The power of words in cancer care

In oncology, there are certain words and phrases that (no matter how carefully said) suck the air out of a room, like “you have cancer,” “you’ve recurred,” “incurable,” “terminal,” and “hospice.” Such phrases require careful consideration before they are spoken, and most (if not all) oncologists understand the power of these words, and use them carefully. However, there are others that can be as powerful, yet remain in common usage in our field.

I still remember my fellowship days at Memorial Sloan-Kettering Cancer Center (MSKCC) like they were yesterday. When I decided to pursue a career specializing in women’s cancers, I joined the medical gynecologic oncology clinic of Dr. Paul Sabbatini. In addition to being an amazing clinical researcher, he is a brilliant clinician and, as a fellow, I always sought to impress him.

On one clinic day, I recall seeing a woman in her 60s with ovarian cancer. She had recurred despite treatment. I went in alone, talked with her, examined her, and then presented her to Paul.

“So, what do you think we should do now?” he asked.

“Well, since she failed this regimen, I think she needs to start on a new salvage treatment. What about a combination?” I recalled saying. Paul’s expression changed, and I still remember it like it was yesterday. He looked at me kindly, but with a degree of exasperation.

“Don–if there’s one thing I’ve learned, it’s that people do not fail chemotherapy. The chemotherapy didn’t work, but no one failed; she didn’t and I didn’t. And, we don’t salvage people. Salvage is what you do with scrap metal and trash.”

I remembered being taken aback by this, primarily because I felt he was criticizing the common language of oncologists. “Salvage” and “failure on treatment” were words and phrases I had heard as a medical resident, and they were phrases used everywhere in oncology. Still, I respected Paul and his experience, and though I did not understand what he was talking about at the time, I was more careful during our clinical discussions after that.

When I completed my fellowship, I was lucky enough to join the Developmental Therapeutics/Gynecologic Oncology service at MSKCC, and counted Paul as a colleague. In my first year as an attending, I took care of a young patient with ovarian cancer. She had just relapsed from first-line treatment and we had discussed where to go next.

“I am hopeful treatment can help and prevent the cancer from causing you symptoms,” I explained. “Despite the failure of first-line treatment, there are many more options for you.”

The words had barely left my mouth when the lesson Paul had tried to teach me came back in full force. My patient, already scared about her recurrence, became teary and turned away from me.

“You make it sound like this was my fault, like I did something wrong!” she said. “I’m sorry I failed chemotherapy, if that’s what you think, and I’m sorry I disappointed you.”

I was stunned. It was never my intention to place “blame” on something so devastating as a cancer recurrence, and I certainly did not mean to imply that she had failed. I remember using the rest of the visit apologizing, ensuring my patient she had done nothing wrong, and that she did not fail chemotherapy, but rather- chemotherapy failed her. These many years later, I still consider this encounter a watershed moment in my career as an oncologist.

Since then I have been sensitive to words and phrases, particularly when they are used in reference to patients, treatment, and circumstances surrounding recurrent disease. I cringe when I hear someone referred for “salvage treatment” or how its “too bad she failed therapy.” Unfortunately, even today, it is still terminology that is part of the lexicon of oncology.

A quick search on clinicaltrials.gov using the search terms FAILURE and CANCER resulted in 145 actively accruing studies, 20 of which had failure in the title. In addition, a search in Pubmed.org using the same terms resulted in 54 papers with FAILURE in their title, published in the last 5 years. While these overall estimates are low, I suspect that in our everyday conversations, it is far more pervasive.

The language of medicine is a special one, and in the context of a serious medical illness, this is especially true. The way we communicate matters and even when we think our audience is our peers, in the era of social media, we must be cognizant of the wider reach of our words, our lectures, our publications, and our presentations. While our colleagues may understand what we mean when we refer to treatment as “salvage therapy,” the same may not be said of how our patients or the public hear it.

Don S. Dizon is an oncologist who blogs at ASCO Connection, where this post originally appeared.

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