Oncology is a hard field to be in at any time of the year, but especially now. It’s winter, the holidays are over, and the days are short and cold. I find this time of year particularly isolating: we may socialize less, sleep more, and suffer from seasonal affective disorders, all of which can depress our collective mood. While many of us are considering (or reconsidering) New Year’s resolutions, many of our patients are taking stock of their life and considering what their future may hold. Will their cancer recur? If it already has, will it progress? What treatment options do they have left, and how much will they suffer from the disease, the treatment, or both? These are just some of the concerns that may be passing through patients’ minds when they come to see us next. So, what can we do to help them?
The first step is to recognize what an important role we play in the daily lives of patients. Whether we admit it or not, we are more than just another health care provider. We are cancer doctors, and cancer is the primary subject on the mind of many of our patients. They listen intently to what we tell them; however, it is not just what we say but how we say it that matters. As Maya Angelou famously said, “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.” It is therefore essential, regardless of their disease status or prognosis, that patients feel one thing when they leave our office—hope.
How to impart hope is not part of the training of medical professionals, especially oncologists—at least it wasn’t when I was going through training. Hope is in many ways antithetical to oncology, which is an increasingly quantitative science, built upon tumor measurements and biomarkers, precision therapies and probability statistics. When we practice informed decision making, we try to be as objective as possible in stating the likelihood of outcomes so that patients can come to their own decisions regarding the risks they are willing to take. So where does hope fit in?
First off, hope must be realistic. We cannot expect cures when they are unlikely to occur. That said, many of our clinical data are incomplete, with a median follow-up of just a few years and small numbers of patients extending beyond that. It is in the long-term data we lack that some of our hope lies. In some circumstances, though, when long-term remission or cure is possible, we need to be comfortable saying that.
Second, even modest effects of treatment can be comforting to patients. Our expectations change as a patient’s cancer journey progresses from localized disease to metastasis and through courses of treatment. Stopping a cancer from progressing, mitigating or stabilizing symptoms, and maintaining quality of life are worthwhile goals for patients, depending on where they are on their cancer journey. Helping patients to value these goals and accept some side effect risks is part of what they need from us. If we don’t value these goals, how can we expect patients to value them?
The third aspect of hope reflects its resilient power through difficult circumstances. Patients who have advanced cancer can experience heightened and volatile emotional states, ranging from fear and anger to self-pity and depression. Hope is the meditative state that keeps people going through these swings, allowing them to disconnect from negative thoughts and to wonder at the simplest things in life. I think of Morrie Schwartz and his famous Tuesday meetings with Mitch Albom, focusing on a small hibiscus plant in his window. As ambassadors of hope, our job is to deliver this calming message: regardless of the stage of disease, life is still worth living.
I was recently talking with a psychiatrist friend of mine about the challenges encountered in communicating hope, and he mentioned a quote from Rainer Maria Rilke: “Let everything happen to you: beauty and terror. Just keep going. No feeling is final.”
Patients need to feel that we care about their outcome and that their life is meaningful to us, their family, and others. Hope requires us to express our compassion for them and their situation. Without compassion, words of hope will fall flat. Finally, remember to be sure that patients end their visit on a positive note. It is this last feeling we want them to experience because it may just be what they remember most.
Sincerely,
Daniel J. George, MD