Three Billboards Outside Ebbing, Missouri (2017)

Three Billboards Outside Ebbing, Missouri is a film about grief and rage, with a police chief dying of pancreatic cancer at its centre. This page is for viewers who want to know what the film gets right and wrong about that illness.

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.

If you are thinking about suicide, or worried about someone else, call or text 988 (the 988 Suicide & Crisis Lifeline) in the US. If someone is in immediate danger, call 911.

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. That sits poorly with the symptoms NCI describes.

NCI's list of what the disease causes as it grows is the opposite of a working week. It includes 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 does not match NCI's symptom list. 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 of pancreatic cancer symptoms. 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 needs a prompt call to your care team rather than watching and waiting.

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: NCI lists pain, fatigue, appetite loss, nausea, breathing trouble and sleep problems, plus emotional and practical concerns. NCI says it may be given at any point in cancer care, from diagnosis to the end of life, and a person can keep getting cancer treatment while receiving it.

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 picture is quieter and harder. NCI lists pain in the upper or middle belly and back, yellowing of the skin and eyes, pale stools, dark urine, weight loss for no known reason, poor appetite and fatigue.

NCI notes that an endoscopic stent can be placed when cancer blocks the flow of bile, and that palliative care exists for symptoms such as pain and weight loss. The film shows none of this.

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 USPSTF concluded that for people with no symptoms, the harms of screening outweigh the benefits. That is a judgment about testing healthy people, not about how serious the disease is.

NCI lists the risk factors. They include a family history of pancreatic cancer or pancreatitis, and inherited changes in genes such as BRCA1, BRCA2, PALB2, STK11 and TP53. Smoking, excess weight, diabetes and chronic pancreatitis also raise risk. NCI adds that having a risk factor does not mean you will get the disease.

If pancreatic cancer runs in your family, ask your care team whether genetic counseling or specialist advice makes sense for you.

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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. Yellow eyes or skin are worth a prompt call to your care team. So are ongoing upper belly or back pain with weight loss for no known reason.

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
• NCI: Pancreatic Cancer Symptoms
• NCI: Pancreatic Cancer Causes and Risk Factors
• NCI: Palliative Care in Cancer
• 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 corrections@cancerexplained.org.