Counsellingthe

CancerPatient:
Surgeon'sCounsel*
George T. Pack, M.D.

In ancient times, the shaman (a when the patient-doctor relationship is

medicine man, a prophet and a priest fully realized can the patient verbalize
in the early Ural-Altaic period of civili his fears and then realistic reassurance
zation) had dual functions to perform. be @iven.
Sick patients sought from him both I advise my young colleagues never
help and solace. So it is today in the to exhibit haste in the care of cancer
case of the surgeon who treats cancer. patients. I say to them: Whenyou
He must take on his shoulders not only walk into the room, if you are in a great
the burden of treating the disease with hurry, then walk more slowly; if you
all of the scientific disciplines at his are in a still greater hurry, sit down
command, but also of taking care of the and talk leisurely to the patient; then,
patient as a whole. In order to make the when you leave the room, you can run
patient feel he is being treated as a per like hell. I also add: Spendsufficient
son, I have found the following points time with your patients. They appre
to be of invaluable aid throughout the ciate it because this is a most critical
years in my own practice. occasion in their lives and time should
he allowed for you to assuage their ap
Do Not Hurry prehensions and comfort them with
If the surgeon wishes to secure his information.
confidence and faith, the patient must
be given time to become acquainted Analyze the Patient
with his surgeon, to establish rapport The surgeon who is called on to care
and to be convinced of the sincere inter for a patient with cancer seldom has
est in his problem. Such a relationship had the opportunity of the general
should be established before transmit practitioner in becoming acquainted
ting any serious information about the with his subject. Therefore, at the time
disease. A critical discussion about the of first consultation, the surgeon must
cancer cannot be consumated at an ini devote his time not only to taking a
tial or single visit. Arthur Sutherland careful history and performing a physi
has properly emphasized that only cal examination, but also to studying
the personality of the individual.
t)r. Pack is an attendjnq surqeon at Memorial
Hospital for Cancer and @lllied Diseases. Ven lark Through years of practice, the surgeon
City. must develop a certain adeptness for
*Reprillted from The Physician and the Total
(are of the (a orer I'a tient. it';i Seien tifie Sesiiion
performing a quick psychological anal
of the .1 meriean Cancer Society. ysis of the personality of the patient,

