Spoiler Alert (2022) and Neuroendocrine Cancer

Spoiler Alert is adapted from the television journalist Michael Ausiello's memoir. He narrates his own life as if it were a sitcom he is reviewing.

Michael, guarded and awkward, meets the photographer Kit Cowan in a Manhattan bar in 2001. Kit is out. Michael is not, and has never had a boyfriend. Over thirteen years they build a life. They get through Kit coming out to his parents, Marilyn and Bob. They separate for a period after infidelity and Michael's withdrawal.

They are in couples therapy and back together when Kit becomes unwell. He is diagnosed in 2014 with cancer. The last act is treatment, hospital rooms and hospice. Kit's parents move close. The couple marry. Kit died on 5 February 2015. The film ends on a deliberately artificial fantasy scene before Michael starts again alone.

Spoilers throughout. The title tells you the ending, and this page discusses it anyway.

This is a real man, so the page will be careful. Public reporting describes Cowan as a photographer, Ausiello's husband, and says he died of a rare form of neuroendocrine cancer on 5 February 2015. Reviews of the film describe the diagnosis as stage 4 neuroendocrine cancer. The memoir covers the last year of his life and their thirteen-year relationship.

The primary site of the tumour is not something this page will assert. Public accounts do not agree on it, and it is not ours to settle.

The phrase sounds specific and is not. It names a family of cancers that start in neuroendocrine cells, which behave a little like nerve cells and a little like hormone-making cells. NCI says these cells sit throughout the chest and abdomen, with most of them in the digestive tract.

The family runs from slow to fast. At one end are neuroendocrine tumours, most of which grow very slowly. At the other are neuroendocrine carcinomas, which are aggressive. So two people can be told they have "a rare neuroendocrine cancer" and be facing completely different years.

That is the first useful question for anyone given this label: is mine the slow kind or the fast kind, and what does that mean for my plan?

The film compresses Kit's route in. Symptoms appear, and diagnosis follows fast. Real life is usually slower, and NCI explains why.

Some of these tumours have no signs at all early on. NCI singles out tumours of the stomach and appendix as ones that may cause nothing, and says neuroendocrine tumours are often found during tests or treatment for something else.

When symptoms do come, they depend on where the tumour sits, and they all look like ordinary complaints:

• In the duodenum: abdominal pain, constipation, diarrhoea, a change in stool colour, nausea, vomiting, heartburn, or jaundice.
• Further down the small intestine: abdominal pain, unexplained weight loss, tiredness, bloating, diarrhoea, nausea and vomiting.
• In the colon: abdominal pain and unexplained weight loss.
• In the rectum: blood in the stool, rectal pain, constipation.

Every one of those has a dozen harmless explanations. That is exactly the problem.

If these tumours spread to the liver, the liver can stop breaking down the hormones they release. NCI calls the result carcinoid syndrome. Its signs are flushing or a feeling of warmth in the face and neck, abdominal pain, bloating, diarrhoea, wheezing or other trouble breathing, and a fast heartbeat.

Flushing that keeps happening is not a normal thing to live with. It is a reason to be investigated.

NCI states that it has no evidence-based screening information for gastrointestinal neuroendocrine tumours. The CDC's list of cancers with recommended screening covers four: breast, cervical, colorectal and lung. Nothing on that list would have found Kit's cancer.

So the only early-detection tool here is a symptom taken seriously. Unexplained gut symptoms, weight loss, or flushing that will not settle deserve investigation rather than another round of reassurance.

The caregiving. The ward routines, the indignities, and the way a partner turns into a clinical secretary tracking scans and drugs.

It is unusually good on how a serious illness rearranges a family. Kit's parents and Michael were wary of each other, and illness forces them into one unit. It shows anticipatory grief honestly: the mourning starts long before the death. And it presents hospice as care rather than surrender, which matches what hospice actually is.

It also refuses to make Kit a saint. He is frightened, irritable and sometimes cruel, and the older damage in the relationship does not dissolve because he is ill.

Stage 4 disease is conveyed mostly through hair loss and tiredness. The long middle is thinned out: more than a year of treatment, including the stretches when a person is too unwell to be funny.

Several relationship details are rearranged from the memoir. And the fantasy final scene, deliberate as it is, risks making dying look like a scene change rather than a physical process.

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Spoiler Alert is a good film about being someone's carer. It is a poor map of the disease, mostly because it cannot slow down.

The part worth carrying is the delay. Neuroendocrine cancers hide behind ordinary symptoms, and there is no test that finds them in advance. If something in your gut has been wrong for months, that is the conversation to have.

• https://www.cancer.gov/types/gi-neuroendocrine-tumors/patient/gi-neuroendocrine-treatment-pdq
• https://www.cancer.gov/types/gi-neuroendocrine-tumors
• https://www.cdc.gov/cancer/prevention/screening.html
• Simon & Schuster — Spoiler Alert: The Hero Dies, by Michael Ausiello
• https://variety.com/2022/film/reviews/spoiler-alert-review-michael-ausiello-1235438892/

This page discusses Spoiler Alert for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].