Mom's Cancer: Metastatic Lung Cancer, Drawn by the Family Managing It

Brian Fies is a journalist who can draw. His mother was diagnosed with lung cancer that had already spread. He started keeping a journal in words and pictures. In 2004 he began posting it online, without his name on it.

It found readers at once, because there was very little like it. In 2005 it became the first webcomic to win an Eisner Award. Abrams Image published it as a book in 2006, at about 114 pages. It is mostly black and white, with color used rarely and on purpose.

The book's point of view is the thing to understand about it. This is not a patient's memoir. It is a family memoir, told by a son. The cast is three adult siblings: Fies and two sisters, drawn as types you would know rather than as saints. Plus a mother who is by turns funny, frightened, stubborn and unwell.

It is also, quietly, a book about a smoker. Fies's mother had smoked for decades. He does not build the book around blame. He does not build it around letting her off, either. He puts the fact on the page. He records what other people say when they hear "lung cancer." Then he lets the reader sit with it.

The register is plain. Short chapters, clean panels, no melodrama. When something goes badly the drawing does not swell to meet it.

The book is built from short chapters, somewhere near thirty of them. Each runs a page or a few pages. That was the webcomic's shape, and it is kept.

Early chapters cover the diagnosis and the shock of the word metastatic. The cancer had already reached her brain, and the outlook was discussed in months. Fies draws the family's crash course in oncology. That includes his own bid to become the one who understands the science.

The middle covers treatment and the running of it. Appointments. Radiation. Drugs. The hospital corridors. Then the splitting up of tasks among three siblings. They live at different distances and can bear different things, and that rubs. One of the best-known sequences shows the family holding different beliefs about what is happening at the same moment.

One well-known page covers a response to treatment better than anyone expected. That news is oddly hard to hold. Hope given back is harder to manage than hope given up.

The later chapters cover decline and the daily facts of care at home. They also cover what is left for the people left. An afterword by Fies discusses where the webcomic came from and how readers replied.

There are no clinical tables and no resource list. Instead there is a set of drawn explanations, covering tumor spread, radiation and statistics. That is Fies putting what he was told into his own terms.

It is the best thing in the cancer literature on siblings. There is the silent contest over who is doing more. The one who researches. The one who nurses. The one who cannot be in the room. And the way each is sure the others are handling it wrong.

It is very good on information itself. Fies draws what it is like to be handed a survival statistic and not know what to do with it. He is honest that knowing some science did not stop him misreading it.

It is good on the small indignities. Waiting rooms. Phone systems. How hard it is to get one straight answer. The way a family turns into an amateur shipping firm.

And the brevity is a virtue. It can be read in an hour by someone whose concentration is gone.

There is one more thing it does that guides cannot. It shows a family arguing about what the truth is, in one room, at one moment. Each of them holds a different version of the outlook. Each of them means it. That is common, and it is lonely. Seeing it drawn tends to make it easier to talk about.

The treatment is from the early 2000s. Since then, lung cancer treatment has changed more than almost any other cancer. NCI's current material lists targeted therapy for tumors with certain genetic changes. It names drugs including osimertinib and gefitinib for EGFR and ALK alterations. It also lists immunotherapy with checkpoint inhibitors, including pembrolizumab, nivolumab and atezolizumab. None of that was standard when Fies's mother was treated. Her options are not a guide to a family's options now.

The prognosis conversation is also dated in style. Numbers handed over as flat sentences, with little talk of doubt, are less common now. They are not gone.

The book shows one family's habits. Many readers know the sibling conflict, but not every family has it. Some readers find it too close for comfort. Some find it unfair to the sisters, who did not choose to be characters.

Finally, the smoking material can read as a verdict either way, depending on what the reader brings. Fies does not deliver one. The book is more use if it is not made to.

NCI describes non-small cell lung cancer in stages. Knowing the shape of that scale explains most of what a family is being told.

Occult means cancer cells found in sputum or bronchial washings, with no tumor seen on imaging. Stage 0 means odd cells in the airway lining that may become cancer. Stage I means cancer formed in the lung only. It splits into IA and IB, and IA tumors are 3 cm or smaller. Stage II means larger tumors, or lymph nodes involved on the same side of the chest. Stage III means spread to lymph nodes on the same side of the chest, or to the other side. Other chest structures may be involved too.

Stage IV is what Fies's family faced. NCI describes stage IVA as tumors of any size, with one or more tumors in the lung that does not hold the first tumor. It can also mean spread to distant organs such as brain, liver or bone. Stage IVB means the cancer has spread to many places in one or more organs away from the lung.

That split matters because it sets the aim of treatment. NCI's stage IV options work through the whole body. They are chemotherapy, targeted therapy where a matching genetic change is present, and immunotherapy. NCI also states plainly that smoking tobacco now or in the past is the most important risk factor for lung cancer.

Lung cancer stages covers the scale in more detail. Metastatic lung cancer: what to ask covers the talk that follows a stage IV diagnosis.

One federal point corrects this book's era more than any other. It is about palliative care.

NCI defines palliative care as care to improve the quality of life of patients who have a serious or life-threatening disease such as cancer. Palliative care specialists give it, working in teams alongside the oncology team. Those teams can include nurses, dietitians, pharmacists, therapists, chaplains, psychologists and social workers.

The part families most often do not know is that it is not a swap for treatment. NCI states that palliative care can be given at the same time as treatment meant to cure or control the cancer. People may keep having cancer treatment while using palliative services, at any point from diagnosis onward.

What it covers is wider than pain. NCI lists physical problems: pain, fatigue, nausea, trouble breathing and sleep problems. It lists emotional concerns, including depression and anxiety, and spiritual questions. It lists support for caregivers handling stress and duties. And it lists practical matters: money, legal and insurance concerns, plus advance care planning. NCI adds that research indicates this joined-up approach can improve quality of life and may extend survival. Palliative care covers what a first visit involves.

On smoking, CDC's help is free and specific. It names 1-800-QUIT-NOW (1-800-784-8669) in English and 1-855-DÉJELO-YA (1-855-335-3569) in Spanish. There are also quitlines in Chinese, Korean and Vietnamese. Other routes are texting QUITNOW to 333888, the quitSTART app, and Smokefree.gov. CDC states that quitting smoking improves health. It says quitting lowers the risk of heart disease, cancer, lung disease and other smoking-related illness, and that it is never too late to quit. Those resources are open to the person with the diagnosis and to everyone else in the house. In this book, that is the point. Quitting smoking sets out what is available. Fies drew the part nobody photographs: the scheduling, the shifts, the arguments about who does what.

It suits adult children handling a parent's advanced cancer. It suits them most in a family where the work is split badly and nobody will say so.

It suits readers who cannot face a long book, and readers who want the caregiver's view rather than the patient's.

It does not suit anyone looking for current lung cancer treatment facts. It is not a guide to decisions. It may also be too close for a family in the same spot this month. The decline is drawn honestly, and honesty is sometimes not what is wanted yet.

• NCI — Non-Small Cell Lung Cancer Treatment (PDQ), Patient Version
• NCI — Palliative Care in Cancer
• CDC — How to Quit Smoking
• Mom's Cancer — catalogue record, 2006 Abrams Image edition

This page discusses Mom's Cancer for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care.