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1. Introduction
Anxious and expectant, the patient sits opposite the doctor. The patient looks sick, tense and tired, as if he had not slept for days. He suspects that he has cancer. What will happen now? Pain? Disability? Special care until death? The doctor is clearly trying to search for the right words but cannot find them. He wants to help as well as he can, but he needs the patient’s co-operation to succeed. He hopes that he will best achieve this aim with the "truth" as he perceives it.
"It is now absolutely clear that your tumour is malignant, which means you have cancer. Now that we have completed all the investigations, I regret to tell you that the illness has already reached an advanced stage, so that we will probably not be able to cure it. Now we must cut open your stomach and remove what we can. After that, aggressive chemotherapy, radiation therapy and your castration will be necessary. These measures are urgent, as otherwise you will die very soon." On hearing these words, the patient turns white, faints and dies of a heart attack.
This account is fictitious and describes an extreme case, even though it may not be unrealistic. Similar scenes certainly occur frequently in reality, even if less spectacularly. It would be a rare event, if the patient dies immediately as in our example, during the ongoing consultation. Usually hope and the will to live die first, to be followed by the clinical death of the patient after a shorter or longer period of suffering. It does not help if the doctor tries to water down or revise his statement after he has noticed its effect. The patient no longer believes him. The patient loses his trust in the doctor, which may goes as far as a denial of the doctor’s competence.
What are actually the bare facts of the situation?
It is true that cancer is often an incurable illness. Cancer thus belongs to the group of chronic diseases which also includes rheumatism, dementia, arteriosclerosis and diabetes mellitus, among others. In mortality statistics, cancer is identified as the direct or indirect cause of death in 25 % of all cases. However, more than 60 % of all deaths are caused by cardiovascular diseases.
Why, in the case of cancer, is the diagnosis implying imminent deterioration and death, but not in the case of angina pectoris, a non-fatal heart attack or a stroke? It cannot be due to the disease of cancer itself. This cannot be the explanation, because it happens far too often, that cancer patients live to old age with their illness and die of other causes. Nevertheless, there are also dramatic cases in which the disease advances rapidly and cannot be stopped by any medical measures. Such cases are the exception rather than the rule. However, these dramatic developments are the ones which are selectively perceived by the general public, whereas the slower, milder forms are hardly noticed. Many apparently healthy people have already had cancer in the past, but few of their acquaintances would know or be aware of this. Sometimes even the former patient himself or herself forgets this part of his history.
Furthermore, not only are there the cases where the course of the illness itself is dramatic, but also those where the therapy for cancer (specifically chemotherapy or radiation therapy, less often operations) cause a deterioration in health which sometimes can hardly be distinguished from the effects of the disease itself. If then these aggressive therapies also fail to achieve cure, which is more the rule than the exception, the illness and the therapy combine in deteriorating the patient’s state of health and mutually reinforce their fatality.
In this article, we intend to illuminate the emotional-psychological side of this situation systematically. Both the perspective of the patient and that of the people around him are to be taken into account. We will show that all actors can cope with the difficulties of communication in the face of cancer. To do this, we will draw on general tenets of psychology and psychotherapy. Beyond this, we will present helpful therapeutic methods.
Next chapter: 2. The psychosocial situation