, worry about the stairs, and want another look at the Feeding and Recrimination Chamber. He would suggest they discuss it over lunch. She would remind him that there were sandwiches in the car, which he had watched her make that morning. The house would still be empty, but the kitchen would already have a buyer.

If I May… Sharon gets ideas for the garden. I have one for the NICU, where my daughter Ashley works: helping buy equipment for babies who have arrived with rather more urgent requirements than an ensuite. My writing remains free. If it gave you a laugh and you can spare a few dollars, please consider donating to our NICU fundraiser. Thank you for helping turn my questionable use of retirement into something useful.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground

Leave a comment

It is seasonal flu vaccination time, when the authorities publish the list of people they would particularly prefer to keep alive through February. People aged sixty-five and over are on it. Ontario says so, and I am comfortably inside the category, although comfort has very little to do with how I feel about being there. Somewhere beneath the sensible recommendation is the faint rustle of someone measuring me for protective packaging.

My own version of the eligibility announcement would include pregnant women, pregnant men, men who can still get erections, men who remember having erections, people without catheters, people currently negotiating with a catheter, and anyone responsible for keeping the rest of us from wandering into traffic. This would save several pages of administrative wording. Those still breathing could roll up a sleeve. Everyone else could unsubscribe.

But sixty-five deserves its own box. There is something magnificent about the confidence of that number. At sixty-four years and eleven months, you are a customer. A month later, you are a population requiring protection. Presumably, at midnight, a small hatch opens in the immune system and a civil servant climbs out carrying a clipboard. Nothing in the mirror explains the change. The government, however, has completed its assessment.

I understand that age affects risk. I also understand that a birthday is a convenient place to draw a line. What interests me is how much else gets dragged across it. A medical category acquires a personality. It starts wearing elasticated trousers. It would like a biscuit. It becomes faintly confused by the parking machine, although the parking machine has defeated several engineers and a woman who used to run an airport.

Once you belong to the older population, perfectly ordinary actions begin attracting applause. You booked online. Well done. You came by yourself. Wonderful. You know your medications. Good for you. In the imaginary vaccination clinic I am constructing for this occasion, a young employee would congratulate me for remembering my date of birth while consulting a computer that has just asked him to restart Windows. I would be tempted to help, but I would hate to interrupt my cognitive assessment.

The language is particularly exquisite. Vulnerable. At risk. Frail. Each word arrives carrying a chair. You may have spent decades making decisions, earning money, raising children and dealing with consequences that required rather more judgment than finding the vaccination tab on a website. Yet the moment your birth year is entered, the room begins preparing for your inability to cope. Someone will soon explain that the sleeve goes up.

Meanwhile, the things we remain capable of doing are remarkably extensive whenever somebody needs them done. Grandparents can look after children. Retired people can volunteer. Older relatives can provide transport, lend money, supervise repairs and spend the afternoon waiting for a delivery. Our alleged fragility is surprisingly compatible with everyone else’s schedule. The vulnerable gentleman is available on Thursday, provided nobody needs to describe him as independent.

There ought to be a form for this contradiction. Are you sufficiently elderly to require assistance? Yes. Are you sufficiently capable to collect two children, feed them, settle an argument about a charger and remain responsible until their parents finish work? Also yes. Please indicate whether your diminished capacity occurs mainly during pharmacy opening hours.

I am also fascinated by the expression “young at heart,” which people offer as though they have found a technical exemption. The heart is precisely the sort of organ I would prefer to have assessed on evidence. Youthful enthusiasm will do very little for an artery. And “age is just a number” is a splendid thing to say until the number appears on a medical form, at which point it becomes the most authoritative statement anyone has made about you all morning.

The campaign photographs would be better if they showed us as we are allowed to be. Give me an older man annoyed because the appointment has interrupted something. Give me a woman who has read the information and has a difficult question. Let someone look impatient, vain, competent or thoroughly fed up. Instead, the imaginary brochure committee keeps arranging pleasantly astonished pensioners around a bowl of fruit. Nobody in these pictures appears to have an opinion about anything stronger than pears.

