The Barbarian Invasions (Les Invasions barbares) (2003)

Rémy is a hedonistic, argumentative history professor in Montreal. He is dying of cancer in a public hospital so crowded that patients lie along the corridors.

His ex-wife calls their estranged son, Sébastien, a derivatives trader in London who despises almost everything his father stands for. Sébastien arrives and solves the problem the only way he knows. He pays hospital administrators and a union official to open and fit out a disused floor as a private ward. He pays for a scan across the border in the United States.

He also finds Nathalie, the heroin-dependent daughter of one of his father's old lovers. When morphine stops holding the pain, he pays her to buy heroin.

Then he gathers his father's circle at a lakeside cottage. Friends, colleagues, former lovers. They eat and argue and keep vigil. Rémy picks his moment, and Nathalie gives him a final, deliberately fatal injection while his son and friends sit with him.

Spoilers throughout. How Rémy dies is central to the film and is discussed openly here.

Dramatically this works. Medically it points people in the wrong direction.

The film's logic is that when prescribed morphine fails, the answer lies outside the system. Buy something stronger from a dealer. That is not what happens in good cancer care, and it is not what the drug itself represents.

Diamorphine is the medical name for heroin, and it is not exotic in medicine. In the United Kingdom it is a routine injectable opioid in palliative care and appears in NHS palliative prescribing guidance. So the substance is not the scandal. The scandal in the film is that nobody offers Rémy a specialist.

Uncontrolled cancer pain is rarely the end of the options. It is usually the point at which a palliative care team gets involved, and they have a longer list than a ward has.

They increase doses carefully. They rotate between opioids, because a drug that has stopped working well can often be swapped for another. They add drugs that treat particular kinds of pain, such as nerve pain. They use nerve blocks, which interrupt pain signals along a nerve. And they treat the things that make pain worse, including sickness, constipation, fear and sleeplessness.

NCI describes palliative care as care to improve quality of life in serious illness, given with or without treatment aimed at curing. Anyone can have it at any age and at any stage. It is not the same as hospice, which begins when cure is no longer the goal.

Asking for a referral is the move the film never lets its characters make.

This fear does real damage, so it is worth stating plainly. Carefully dosed opioids given for cancer pain relieve suffering. They are standard care. Being properly medicated is not the same as being sedated into an early death, and worrying that it is leads people to under-treat their own pain.

The film blurs this by ending on a deliberate overdose. That is euthanasia, a separate question with its own law and its own arguments. It is not what pain management is.

Rémy's disease is never named or staged. So nothing in the film can tell you how it might have been caught earlier, and this page will not invent an answer.

What can be said is more general and more useful.

There is no general test that checks an average-risk adult for cancer overall. The CDC supports screening for four: breast, cervical, colorectal and lung.

The US Preventive Services Task Force sets the detail:

• Colorectal cancer: screen adults aged 50 to 75 (grade A) and adults aged 45 to 49 (grade B).
• Breast cancer: a mammogram every two years for women aged 40 to 74 (grade B).
• Cervical cancer: screening from age 21 to 65 (grade A), by cytology every three years, or from 30 by HPV testing every five years, or both together every five years.
• Lung cancer: a yearly low-dose CT scan for adults aged 50 to 80 with a 20 pack-year smoking history who still smoke or quit within the past 15 years (grade B).

For everything else, including cancers of the pancreas, liver, stomach and brain, detection depends on somebody reporting a symptom.

The general warning signs are the ones that persist without explanation. Weight loss you did not intend. Pain that does not settle. A lump that stays. Blood in stool or urine. A change in bowel habit. A cough or hoarseness lasting weeks. Unusual fatigue.

The gap between what a health system can deliver and what a dying person needs is real, and so is the fact that money buys around it.

The social portrait is exact. Friends who cannot say the important thing. Former lovers with unfinished business. An adult child doing practical tasks because the emotional ones are unbearable. And the way the last phase becomes less about cure and more about who is in the room.

Where it flatters reality is Rémy himself. He stays witty and mobile almost to the injection. Advanced cancer more often brings a long, unglamorous decline that a dinner party cannot accommodate.

This page has no sponsor and no shop attached. If the section on pain control gave you something to ask for, you can help keep it available. Support our work.

The Barbarian Invasions is a fine film about dying badly in a good system. Its central medical suggestion, that the answer to unbearable pain lies with a dealer, is the part to leave behind.

The real answer is duller and better. Ask for palliative care, ask early, and ask again if the pain is not controlled.

• https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
• https://www.cdc.gov/cancer/prevention/screening.html
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
• https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
• https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/16-palliative-care/16-2-pain-control-in-palliative-care

This page discusses The Barbarian Invasions 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.