210
his temperament, the presence or ab
sence of fear and how the patient may
accept the verdict given him. In addi
tion to this, of course, the surgeon must
assess the patient's physical ability to
undergo the contemplated operative
procedure.
There is no way in which one can
describe or define in proper terms this
ability to analyze the patient, though
I am certain every physician has ex
perienced it. After the few minutes
allotted to him, the surgeon will be
faced with the task of discussing with
the patient and his inquisitive relatives
all the details of the case, including
treatment, outlook and prognosis.
Perhaps in no other field of medicine,
with the exception of psychiatry, is an
analysis of the patient's temperament
and psyche as important as it is with
the cancer therapist. Professor William
B. Bean of Iowa has defined the essen
tial quality of the physician as caritas
medici which is that vigilant and therapist's
humane insight and care, compact of
wisdom and spirit, which the doetor
owes his patient, be it for sympathy or
discipline. We, as doctors treating can
cer, need to administer to man's so
matic, psychic and spiritual needs as
well. I do not believe that any therapist,
either a radiologist, a chemotherapist
or a surgeon, can ignore this necessary
aptitude.
Control the Conversation
Another point in this relationship is
to never let the patient put the surgeon
on the defensive. Attempt to control
and direct the conversation with the
patient. In the recital of the history of
the illness, the patient is encouraged to
talk and he should be listened to with
full attention and without disrupting
intrusions. But once the patient's story
is elicited, the conversation thereafter
should be controlled. If this is not done,
the questions may be so embarrassing
that the patient himself will be hurt by
the answers, which must be truthful.
Anticipate the worst type of ques
tions and answer them in advance,
couching them in your own terms. This
will give the patient additional confi
dence. He gets a great deal of comfort
from the thought that the surgeon is
prepared to shar.e the responsibility of
the disease and to suffer more or less
vicariously with him.
The patient comes for advice, and the
surgeon gives it according to his con
science and experience. Never permit
the patient to argue concerning choice
of treatment. Some would like to accept
the treatment that is less burdensome
to undergo and which appeals to them.
They are entitled to the explanation
that for their particular type of cancer,
surgery might be the only procedure
indicated, that radiation therapy is
preferable, chemotherapy is indicated,
or that a combination of all three may
be necessary. In doing this, it is the
obligation to ease their
fright about the toxic effects of chemo
therapy or the possible injurious seque
lae of radiation therapy. Assure them
that these treatments are helpful and
that combinations are sometimes neces
sary. Never let the patient assume the
responsibility of choosing the therapy.
Do Not Go Into Detail About
Operative Techniques
Discussion also arises in those in
stances when cancer surgery is muti
lating, e.g., the removal of the entire
stomach, the amputation or major dis
articulation of an extremity, the re
moval of the larynx, or exenteration of
the pelvic viscera. Spare the gory de
tails! In such cases, do not dwell upon
all the possible complications that can
happen following such a procedure. We
must tell the patient the truth and what
he is to undergo, but we do not need
to go into great detail about the opera
tive techniques. Do not tell him how
many pints of blood will be used or
211
other information of that nature. The
patient knows as well as the surgeon
that certain hazards attend any major
operative procedure and recital of re
ported operative mortalities is never
reassuring at such a time.
Emphasize to patients that even if
they sacrifice an organ, it is a part that
can be dispensed with these days. Sub
stitute measures are available to re
store them as useful members of so
ciety. Also, emphasize that the whole
is more important than any of its parts
atrite algebraic expression perhaps, tion. I will not operate on a patient who
but one that is important to them.
Health and life are far more important
than any of these dispensable organs
or parts.
Stress Rehabilitation
Stress the rehabilitation. I mean the
use of substitute stomachs, artificial
limbs, artificial or substitute bladders
and all such prosthetic devices.
Furthermore, it is the surgeon's duty
and responsibility to follow through on
these rehabilitative measures to see
that artificial devices are satisfactory.
He should be interested in the restora
tion of arm function after radical mas
tectomy, the correction of metabolic ab
normalities after total gastrectomy,
etc. In other words, the cancer patient
is never abandoned. It is not enough for
the cancer surgeon to do the operation
and then lose interest in the patient ex
cept as a figure pertaining to operative
mortality or long-time definitive cure.
The surgeon properly should be a
party to the patient's follow-up pro
cedures and see him at specified inter
vals. Patients should know in the initial
conversation that they will be observed
following surgical treatment. My own
plan is to see them every two months
during the first postoperative year,
every three months during the second
and third years, every four months dur
ing the fourth and fifth years and every
six months thereafter. This reassures
212
them because they say to themselves,
He
will continue his interest in me and
I will be safer on account of it.His
postoperative visits serve as an insur
ance policy for his protection.
Learn to Deal With Patient's Fears
Fear is a serious handicap or deter
rent to any patient who is ill or about
to undergo a major operation. Only a
few times in my own experience has a
patient seriously and repeatedly stated
that he is afraid to undergo an opera
is in deadly fear. I recall an instance
when I was an assistant to the late Dr.
Burton J. Lee: A woman said, Doctor,
I am going to die under the anesthesia.
Her preliminary examinations indi
cated she was in excellent health, and
the operation on her breast was started.
She did die under the anesthesia. Be
cause of this experience, I believe the
surgeon should always offer a last word
of encouragement, and reassure to the
patient before the anesthesia.
Do Not Frighten the Child Patient