And then there is the caregiver, hovering in the wording like a person authorized to take delivery. The term can cover exhausting, intimate work, but in a vaccination announcement it also leaves me wondering when I became an item that might require an accompanying signature. I can picture myself arriving with Sharon and watching a fictional receptionist direct every question towards her. She could tell them I bite. It might be the quickest way to get addressed directly.

I have no wish to make influenza prove how independent I am. I have already supplied medicine with enough opportunities to inspect my internal arrangements. A vaccine can be a sensible precaution without my having to accept a new identity built around the possibility of falling over. I would like the protection with a little less advance mourning.

So, in my version of the clinic, I would take the chair, confirm the details and roll up my sleeve. The young man would ask whether I had brought a responsible adult. I would tell him I had been one for several decades, with mixed results, and was hoping to continue. Then his computer would freeze, and we would both sit there waiting for someone qualified to help us.

If I May… I object to being described as vulnerable, but the babies in the NICU have rather more pressing concerns than my injured vanity. My daughter Ashley works there, and our fundraiser helps buy equipment for their care. These essays remain free. If one gave you a laugh, please consider putting something towards the NICU. I can manage the indignity of getting older without new equipment.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. Always. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share

There is something spectacularly wrong with a medical system when a frightened person leaves an appointment with a specialist and asks strangers on the internet to explain what happened. The specialist has the training, the records and the authority to prescribe something that could rearrange the patient’s life. The strangers have usernames. Yet here we are, posting our blood results beneath a photograph of someone’s Labrador, hoping a retired electrician in another time zone can explain why we are taking the tablets.

I keep seeing medical and pharmaceutical questions on sites supposedly intended to offer patients information and support. People want to understand their treatment, their side effects, their results, the choices they have been given and the choices nobody mentioned. I have no census of these sites, and a crowded discussion board cannot tell me how every consultation went. It can, however, make me wonder how much of the consultation has been left for the comments section to finish. At some point, “peer support” starts to look suspiciously like unpaid after-sales service for medicine.

Of course questions occur later. You hear the word cancer and the next several minutes may as well be delivered through a faulty airport loudspeaker. You nod because your head still works, and everyone mistakes this for comprehension. A question arrives in the car. Another arrives when you read the prescription. By midnight you have assembled the conversation you should have had at eleven that morning. Any system designed for actual human beings would expect this. Designing care around the assumption that a frightened patient will absorb everything immediately is like explaining the fire evacuation procedure while setting his trousers alight.

What should infuriate all of us, is the patient who still cannot explain why a treatment was chosen, what benefit it is supposed to offer, or what to do when something goes wrong. Being handed a drug name and a follow-up date does not settle those questions. Neither does “standard of care,” that magnificent phrase which can identify a defensible treatment while doing absolutely nothing to explain it. The doctor may have sound reasons. The patient is entitled to hear them in a language he speaks before being asked to live with the consequences.

The National Cancer Institute treats communication as part of cancer care, linking good communication with better understanding, less anxiety and a greater likelihood of following through with treatment. Yet explaining a treatment can still be treated as the portion of the appointment that happens if there is time after the treatment has been decided. Imagine a pharmacist handing over a bottle with instructions reading, “Discuss amongst yourselves.” We would find that alarming. Put the discussion on a website, add a ribbon to the logo, and suddenly we have a community.

And the community can be extraordinary. Another patient can tell you what an experience felt like without sanding it down into the language of a leaflet. Someone can help you find the words for a question, recognise that you need proper help, or sit with the fear when everyone else has become exhausted by your failure to be reassuring. I have no wish to sneer at people helping each other through something dreadful. I object to their kindness being used to patch a hole through which professional responsibility has quietly escaped.

Then comes the hazardous little crossing from “this happened to me” to “you should do what I did.” Two people can share the name of a cancer without sharing the circumstances that determine their treatment. “It worked for me” also leaves the word “worked” carrying an enormous load. Did the tumour shrink? Did the person sleep better? Did the scan improve after surgery, radiation, prescribed medication and a new supplement, with the supplement somehow collecting the entire credit? A testimonial can be completely sincere and still be a dreadful basis for someone else’s medical decision.

