Every day, thousands of doctors tell patients they have cancer. Or that a cancer, perhaps thought cured, has now spread.
The news is never good. It must be stated honestly, most physicians feel. Stating it is part of their job. How well do they do it?
Many, one hopes most, try to take an unhurried parcel of time to convey the facts -- the findings, the possibilities for treatment, the hope for survival -- and, equally important, give the shocked recipient time to react, to begin to adjust.
But also, says Dr. Stephen Hersh, a student of the way doctors report bad news, "We see people who are upset and depressed, left with feelings of hopelessness, and very angry at the physician who gave them the news.
"Frequently they say the physician was curt and hurried and sometimes just crass, saying, 'We have the X-rays. The cancer has spread. And you have three months or six months to live.'
"They often feel the physician didn't want to spend much time with them, but wanted to get away quickly."
Hersh, codirector of the Medical Illness Counseling Center in Chevy Chase, is a psychiatrist who sees the casualties of such encounters. They are among patients who seek professional help in coping.
"A physician has a particular role," he says. "It is very much more than the technology of treating a particular disease. It is assuming a responsibility for that human being."
"Nobody," he adds, "can say you will be dead in three months. We have nothing but bell-shaped curves to go by. There are always some longer survivors at the end of the curve. All the time, I have people coming in three years after they've been told they'll be dead in six months."
Many patients do at some point have poor prospects, of course. That news must also be stated honestly, says Dr. John F. Potter, director of Georgetown University's Lombardi Cancer Center.
"Most patients respond adequately, and some even with heroism," he says. "The patient who is completely devastated is exceptional. It is an extremely traumatic thing to tell anyone, but it's amazing how human nature can cope."
Also, he adds, "you can present even that news in an encouraging or supporting way."
How? "There are always many things that can be done even in the most extreme circumstances," Hersh points out, and gives examples:
*"We can prescribe medications that will control discomfort and pain."
*"We can help improve the quality of life in whatever time may be ahead -- by improving nutrition, by exercise, by encouraging involvement in things that help focus your attention beyond illness, even simple things such as gardening or watching sports."
*"We can treat psychological problems like anxiety states or depression."
*"There are techniques patients can betaught. Self-hypnosis for pain. Imaging." Imaging is a still experimental technique in which the patient tries to summon the body's own defenses by visualizing a successful battle within the body.
*"By doing these and other things," whether or not all are ultimately successful, "we can give the patient some sense of control. Up to the very time of death, here is always some control possible over some things.""There are practical things, too, that are important to patients, such as guidance to the patient and family in dealing with practical problems. Telling them what practical things and services are possible. Making sure the patient is responsibly taking care of such things as wills and instructions."
*"When necessary, helping the person deal with death. If the physician is not comfortable doing that, there are other persons, mental health professionals and trained clergy, who can help."
Obviously, all this cannot be done in a flash. In a new textbook on cancer, Hersh says the physician should even plan for more than one meeting on the initial diagnosis because "very little" of what is said then is remembered.
Dr. Philip Cohen, an oncologist at George Washington University, says that in any serious illness, "You have to schedule a long time in these initial encounters. You really have to sit there and find out a great deal about the patients -- how they are reacting, other stresses they've had, their families."
"You have to do this to get the patient's cooperation in treatment," he maintains. "Say a patient's parent had a traumatic experience with another kind of cancer. As a result, the patient may feel completely without hope about an entirely different kind of cancer with better prospects. You have to find this out."
He says cancer patients have three com- mon fears: pain, suffocation and loneliness or isolation. "I think it's important to address these right away. A lot of people worry about suffocation, that sometime they won't be able to breathe. We have to reassure them that this, and pain too, are either unlikely or there are things we will do."
Combating a patient's feeling of utter isolation may be more difficult. After all, a patient with any serious disease may after a bit no longer hear from many old friends.
"We must do what we can to ease that loneliness," Cohen says. For instance: "Fifteen, 20 years ago, but now rarely, the family would come in and say, 'Don't tell the patient it's cancer.' Far more commonly now, a person has just learned he has cancer. He feels he can accept it, but says, 'Don't tell my wife and children.'
"Except in some unusual cases -- maybe not yet telling a daughter who's going to have an important examination in three weeks -- I think this is wrong. It's important that the persons close to the patient be participants.
"They invariably know anyway. Your close ones know something is wrong, and if they don't feel they can be a part of it, they probably feel more uncomfortable than if they were able to help you handle it. And if things don't go well, they'll blame themselves for not helping."
And when all treatment fails? "A patient should not be isolated in talking about that part of life called death," Hersh says. Too often, "Everyone fails to talk about it because no one wants to get the patient upset. The physician, the family -- nobody talks about it.
"All this does is isolate the patient, and enhance loneliness, and that never helps. When timing is right, patients find talking about death a release. The availability of a warm, open, nonjudgmental listener always helps, but the patient must remain in control and indicate the right time."
To me, all these actions by doctors, families and others accomplish one other important thing. They let the cancer patient know that people care.