The doctor started working on ways to simplify that moment for patients. While drawing with his two daughters, ages 5 and 2, an idea came to him and morphed into his cartoon, “Cancer Ninja,” which launched in May. The tagline? “A doctor fighting cancer, one drawing at a time.” Howard talked about understanding diagnoses and how Jane, the patient in his comic, can help. Howard treats patients with breast cancer, but aims to make the cartoon helpful for all. This is an edited transcript.
Q: Your cartoon, “Cancer Ninja,” follows Jane through her cancer diagnosis, explaining what’s happening through her story. How did the idea for this begin?
A: It all really started as a rant to my very patient wife about how little my patients understood about everything they were going through. (For example,) nobody understood the difference between chemotherapy and radiation. From a doctor’s standpoint, those things could not be more different. So I started making a list of things my patients didn’t understand: what is meant by cancer stage, what a prognosis means.
Q: These are all terms that, to doctors, might be everyday words but, for a patient, are new and potentially scary. You first thought of writing a book – how did that change to a comic strip?
A: I started drawing with (my daughters) and realizing how much I enjoyed drawing with them. They like to draw dinosaurs and hot air balloons. At the same time, I started reading more picture books. I realized how some of these illustrators are amazing. They can communicate so much with a very simple line drawing. That pushed me to improve my hot air balloons with my daughters, and then my wife suggested, “Well, why don’t you combine your interests?”
Q: What was the first cartoon, and how did you decide that?
A: I had the idea of telling a story, like a single patient. I treat a lot of breast cancer patients and it’s a really well-understood cancer. We know what to do for just about every situation a patient can find herself in. I’ve decided to make Jane a very early-stage case, but I wanted her advanced-stage enough that she could get surgery, plus go through chemo, plus go through radiation. I want her to go through all of those. (Also), people are left psychologically reeling after and so I want to follow her through that.
Q: The moment of diagnosis is such a specific moment to focus on – it’s life-changing. What do they teach doctors about handling those moments?
A: I went to college at the University of Wisconsin at Madison (and then medical school at the Medical College of Wisconsin). There, they actually took a lot of pride in (training doctors on delivering a diagnosis). They have a course on breaking bad news. So (we were instructed) to the point where they taught us how to arrange the room, how to make sure everyone’s sitting.
Q: And how do you arrange everything? You’re sitting in front of patients whose worst fear is likely what you are there to tell them.
A: As a radiation doctor, I usually am not the one breaking the news. I will sometimes break the news that “it’s more advanced than we thought.” You’re supposed to go through all these steps: “What’s your understanding of what your cancer is right now and the prognosis? Do you want to know what the prognosis is?” Often people don’t. And then you always want to make sure the patient’s not the only one there – there’s someone else in the room, so they can talk about it later. Then you’re supposed to make an appointment afterward to talk again soon, within a week or so, because they will miss so much of what you said.
Q: What do you find that people didn’t understand?
A: I’ll ask them, “Have you ever gotten radiation before?” And they’ll say, “Oh, yeah, of course I did.” And they’ll describe and I’ll realize, “Oh wait a second, that was chemotherapy.” That happened a lot.
Staging is a very confusing thing, but it roughly divides people into prognostic groups, like what’s going to happen. And we also tailor our treatments. (The American Joint Committee on Cancer sets the staging system for breast cancers.)
Prognosis is mostly understood by people thinking the prognosis is poor. A lot of cancer survival data is published in the form of median survival. But if you tell someone that the median survival is 14 months, then they think, “Oh, my gosh, it’s been three months, so I have 11 months left.” I found myself repeating; even if I’ve explained it once before, you have to say it over and again, “Median means a lot of people live longer than that.”
Q: So sometimes people can’t take it in and other times people are almost grasping too much for any detail. That’s hard to balance.
A: Being a radiation doctor, we’re the ones who often have the time (to spend time talking with patients). With the cartoon, I feel like there’s so much more (to cover in detail). In the beginning, such-and-such a cell experienced mutation, but that step where a cell goes through mutation, there are so many micro-steps in that. There’s so much more I could explain in that part. But I’m hoping that, once Jane’s story is all done, maybe I’ll go back and fill in more.
Q: I imagine simplifying it is a challenge.
A: (The patient) doesn’t necessarily need to know the mechanization of such-and-such of chemotherapy. They just need to know, “You’re going to be sitting in a recliner. You might feel some nausea; they have nausea medication if you need it.” I’m trying to think about more – what will be their experience.
Q: What’s the biggest challenge in the cartoon?
A: I’ve gone through a very general situation with Jane, just being diagnosed with breast cancer. Now, it’s going to get much more specific, because she has a particular stage of cancer. But I want to keep it as broadly interesting as possible (for all cancer patients), so that’s going to be a tricky balance.
Q: Do you feel this has changed how you interact with patients?
A: There are a lot of booklets and pamphlets that you can give patients about cancer. But they’re kind of dense and they’re kind of boring to read. So I thought, well, what if I translated one of those booklets into cartoon form and then pass that out to patients?
Q: What do you think patients most need during that moment of hearing their diagnosis?
A: I think they need to hear it in a kind way. I think they need it to be repeated over and over again. And I think – and I know because I critique myself when I do this – you really need to check in with the patient over and over again about how much they’re understanding and how much they want to hear. I think some people underestimate their own intelligence, their own ability to grasp what’s going on. So sometimes I think they kind of give up.