Into this uncertainty steps the natural-cure enthusiast, delighted to explain that the problem is your relationship with vegetables. Suck a carrot. Eat your blueberries with a kale infusion and wash the whole miserable arrangement down with cranberry juice. Your oncologist has apparently overlooked the produce aisle. Years of study, and the poor bastard never thought to ask the greengrocer.

I have nothing against blueberries. They have done nothing to deserve this promotion. A blueberry is perfectly respectable as a blueberry; it becomes troublesome when someone appoints it head of oncology. The National Cancer Institute says no special food, diet or supplement has been proved to cure cancer, and warns that some supplements can interfere with treatment. There are complementary approaches with evidence for helping particular symptoms, which is a different claim from curing the disease. The distinction is rather inconvenient when your business depends on sliding from “may help you feel better” to “your doctor doesn’t want you to know.”

“Natural” does a tremendous amount of unpaid work in this business. It is expected to establish safety, effectiveness and moral superiority without submitting a single piece of evidence. Cancer itself is a biological process. Nature has no difficulty producing things that kill us, and no customer complaints department afterwards. The leaf printed on the bottle tells me somebody hired a graphic designer. I would still like to know what is inside it.

The more accomplished seller understands that the unanswered question is his opening. He has time. He replies. He tells the patient that their concerns are justified, which they may well be, and then offers a conclusion that does not follow. The doctor was dismissive; therefore this extract works. The appointment was rushed; therefore the treatment is wrong. Pharmaceutical companies make money; therefore the man selling powder in monthly instalments must be acting from love. Apparently a conflict of interest disappears when the invoice is printed on recycled paper.

The packaging can be remarkably authoritative. A laboratory photograph, a diagram of a cell, a reference to a study, and a confident voice explaining a mechanism. But showing that a substance does something in a laboratory is not the same as showing that a particular dose safely helps a person with a particular cancer. That missing stretch is precisely where the work belongs. The sales pitch steps over it and lands beside the payment button. Anyone who asks for the missing evidence is accused of being closed-minded, which is an interesting description of someone still waiting for an answer.

Nor does every dangerous recommendation come from a conscious fraud. People can become missionaries for something they sincerely believe saved them. Gratitude turns into certainty; certainty acquires instructions for strangers. But good intentions do not inspect a medication list, and confidence does not establish whether somebody should delay treatment. Harm can arrive through what a product contains, what it interferes with, or what the patient gives up while waiting for the promised improvement. You can lose something irreplaceable while swallowing something that does absolutely nothing.

This is where the medical profession should resist the temptation to congratulate itself for being right about misinformation. Being right does not absolve you of leaving someone unable to understand your advice. A clinician can make an excellent treatment decision and explain it so badly that the patient becomes easy prey for someone making an atrocious one. The predator remains responsible for the lie. The unanswered question remains the clinic’s unfinished work.

I do not expect a doctor to know everything, predict everything or guarantee my survival. I expect an explanation of what is known, what is uncertain, and why the proposed decision makes sense for me. If the question needs a pharmacist, a nurse or another appointment, give it somewhere to go. “Ask your doctor” becomes a particularly vicious little joke when the patient has already asked, has failed to get an answer, and is now being sent back around the same exhausted circle.

A support forum should be able to offer companionship without having to impersonate a clinic. Patients should be able to compare experiences without accidentally conducting an unlicensed prescribing session. And someone selling certainty to frightened people should face a little more scrutiny than whether their profile photograph looks peaceful. Instead, the patient sits between a professional who may have the answer but no time to explain it and a salesman who has an answer for everything. The appointment is over. The shopping cart is still open.

If I May… The Oncology Underground stays free. I refuse to charge admission to a room where people are already having a sufficiently expensive time being alive. If you would like to support something through this writing, please consider our fundraiser for equipment for the NICU, where my daughter Ashley works. Every contribution helps put equipment in the hands of the people caring for these babies. Thank you for turning my complaints into something considerably more useful than complaints.

If you are able, the donation link is below. Every contribution, no matter the size, helps give a newborn the chance to grow up and one day argue about something much more sensible.

The essays will remain free. The bassinets, unfortunately, are not.

https://gofund.me/a0fc0777e

Share The Oncology Underground