Telling the truth about cancer

X-Ray showing lung cancer

There is no area in medicine where communication skills are more tested than in dealing with cancer. In Britain, there used to be a tradition that it was best for the patient “not to know the truth”. Thankfully, that is now less common.

It was always better in the USA, or it certainly was when I worked there.

“George, you have a malignant tumour in your lung and it’s inoperable. There is an 80% change you will die within a year or so.” Well, not quite as abrupt as that, but not far short. American doctors are better at the truth and, of course, they dare not make light of serious conditions for fear of being sued.

Communication problems are compounded by patients. Most people say, “Oh yes, when my turn comes, I shall want to know the truth.” When their time does come, they start asking the right questions and then shear of at the last moment. The doctor will usually, possibly subconsciously, conspire with them to avoid the difficult issues.

Let us follow George, with his inoperable lung cancer, through a consultation with his GP. George has had his palliative radiotherapy, it has helped his cough, and he is feeling better than he has in months. He is unlikely to live more than a year. This is how it goes:

Doctor: So, George, how’s things?
George: Not bad, doc, my wife’s a bit worried that I am not putting weight on. (1)
Doctor: Are you eating? (2)
George: Like a horse, doc.
Doctor: Any pain, George?
George: No, not now, not since the radiotherapy.
Doctor: When is the specialist seeing you again?
George: Oh! He isn’t doc; he said he was very pleased and did not need to see me again. (3) He said he would get a nurse to call on me at home. (4)
Doctor: Oh.
George: Doc, we were thinking of booking a holiday in France, what do you reckon?
Doctor: Good idea, George, get it booked. Get it booked.

There is a pause. George looks the doctor in the eye.

George: Doc, am I going to die? (5)
Doctor: We are all going to die sometime, George, and you are seventy-two and obviously with the tumour…I mean, it’s serious, you know…(6)
George: (cutting in) But I responded to the radiotherapy, didn’t I doc. That’s good, isn’t it? (7)
Doctor: It was encouraging.
George: Great, well, I will see you next month then. I’m so grateful. You have been such a wonderful doctor over the years.
Doctor: Thanks, George…yes, of course. See you next month. Any problems give me a ring. And George, you know that if there is ever anything you want to know, you only have to ask. (8)
George: I know that doc.

1. Older patients are often too reserved to articulate their own worries; they express them through their partners.
2. Trying to feed the crab. It never works.
3. Radiotherapy for lung cancer is a short sharp course. It is not curative. The radiotherapist is too busy to do a routine “how are you” follow up.
4. Total abdication by the radiotherapist. The new way of telling patients they have terminal cancer is to offer the services of the MacMillan Nurse. “Don’t they just see patients who are dying, doc?” Quite.
5. George finally summons up the nerve to ask the question.
6. The doctor ducks.
7. Phew! He didn’t say I am dying. From now on, the doctor and George are playing charades.
8. I’m an honest doc. I tell my patients the truth.

At the end of the consultation, both George and the GP will agree that they had a full and frank discussion about the cancer. Ask each for the details of what transpired, and you will find it hard to believe they were in the same room.