Three Billboards Outside Ebbing, Missouri (2017)

Seven months after her daughter Angela is raped and murdered, Mildred Hayes rents three derelict billboards on a road outside Ebbing. She has them painted with a question aimed at the town's respected police chief: why has no one been arrested? The town turns on her.

Chief Willoughby is dying of pancreatic cancer, and everyone in Ebbing seems to know it. The billboards are read as cruelty toward a sick man. Willoughby is gentler than his officers. He interviews Mildred, coughs blood mid-conversation, and quietly pays to keep the billboards up another month.

After a day at home with his wife and daughters he takes his own life in the stables, rather than let them watch him deteriorate. He leaves letters to his wife, to Mildred and to his deputy Dixon. His death sets off everything that follows.

This page describes that death and what leads to it.

The letters are the best writing in the film about being ill. They are practical, funny and unsentimental. He settles money, corrects a misunderstanding, and gives one person permission to change.

That is closer to how people with a short prognosis actually behave than a bedside speech would be. Much of the real work is administrative: wills, passwords, the mortgage, who gets told what.

The film is also honest that his family's grief is not softened by having known it was coming. Expecting a death does not pre-pay for it.

And it catches something true about illness in a small town. The diagnosis is public property, discussed by everybody except the man himself, and used to judge other people's behaviour.

Willoughby is comfortable, mobile and working full time as a police chief until virtually the day he dies. Advanced pancreatic cancer does not usually allow that.

NCI's list of what the disease causes as it grows is the opposite of a working week: jaundice, pale stools and dark urine, pain in the upper or middle abdomen and back, weight loss with no known cause, loss of appetite, and fatigue.

There is no diagnosis story at all. No scan, no biopsy, no staging. The cancer exists in the script as a fixed sentence and a deadline, which is what the plot needs it to be.

The most-quoted illness moment in the film is medically wrong. Willoughby coughs blood into Mildred's face during an interview.

Coughing up blood points at the lungs or the airway. It is not on NCI's list for pancreatic cancer. It is generic film shorthand for being fatally ill, and it teaches viewers the wrong thing to watch for.

The symptom that should actually send someone to a doctor is far less dramatic. Yellowing of the skin or the whites of the eyes, especially without pain, needs assessing quickly rather than watching.

No oncologist appears. No palliative care team appears. Nobody discusses controlling his pain.

That absence does real work in the plot. Because no one has offered him anything, his suicide reads as the only available escape from a bad death.

Palliative care is not the same as giving up on treatment. It is specialist care aimed at symptoms: pain, sickness, breathlessness, sleep, and the practical mess around them. It can run alongside cancer treatment and it is available long before the final weeks.

A viewer who takes Willoughby's reasoning at face value would conclude that dying of pancreatic cancer means untreated agony. That is the film's most consequential distortion, and it is worth naming clearly.

The realistic version of Willoughby's last months is quieter and harder. Pain in the upper abdomen that radiates to the back. Jaundice as the bile duct becomes blocked, which can often be relieved with a stent. Weight loss that does not stop. Trouble digesting food. Fatigue that no amount of rest fixes.

Almost every item on that list has something that can be done about it. That is the fact the film withholds.

There is no screening test for pancreatic cancer for people at average risk. In August 2019 the US Preventive Services Task Force reaffirmed a grade D recommendation, which means it recommends against screening adults who have no symptoms.

The reasoning is arithmetic, not pessimism. The disease is uncommon in the general population. The available tests are not accurate enough. Most abnormal results in a healthy population would be false alarms, and chasing them means scans, procedures and fear for people who never had cancer.

A small group is managed differently. NCI lists the relevant risk factors: a family history of pancreatic cancer or pancreatitis, and inherited conditions such as Lynch syndrome, Peutz-Jeghers syndrome, hereditary breast and ovarian cancer syndrome, familial atypical multiple mole melanoma syndrome and ataxia-telangiectasia. Smoking, excess weight, diabetes and chronic pancreatitis also raise risk.

People with a strong family history should be referred for specialist assessment, where repeat imaging may be offered through a surveillance programme. That is a different thing from population screening, and it is not something to request off the back of one relative.

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Three Billboards is about rage and its costs. The cancer is scaffolding, and it is built out of movie conventions rather than the disease.

The part to keep is small. Painless yellowing of the eyes or skin is worth an urgent appointment. Persistent upper abdominal or back pain with weight loss is worth one too.

And if someone you love is facing a short prognosis, ask about palliative care early. Three Billboards Outside Ebbing, Missouri cannot tell you what to watch for, but screening and possible warning signs can.

• NCI — Pancreatic Cancer Treatment (PDQ®), Patient Version
• US Preventive Services Task Force — Pancreatic Cancer: Screening (2019)

This page discusses Three Billboards Outside Ebbing, Missouri 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].