The Professor (2018) and Stage IV Lung Cancer

Richard Brown teaches literature at a comfortable New England college. At a routine appointment he is told he has stage IV lung cancer. Roughly eighteen months if he starts treatment now. About six if he does not.

He declines treatment and tells nobody. That same evening his wife Veronica admits an affair with the dean. Soon after, his daughter Olivia comes out to him. Instead of falling apart, Richard begins dismantling the life he has been performing. He empties his seminar of students who are not genuinely interested. He drinks and smokes openly. He teaches with a recklessness colleagues read as a breakdown.

He confides in his best friend Peter, then in Olivia. Finally he announces the diagnosis at a faculty dinner, in front of the dean. The film never shows him in a hospital bed. It ends with him driving away with his dog, off the road and into an open field.

Spoilers throughout. Richard's diagnosis and the film's deliberately open ending are both discussed here.

This is the thing the film gets right, and it is worth defending.

Richard turns down treatment because the extra months on offer are not months he wants. That decision is legitimate, it happens, and oncologists meet it regularly. The film pointedly does not moralise about it.

It also captures how a terminal diagnosis is often felt first as social isolation rather than physical suffering. The urge to protect other people by not telling them. The awkward etiquette of when to say it. The fear of being turned into a patient by everyone who knows. When he finally tells Olivia, she is angrier about being kept out than about the illness, which is how families really take this news.

Declining anti-cancer treatment is not the same as declining care, and the film blurs the two.

There is no oncology follow-up, no palliative care team, no symptom management at all. NCI describes palliative care as care to improve quality of life in serious illness, which can be given with or without treatment aimed at curing, to anyone at any stage. It is exactly what a person in Richard's position would be offered, and exactly what makes six months without treatment tolerable rather than terrifying.

The other omission is his body. Richard stays articulate, mobile and physically unmarked for the whole film. Untreated stage IV lung cancer does not usually allow that. Breathlessness, pain, weight loss and heavy fatigue typically arrive well inside six months.

NCI is blunt that sometimes lung cancer causes no signs or symptoms at all, and is found on a chest X-ray done for another reason. That is a large part of why so many cases are found late.

When symptoms do appear, NCI lists these:

• Chest discomfort or pain.
• A cough that does not go away, or gets worse over time.
• Trouble breathing.
• Wheezing.
• Blood in the sputum a person coughs up.
• Hoarseness.
• Loss of appetite.
• Weight loss for no known reason.
• Fatigue.
• Trouble swallowing.
• Swelling in the face, or in the veins of the neck.

Any of these lasting more than a few weeks deserves an assessment. That goes double for anyone who smokes or used to.

Lung cancer does have a screening test, and it is the only one of its kind on this list: it is offered by risk rather than by age alone.

The US Preventive Services Task Force gives a grade B recommendation for annual screening with low-dose computed tomography in adults aged 50 to 80 who have a 20 pack-year smoking history and who currently smoke or quit within the past 15 years.

A pack-year is one pack a day for a year, so 20 pack-years is a pack a day for twenty years, or two packs a day for ten. The Task Force widened this in its most recent update, from 55 to 80 down to 50, and from 30 pack-years down to 20.

Screening stops once a person has not smoked for 15 years, or if another health problem would make curative lung surgery impossible or unwanted.

The film never mentions whether Richard smoked, and never mentions screening at all. That silence hides a real problem.

If you have never smoked, or you fall outside those criteria, there is no recommended lung cancer screening for you. Nothing would have found this early. For that group, reporting a symptom promptly is the only route to an earlier diagnosis.

And the largest single thing anyone can do about lung cancer risk remains the least cinematic. Not smoking, and stopping if you do.

Nothing here is sponsored and nothing is for sale. If the low-dose CT criteria were news to you, you can help keep that explanation free to read. Support our work.

The Professor takes a real decision seriously, which is more than most films about terminal illness manage. What it misses is that refusing treatment is not refusing care.

Underneath it sits the least understood screening programme in medicine. Low-dose CT is offered on smoking history, not on age alone, and most people have no idea whether they qualify. It is a fair question to ask at your next appointment.

• https://www.cancer.gov/types/lung/patient/non-small-cell-lung-treatment-pdq
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
• https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet

This page discusses The Professor 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].