In the case of children with cancer
who face mutilating extirpative pro
cedures, I prefer not to discuss any de
tails of the illness, the nature of the
necessary operation or the possible
consequent disabilities. It is enough for
the child to accept the mystery of a
forthcoming operation with as much
equanimity and courage as can be mus
tered. The family knows the ordeal the
child is facing. It is unmerciful to per
mit a child to go to the operating room
in great fear. I commonly resort to
steeling the child patient by the judi
cious and appropriate use of narcosis.
Children old enough to comprehend can
be comforted by the surgeon after re
covery from the anesthesia. For exam
ple, after enucleation of an eye or am
putation of a limb, I ask the young pa
tient to help me because his parents
are so disturbed: Please bear in mind
that your mother and father, the peo
ple who love you most, are very much
distressed by what has happened to you
and they are worried how you will take
it. This is perhaps the one moment in
your life when you can show your par
ents how truly brave you are. They truthfully add that he has removed all
are, in fact, sometimes more cour
ageous than their parents.
Do Not Guarantee a Cure
In the course of conversation with
the patient and his family, do not guar
antee a cure. No cancer is so early as
to be invariably curable. Even though
the cancer patient wishes assurance,
more than for any other disease, the
surgeon is neither ethically nor legally
required to make extravagant prom
ises. Although some cancers may be so
extensive in their local growth as to
seem incurable, occasionally they may
be controlled. Certainly, a patient will
never forget the surgeon who promised
a cure which failed, or let a doctor for
get his fallibility for pronouncing a
cancer as incurable, when he continues
to survive and live comfortably. We
must remember that we deal with our
patients' hope for life and their rejec
tion of death.
Don't Be a Prophet of Doom
If a surgeon has successfully com
pleted a radical operation for an ad
vanced, highly malignant cancer of
borderline operability, with no tangible
evidence of metastasis, no useful pur
pose is achieved by being a prophet of
doom and expressing a certainty of ulti
mate recurrence and death. Until recur
rence has been discovered by examina
tion or through the appearance of
symptoms, it is merciful and proper to
permit the patient and his family to
enjoy this indefinite period, free of
worry. Many patients whose cancer is
resected with the intent and hope of
cure, ultimately develop recurrence. A
palliative year is just as appreciated by
the patient as a curative year, if the
handicap of fear can be largely elimi
nated. The family should be fully in
formed of the danger and impressed
with the necessity for frequent check
up observation, but the surgeon can
tangible evidence of the cancer. Let
everyone concerned enjoy the respite as
long as possible. A surgical colleague,
after performing a penectomy for a
rare, highly malignant hemangioendo
thelioma, told the patient's sons that
although no evidence was apparent, it
was his belief that cancer very likely
had disseminated widely throughout
the patient's body. In the following two
weeks, he was bombarded by questions,
increasingly critical and accusatory,
viz: How long will my father live ?
Why are you procrastinating in de
laying further treatment for the cancer
which riddles my father's body ? How
can you be so cruel as to deny help to a
poor man dying of cancer ? The patient
himself, ignorant of forecasted doom,
was enjoying a good convalescence.
Cancer Is an Impoverishing Disease
Cancer is an impoverishing disease.
The cost of prolonged hospitalization;
the radical character of many opera
tions (some of which are staged pro
cedures) ; the ancillary therapies such
as transfusions, antibiotics; correction
of metabolic abnormalities; protracted
and repeated chemotherapy; fraction
ated radiation therapy; nursing care;
delayed convalescence and occupational
deferment, render the costs of such an
experience almost prohibitive for many
patients. For the patient with incur
able cancer, the financial burden
mounts without surcease until time, by
the termination of life, brings relief.
The patient and his family should be
given an appraisal of costs as accu
rately as possible by either the surgeon
or his staff. If possible, this informa
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tionshouldbe foretold. Realismshould a contemplatedcastration of husband
prevailoverprideinselecting thetype orwifeoran operationon a minorchild.
of hospital accommodations. Moreover, sometimes it is not enough
for the patientto sign consent for an
Assume Medico-Legal Liability operationon the breast.
If cancer is
But Protect Oneself found during the operation, and the
In the surgeon's relationship with breast is removed, reasonably this
thecancerpatient, he must realize
that should not constitute malpractice be
he is constantly assuming certain cause a radical mastectomy is generally
medico-legalliabilities. It is a strange accepted as an orthodox or proper pro
paradox and an unrewarding denial of cedure. But, if the signed consent does
gratitude that some lawsuits against not specify for a possible radical mas
surgeons have been initiated by pa tectomy, the surgeon can be sued for
tients they have cured of cancer. A New assault
by the patient who, in court,
York City jurist recently stated that 80 may claim that she would have refused
per cent of the civil suits in this city the mutilatingoperation had she
were concerned with matters of health. known. A surgeon may be sued for de
It would seem superfluous and unneces ceitif he knows it is cancer, and if his
sary to state here that consent for all records show that a biopsy has con
operations should be signed by the pa firmed the diagnosis of cancer, and in
tient and in many instances by other stead he has operated on a patient for
members of the family concerned, e.g., an alleged benign
condition.

TheAmericanCancer Societyannouncesthe publicationof a bookletentitled Cancer

of the Larynxby the late Chevalier L. Jackson,M.D. and CharlesM. Norris, M.D. This
booklet containsthe six-part serieson laryngeal cancer, which is concludedon pages
233-238 of thisissueof CA.
Copies will be available from the 59 Divisionsof the American Cancer Society.

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