The Big C (2010) and Stage IV Melanoma

Cathy Jamison teaches at a suburban high school near Minneapolis. She is told she has stage IV melanoma, and she tells nobody. Instead she starts behaving as if consequences no longer apply. She builds a pool. She burns the sofa she has always hated. She empties her retirement account and begins an affair.

Her hostile elderly neighbour Marlene is the first person she tells. Her separated husband Paul finds out later. Marlene's suicide is what finally pushes Cathy into treatment.

She enters a clinical trial and befriends another participant, who quits and dies. Cathy reaches remission while the family drowns in medical bills. In the third season her tumours regrow and she is told she has about a year.

Disease in her brain causes a vivid hallucination and needs surgery. She starts chemotherapy, then stops it as pointless. She sets one goal: to see her son Adam graduate. She moves into hospice, then comes home when the insurance runs out. Adam finishes school online in time. Cathy dies at home while Paul is out buying flowers.

Spoilers throughout. Cathy's four seasons are discussed here, including how the series ends.

The series names melanoma and then skips its entire beginning. There is no mole. No biopsy. No staging conversation. Cathy arrives already at stage IV.

That is a real loss, because melanoma is one of the cancers that gives an early visual warning. A viewer finishes four seasons without learning what that warning looks like.

Melanoma begins in melanocytes, the cells that give skin its colour. NCI says the first sign is often a change in the shape, colour, size or feel of an existing mole, or a new coloured or unusual patch of skin.

The checklist is ABCDE:

• Asymmetry. One half does not match the other.
• Border. The edges are ragged, notched or blurred, and colour may spread into nearby skin.
• Colour. Uneven, with shades of black, brown and tan, sometimes white, grey, red, pink or blue.
• Diameter. Usually a change in size, normally an increase. Most melanomas are wider than 6 millimetres, though they can be tiny.
• Evolving. The mole has changed over the past weeks or months.

NCI notes that many melanomas show all five features and some show only one or two. In more advanced disease the surface may break down, look scraped, ooze or bleed, and it can itch or hurt.

Melanoma also turns up where the sun rarely reaches. NCI describes melanoma under the fingernails or toenails, on the palms and on the soles, and in the eye. In people with darker skin those are the typical sites, and diagnosis tends to come later, at a more advanced stage.

Here the show and reality agree by accident. Nobody was ever going to catch Cathy's cancer with a routine test, because no such test is recommended.

The US Preventive Services Task Force concludes that the current evidence is not enough to weigh the benefits and harms of a clinician doing a visual skin check in adolescents and adults without symptoms. That is an I statement, which means unresolved rather than useless. It does not apply to anyone with a personal or family history of skin cancer, or to anyone with a changing mole or growth.

What is recommended is sun protection, and getting anything new or changing looked at rather than watched.

The show is unusually good on the money. Paul takes a job he hates purely for the benefits. The bills stack up. Cathy's hospice coverage simply expires and she comes home.

This is not decoration. For many families the practical questions arrive at the same time as the medical ones, and nobody warns them. Asking early what a plan actually covers, and what happens if it runs out, is a legitimate part of care.

The trial thread is well observed. The anxiety about whether you will qualify. Side effects read hopefully as proof the drug is working. A friend on the same protocol who does worse and stops.

What the show cannot do is admit its own age. It aired from 2010, before immunotherapy and targeted drugs reshaped advanced melanoma. Treatment for stage IV disease today does not look like the treatment Cathy is offered, and outcomes for some people are very different. Anyone using this series as a picture of current care is reading an old map.

Cathy stays photogenic, mobile and quick-witted through years of stage IV disease. Real advanced melanoma usually brings pain, exhaustion and cognitive change much earlier.

The trial delivers a dramatic remission on a television schedule. And a prognosis of "about a year" is handed over as if oncologists give numbers that cleanly. They give ranges, and they say so.

What the show gets right at the end is quieter. Stopping chemotherapy once it stops helping is a normal decision. Choosing one concrete milestone to aim for is something people really do. And dying at home, unwitnessed, is closer to reality than most screen deaths.

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The Big C is sharp about American medical bills and vague about melanoma. Its biggest omission is the beginning: the changing mole that no one in four seasons ever mentions.

Learn ABCDE. There is no screening programme to fall back on, so a spot that is changing is the whole early-warning system.

• https://www.cancer.gov/types/skin/moles-fact-sheet
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/skin-cancer-screening

This page discusses The Big C 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].